Orthopaedic Staff Research Articles

Barriers to the identification of fragility fractures for secondary fracture prevention in an orthopaedic clinic-based fracture liaison service: a prospective cohort study

Background: The goal of this study was to determine the identification and participation rates of fragility fracture patients in a Fracture Liaison Service (FLS). We also identified factors affecting performance in patient identification. Methods: Surgeons, staff, and FLS nurses of an outpatient orthopaedic clinic from a hospital (Montreal, Canada) identified patients 50 yr of age or older with a fragility fracture eligible to join an FLS from January 2014 to March 2015. The list of orthopaedic referrals for the same period was retrieved and compared to our list of patients in the FLS to determine the participation rate. An in-house questionnaire was dispensed to volunteer staff to identify gaps in fragility fracture identification. Results: We identified 1011 patients with fractures from the orthopaedic referral list. Two hundred forty-nine patients (24.6%) were not identified because of nonreferral by surgeons or staff. Of the 762 remaining patients, 288 were excluded for high-energy trauma (n = 126), fracture of the face, skull, foot, or hand (n = 87), and other reasons (n = 75). Out of 474 patients with fragility fracture, 295 (62.2%) joined the FLS (178 refusals (37.6%). FLS managers only accessed 46.9% (474/1011) of eligible patients. The highest difficulty reported by the staff was about the time allocated to patient identification considering their workload. Conclusions: Major barriers to diagnosis and treatment of underlying osteoporosis in fragility fractures are nonreferral from orthopaedic surgeons or staff, and patient refusal. Challenges reside in implementing an institutional policy for optimal screening, better surgeon, staff, and patient education combined with improved systematic clinical management programs.

A prospective questionnaire-based study on staff awareness of intimate partner violence (IPV) in orthopaedic trauma patients

AimsInvestigate awareness in the multidisciplinary orthopaedic trauma team regarding intimate partner violence (IPV), willingness to ask patients and knowledge of available support. MethodsOrthopaedic staff in several UK centres completed an anonymous online validated questionnaire reflecting their opinions on IPV in orthopaedics. Respondents from orthopaedic surgery, nursing, and physiotherapy participated. ResultsThere were 121 respondents with a mean 10 years' experience. 52% of respondents had previously had a disclosure of IPV from at least one orthopaedic patient. Doctors and nurses were equally likely to have cared for IPV patients (50% versus 56%), but doctors thought abuse was less common (57% doctors compared to 15% nurses thought IPV affected less than 1% of trauma patients, p < 0.05).74% of respondents reported asking patients about abuse (77/104 answered) but only 24% (29/121) knew about the support currently available. Staff who did not know about available support were less likely to ask about possible abuse (46% versus 22% respectively, p < 0.05). 74% of respondents felt it was important/very important to ask about IPV. ConclusionsThis is the first study investigating IPV in UK orthopaedics. Although three quarters of the staff interviewed thought that it was important to ask trauma patients about IPV, only 2% routinely ask patients presenting with musculoskeletal injuries about IPV. Orthopaedic staff are well placed to identify vulnerable patients. This study highlights the need for training staff on how to identify IPV and manage disclosures of abuse given that the incidence of IPV is on the increase.

Cone-Beam Computed Tomography-Guided Navigation in Complex Osteotomies Improves Accuracy at All Competence Levels: A Study Assessing Accuracy and Reproducibility of Joint-Sparing Bone Cuts.

The objective of this study was to assess the accuracy and reproducibility of a novel cone-beam computed tomography (CBCT)-guided navigation system designed for osteotomies with joint-sparing bone cuts. Eighteen surgeons participated in this study. First, 3 expert tumor surgeons resected bone tumors in 3 Sawbones tumor models identical to actual patient scenarios. They first performed these osteotomies without navigation and then performed them using a navigation system and 3-dimensional (3D) planning tools based on CBCT imaging. The 2 sets of measurements were compared using image-based measurements from post-resection CBCT. Next, 15 residents, fellows, and orthopaedic staff surgeons were instructed on the use of the system, and their navigated resections were compared with navigated resections performed by the 3 expert tumor surgeons. One hundred and twenty-six navigated cuts done by the orthopaedic oncologists were compared with 126 non-navigated cuts by the same surgeons. The cuts violated the tumor in 22% (6) of the 27 non-navigated resections compared with none of the 27 navigated resections. The navigated cuts were significantly more accurate in terms of entry point, pitch, and roll (p < 0.001). The variation among the 3 surgeons when they used navigation was <0.6 mm for the entry cut and, on average, 1.5° for pitch and roll. All 18 surgeons then completed a total of 144 navigated cuts. The level of experience did not result in a significant difference among groups with regard to cut accuracy. Two cuts went into the tumor. The mean distance from the planned bone cuts to the actual entry points into bone was 1.5 mm (standard deviation [SD] = 1.4 mm) for all users. The mean difference in pitch and roll between the planned and actual cuts was 3.5° (SD = 2.8°) and 3.7° (SD = 3.2°) for all users. Even in expert hands, navigated cuts were significantly more accurate than non-navigated cuts. When the osteotomies were aided by navigation, their accuracy did not differ according to the level of professional experience. CBCT-based metrics enable intraoperative assessments of cut accuracy and reconstruction planning. CBCT-guided navigated osteotomies can improve accuracy regardless of surgeon experience and decrease the variability among different surgeons.

Orthopedic resident education on postoperative pain control: bridging knowledge gaps to enhance patient safety

As the United States population continues to age, the number of orthopedic procedures continues to grow.1 Not infrequently, many of these patients who are admitted for orthopedic surgical procedures are already on complex pain regimens preoperatively. This is due not only to the increasing comorbid state of our aging population but also the wide variety of analgesic management strategies employed throughout the nation amid chronic opioid use.2 Expanding surgical volumes, particularly when involving increasingly complex and opioid-tolerant chronic pain patients, pose significant challenges for perioperative management. Inpatient hospital pain services3,4 can be of tangible benefit for these complex pain patients.5 Miaskowski and colleagues found that patients cared for by an acute pain service were discharged sooner, had lower pain intensity scores, lower incidences of pruritis, sedation and nausea compared to those without the anesthesia service involvement.5 With a growing number of surgical cases, pain management consultations have increased to a number that is not always sustainable, leading some hospitals to adopt a nurse care model.6 There is minimal medical literature assessing the types of pain management consultations.4 A local and unpublished study on resource utilization at Mayo Clinic Rochester demonstrated that orthopedic surgeons place roughly 40% of all surgical specialty consultation requests for acute postoperative pain management. The majority of these consultations are requests for pharmacologic analgesia management, such as titrating oral narcotic medications. A smaller number of these requests are focused on interventional pain procedures, such as joint injections. Since not all hospitals have dedicated inpatient pain services, this places additional pressure on surgeons in the perioperative period, making pain education for these specialties even more important. To improve postoperative pain management, the inpatient pain medicine service at Mayo Clinic, a subspecialized physician practice with credentials specifically in Pain Medicine, founded an educational seminar for the incoming orthopedic surgery residents. The purpose of this program was to optimize their understanding of the role that the inpatient pain service plays in managing postoperative pain, as well as to educate them in the founding principles of pharmacologically-directed pain management. Educational Seminar In 2011, the Orthopedic Staff Leadership Committee (OSLC) at the Mayo Clinic, which consists of a core group of staff nurses and nursing leadership, participated in an educational seminar with new orthopedic residents to help guide them through the dynamic perioperative hospital course to ensure safe, satisfactory patient care. These residents received clinical education from various hospital groups, including physical and occupational therapy, social services and pharmacy. The seminars guided them through clinical techniques, such as surgical wound management, pressure ulcer prevention, and proper application of splints and casts. As an extension of this training, the OSLC, in conjunction with the Anesthesiology Division of Pain Medicine, developed a seminar to orient the resident trainees to common strategies of postoperative pain management. The training seminar consists primarily of a one-day, three-hour discussion and didactic lecture. This lecture is presented by a core faculty member of the division of Pain Medicine. The core principles it addresses are the nuances of the functions of the Anesthesia Acute Pain Management Hospital Service, as well as the pharmacodynamic and pharmacokinetic principles of a number of common medications used in the postoperative setting. These include medications such as oral and IV narcotics, NSAIDs, Tylenol, topical local anesthetics, and Tramadol. Specific information on opioid titration, parenteral to oral opioid conversion, and postoperative opioid weaning strategies (once healed from surgery) was also provided. The content consisted of defining the concept of multimodal analgesia, reviewing opioid pharmacokinetics and pharmacodynamics, demonstrating how to calculate oral morphine equivalents, understanding the utility of regional anesthesia, and reviewing methadone and pharmacokinetics and pharmacodynamics. A pre and post-assessment, audience response system test was given to improve attention and retention.

A descriptive study of accidental skeletal injuries and non-accidental skeletal injuries of child maltreatment

BackgroundLack of awareness and recognition of child maltreatment is the major reason behind underreporting. All victims often interact with the health care system for routine or emergency care. In several research works, non-accidental fractures are the second most common injury in maltreated children and it is represented up to one-third of cases. Aim of the studyTo determine the incidence of different types of accidental and non-accidental skeletal injuries among children, estimate the severity of injuries according to the modified injury severity score and to determine the degree of fractures either closed or opened (Gustiloe-Anderson open fracture classification). Moreover, identifying fractures resulting from child abuse and neglect. This aimed for early recognition of non-accidental nature of fractures in child maltreatment that can prevent further morbidity and mortality. Patients and methodA descriptive study was carried out on all children (109) with skeletal injuries who were admitted to both Main Alexandria and El-Hadara Orthopedic and Traumatology University Hospitals during six months. History, physical examination and investigations were done for the patients. A detailed questionnaire was taken to diagnose child abuse and neglect. Gustiloe-Anderson open fracture classification was used to estimate the degree of open fractures. ResultsOut of 109 children, twelve cases (11%) were categorized as child maltreatment. One case was physical abuse, eight cases (7.3%) were child neglect and three cases (2.8%) were labour exploitation. Road traffic accidents (RTA) was the commonest cause of skeletal injuries followed by falling from height. Regarding falls, they included 4 cases of stair falls in neglected children and another four cases of falling from height (balcony/window). The remaining 36 cases of falls were accidental. The skeletal injuries were in the form of fractures in 99 cases, dislocation in two cases, both fracture and/or dislocation in three cases, and bone deformity from brachial plexus injury in five cases. Fractures of the lower limb (42.2%) and both bones of the forearm (35%) represented the highest incidence of skeletal injuries in children. 54.5% of fractures due to neglect were lower limb fractures due to falling from height. Ninety-nine cases were diagnosed as long bone fractures and classified as the following; eighty patients as closed fractures, six patients as open grade I fractures, three patients as open grade II fractures, three patients as open grade IIIA fractures, four patients as open grade IIIB fractures and three patients as open grade IIIC fractures. Conclusion and recommendationCases of neglect and child abuse represented 11% of all the studied cases, where neglect was the main cause. RTA and falling from height represented the most common cause of skeletal injury in children. Most fractures due to neglect were lower limb fractures resulting from falling from height. This demonstrates the need for early detection of neglect and child maltreatment aiming for early initiation of parental educational programs about child care and safety. Misinterpretation of skeletal injuries due to neglect or abuse can be avoided by proper training of orthopedic and traumatology staff on signs of child neglect and abuse.

How noisy are total knee and hip replacements?

Orthopaedic theatre can be noisy. Fifty percent of orthopaedic theatre staff have features of noise-induced hearing loss (NIHL). In this study, decibel (dB) levels were recorded in 17 total knee replacements (TKRs) and 11 total hip replacements (THRs). Noise levels reached 105.6dB(A) using a hammer and 97.9dB(A) with an oscillating saw. Exposure to levels above 90dB (which occurred in every case) even for short time periods is proven to cause irreversible loss of hearing. Tools used in orthopaedic theatre produce impulse noises that can cause NIHL. Further investigation is required.

Perioperative participation of orthopedic patients and surgical staff in a nasal decolonization intervention to reduce Staphylococcus spp surgical site infections

With the goal of reducing rates of surgical site infections in our spine patients, we initiated a trial to investigate the impact of adding perisurgical nasal decolonization involving patients and surgical and nursing staff. We combined immediate presurgical application of a nonantibiotic alcohol-based nasal antiseptic with existing chlorhexidine bath or wipes in a comprehensive pre- and postoperative decolonization protocol. Mean infection rates were significantly decreased by 81% from 1.76 to 0.33 per 100 surgeries during the 15-month trial, when compared with the prior 9-month baseline.

Wearing ID Badges in the Operating Room Environment: Is Reconsideration Warranted?

BackgroundSurgical site infection and nosocomial infections in general have appropriately undergone increased scrutiny over the last decade. Numerous studies have documented pathogenic bacterial contamination of personal items such as cell phones, pagers, ties, and pens in the hospital setting. It is our understanding that Joint Commission on Accreditation of Healthcare Organizations requires all personnel to wear an identification badge at all times, which includes the operating room environment. MethodsBadges, lanyards, and pagers from operating room personnel were swabbed and cultured using the same protocol used for surgical specimens in the operating rooms. Personnel included orthopedic attendings (14), orthopedic residents (20), nurses (19), and anesthesia personnel (11). ResultsA total of 64 badges were sampled, with no methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant S. aureus (MRSA) cultured on any of the badges. Two of 64 had enterococcus (3%), and 1 of those was vancomycin resistant. Pagers had similar results, with only 1/42 growing MSSA or enterococcus (2.4%), and no MRSA. Lanyards showed higher rates of contamination. There were 11% with MSSA or MRSA out of 27 sampled. Highest contamination rates were with orthopedic staff and resident lanyards, with 3/22 (13.6%) growing MSSA or MRSA. No lanyards grew enterococcus. When comparing rates of MSSA and/or MRSA between groups, lanyards had a statistically significant higher rate (P < .05). ConclusionAt a minimum, operating room personnel should probably not use lanyards to display their ID badges.

Health Literacy in Orthopaedic Trauma Patients.

This study aimed to determine the level of health literacy in a postoperative orthopaedic trauma population and to evaluate the efficacy of a simple predischarge discussion strategy, targeted at improving health literacy. A pre-post intervention study was conducted from April 2014 to January 2015. Academic Level 1 trauma center. One hundred ninety consecutive orthopaedic trauma patients with operatively managed lower limb fractures were recruited. All eligible participants agreed to participate. The first ninety-nine patients received usual care (UC). The following 91 patients received a structured predischarge discussion, including x-rays, written and verbal information, from the orthopaedic staff (DG). Patients were then randomized into health literacy evaluation before first outpatient review or after first outpatient review. The primary outcome measure was a questionnaire determining health literacy. Ninety-six (97%) of the UC patients and 87 (96%) of the discussion patients (DG) completed the interview. UC preoutpatient (n = 46) demonstrated a mean score of 4.67 of a maximum 8. UC postoutpatient (n = 50) demonstrated a mean score of 5.42. DG preoutpatient (n = 47) demonstrated a mean score of 6.70. DG postoutpatient (n = 40) demonstrated a mean score of 7.08. Australian orthopaedic trauma patients demonstrate poor health literacy, with this not showing improvement after their first outpatient follow-up visit. The use of a time efficient, structured predischarge discussion improved patient health literacy. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Pre- and Post-Operative Participation of Orthopedic Patients and Surgical Staff in a Novel Intervention to Reduce Staphylococcus aureus infection.

Pre- and Post-Operative Participation of Orthopedic Patients and Surgical Staff in a Novel Intervention to Reduce Staphylococcus aureus infection.

A prospective study about the preoperative total blood loss in older people with hip fracture.

PurposeOur study is to confirm that hemoglobin (Hb) level is significantly reduced before operation in elderly patients with hip fracture and to specify potential amounts of bleeding and Hb decline in different types of fractures.MethodsA prospective analysis was made on the clinical data of 349 patients with both a diagnosis of hip fracture and an operative delay of greater than 72 hours between April 2014 and February 2016. Hb concentration was measured on a daily basis before the surgery. Patients were grouped according to the type of fracture (intracapsular and extracapsular) for calculation of the total blood loss (TBL). All data analyses were done by SPSS version 21 software.ResultsThere was a significant decrease preoperatively in the Hb concentration of nearly 21.55 g/L (standard error of the mean [SEM] 7.67) in patients with extracapsular hip fractures and nearly 15.63 g/L (SEM 6.01) in patients with intracapsular hip fractures. The preoperative TBL in patients with extracapsular fracture was significantly larger compared to that in patients with intracapsular fracture (790.3 mL and 581.7 mL, respectively, P<0.05 using Student’s t-test). We found no significant difference in the preoperative TBL between the male and female groups.ConclusionHip fracture patients have an obvious blood loss after the injury, yet prior to the surgery the Hb levels were found to be normal. Anesthetic and orthopedic staff should pay additional attention to the problem of low preoperative Hb concentration, even if the initial Hb level was apparently normal.

Plain film measurement error in acute displaced midshaft clavicle fractures.

Clavicle fractures are common and optimal treatment remains controversial. Recent literature suggests operative fixation of acute displaced mid-shaft clavicle fractures (DMCFs) shortened more than 2 cm improves outcomes. We aimed to identify correlation between plain film and computed tomography (CT) measurement of displacement and the inter- and intraobserver reliability of repeated radiographic measurements. We obtained radiographs and CT scans of patients with acute DMCFs. Three orthopedic staff and 3 residents measured radiographic displacement at time zero and 2 weeks later. The CT measurements identified absolute shortening in 3 dimensions (by subtracting the length of the fractured from the intact clavicle). We then compared shortening measured on radiographs and shortening measured in 3 dimensions on CT. Interobserver and intraobserver reliability were calculated. We reviewed the fractures of 22 patients. Bland-Altman repeatability coefficient calculations indicated that radiograph and CT measurements of shortening could not be correlated owing to an unacceptable amount of measurement error (6 cm). Interobserver reliability for plain radiograph measurements was excellent (Cronbach α = 0.90). Likewise, intraobserver reliabilities for plain radiograph measurements as calculated with paired t tests indicated excellent correlation (p > 0.05 in all but 1 observer [p = 0.04]). To establish shortening as an indication for DMCF fixation, reliable measurement tools are required. The low correlation between plain film and CT measurements we observed suggests further research is necessary to establish what imaging modality reliably predicts shortening. Our results indicate weak correlation between radiograph and CT measurement of acute DMCF shortening.

Burnout in U.S. Military Orthopaedic Residents and Staff Physicians.

The purpose of this study was to measure the prevalence of burnout among military orthopaedic residents and staff surgeons at the U.S. Army Medical Center. 37 residents and 21 staff surgeons of a military orthopaedic residency program were asked to voluntarily complete an anonymous electronic survey. The survey consisted of two parts: first, a demographic section including questions about relationship status, work hours, deployment history, medical education debt, mentorship, and job satisfaction and second, the Maslach Burnout Inventory. 27 residents and 11 staff completed the survey for a 67% response rate. The rate of burnout among military orthopaedic surgeons in our study was 7.7% (3.7% of residents and 16.7% of staff surgeons). In addition, 25.6% of surgeons (33% of residents and 8.3% of staff) were found to be at risk of burnout. Future studies should focus on causal relationships among specific aspects of the work environment and possible preventive or protective measures. Expanding future studies to include multiple study sites would improve the quality and generalizability of the results.

Determining Measurement Error for Bohler's Angle and the Effect of X-Ray Obliquity on Accuracy.

Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA. A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement. A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity. Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph. Level V: Cadaver bench study.

Can A Smartphone Replace The Operative Note?

Objectives:A large portion of the body of orthopedic surgical research is conducted retrospectively, using the operative note as a main data source. Operative notes tend to infrequently report quantitative data, significantly limiting the precision with which research questions can be assessed (Scherer et al., 2003). Large scale surgical outcomes studies have identified specific surgical parameters as valid predictors of key surgical outcomes (Kaeding, Pedroza, Reinke, Huston, & Spindler, 2015). Thus, it is now feasible to develop a data capture system that collects more accurate, robust surgical data quickly and with lower cost than operative note dictation. The objectives of this study are as follows: 1. Develop a provider-friendly, evidence-based, data capture system for lower limb orthopedic surgeries.2. Assess the performance of the data capture system on the dimensions of agreement with operative note and implant log, consistency of data quality, and speed of provider input.Methods:A multidisciplinary team including administration, orthopedic surgery staff, and software development was assembled for the design of the surgical database. The database was developed in Redcap and user interfaces were created for Android and IOS operating systems. Branching logic was created to streamline provider data input. All data input was created with discrete fields. Cleveland Clinic owned I-Phones were used for surgeon data input. All surgeons at Cleveland Clinic Sports Health were included in the dataset. One hundred cases were randomly selected from the first four months of data collection (February- June 2015). Cases were limited to those undergoing ACL repair, meniscal repair, or both. Duplicate data on these 100 cases was collected via chart review. These two datasets were compared. Cohen’s Kappa statistic was used to assess agreement.Results:Table 1 shows the Kappa statistic and 95% confidence interval for agreement between the database and the chart review collected data. Agreement across all variables was greater than Kappa of 0.85. These variables include, but are not limited to: ACL status (Kappa = 0.904, 95% C.I.[0.717, 1.090]), medial meniscus treatment (Kappa = 0.992, 95% C.I0.860, 1.045]), and tibial screw type (Kappa =0.933, 95% C.I.[0.860, 1.007]). Moreover, the frequency of reporting key information was higher in I-phone based data capture system as compared to traditional operative note (graft strand number: 100% vs. 80%; femur tunnel size: 100% vs. 85%; tibial tunnel size: 100% vs. 81%). Median surgeon data input time was 151 seconds.Conclusion:The database and smartphone data capture tool shows almost perfect agreement (Kappa>0.81) for all data tested. Additionally, data are more comprehensive with near perfect provider completion (100% for all data tested). Additionally, provider data entry is efficient (median 151 s completion time). A well designed database and user friendly interface have greater potential for research utility, clinic efficiency, and thus cost effectiveness when compared to traditional operative notes. Widespread utilization of such tools can accelerate the pace and improve the quality of orthopedic clinical research.

Safety and Appropriateness of Tourniquets in 105 Civilians

Background: The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether tourniquets are safely applied to the appropriate civilian patient with major limb trauma of any etiology. Methods: Following IRB approval, patients arriving to a level-1 trauma center between October 2008 and May 2013 with a prehospital (PH) or emergency department (ED) tourniquet were reviewed. Cases were assigned the following designations: absolute indication (operation within 2 hours for limb injury, vascular injury requiring repair/ligation, or traumatic amputation); relative indication (major musculoskeletal/soft-tissue injury requiring operation 2–8 hours after arrival, documented large blood loss); and non-indicated. Patients with absolute or relative indications for tourniquet placement were defined as indicated, while the remaining were designated as non-indicated. Complications potentially associated with tourniquets, including amputation, acute renal failure, compartment syndrome, nerve palsies, and venous thromboembolic events, were adjudicated by orthopedic, hand or trauma surgical staff. Univariate analysis was performed to compare patients with indicated versus non-indicated tourniquet placement. Results: A total of 105 patients received a tourniquet for injuries sustained via sharp objects, i.e., glass or knives (32%), motor vehicle collisions (30%), or other mechanisms (38%). A total of 94 patients (90%) had indicated tourniquet placement; 41 (44%) of which had a vascular injury. Demographics, mechanism, transport, and vitals were similar between patients that had indicated or non-indicated tourniquet placement. 48% of the indicated tourniquets placed PH were removed in the ED, compared to 100% of the non-indicated tourniquets (p < 0.01). The amputation rate was 32% among patients with indicated tourniquet placement (vs. 0%; p = 0.03). Acute renal failure (3.2 vs. 0%, p = 0.72), compartment syndrome (2.1 vs. 0%, p = 0.80), nerve palsies (5.3 vs. 0%; p = 0.57), and venous thromboembolic events (9.1 vs. 8.5%; p = 0.65) and were similar in patients that had indicated compared to non-indicated tourniquet placement. After adjudication, no complication was a result of tourniquet use. Conclusion: The current study suggests that PH and ED tourniquets are used safely and appropriately in civilians with major limb trauma that occur via blunt and penetrating mechanisms.

Radiation exposure to orthopaedic registrars in the Pietermaritzburg Metropolitan Complex

INTRODUCTION: Modern orthopaedic surgery increasingly involves the use of fluoroscopic imaging in theatre. This has led to an increase in radiation exposure to the orthopaedic surgeon and other theatre staff. There is very little research as to which orthopaedic subspecialty may lead to higher exposures. This study aims to demonstrate whether radiation exposure levels in orthopaedic registrars in the Pietermaritzburg Complex are within safety limits and also to determine which subspecialty rotations lead to increased exposure levels. MATERIALS AND METHODS: A retrospective quantitative observational study analysed the dosimeter readings of 20 registrars over a one-year period. Dosimeter readings were also analysed per subspecialty rotation, namely orthopaedic trauma, spinal surgery, arthroplasty, ortho-paediatrics, upper limb surgery, and tumour sepsis and reconstruction. RESULTS: No registrar was found to have a dosimeter reading exceeding the International Commission on Radiological Protection guidelines. Rotations in which registrars received measureable readings were orthopaedic trauma, upper limb surgery, spinal surgery and arthroplasty. CONCLUSION: Trauma rotations appeared to produce to highest radiation exposure readings, although these were still within international safety limits. Knowledge of radiation safety, staff education and safety measures to limit any unnecessary exposure should be employed.

Methods of orthopedic treatment developed during the great patriotic war and post-war years by the orthopedic dentistry department Staff of Kazan State Dental Institute

During the Great Patriotic War in Kazan, evacuation hospitals were established in Kazan. Teachers of the Kazan State Dental Institute made an invaluable contribution to their work, offering advice and medical aid to the wounded and sick. During the war, members of the department significantly improved the quality of the treatment of the wounded in the maxillofacial region, which contributed to their rapid recovery and return to the troops or to labor. The Great Patriotic War was a special period for the Department of Orthopedic Dentistry of Kazan State Dental Institute, when everything was aimed at providing high quality care and rehabilitation of patients. Staff members of the department of orthopedic dentistry proposed a number of original methods, orthotics and prostheses for the treatment of severe wounds in the maxillofacial region, which have been successfully used in those years. The designs of these devices and prostheses are not outdated; they are successfully used today to treat patients with maxillofacial injuries. Researches of thoughtful and talented scientists, whose labors are methodically published not only in scientific works, but also in prosthetic dentistry textbooks, valuable for the professional development of a new generation of students of dental faculties. Teaching staff of the department of orthopedic dentistry cherishes the memory of the staff members, who contributed to the development and improvement of dental education in the city of Kazan.

Traffic in the operating room during joint replacement is a multidisciplinary problem.

Door openings disrupt the laminar air flow and increase the bacterial count in the operating room (OR). We aimed to define the incidence of door openings in the OR during primary total joint arthroplasty (TJA) surgeries and determine whether measures were needed and/or possible to reduce OR staff traffic. We recorded the number of door openings during 100 primary elective TJA surgeries; the OR personnel were unaware of the observer's intention. Operating time was divided into the preincision period, defined as the time from the opening of surgical trays to skin incision, and the postincision period, defined as time from incision to dressing application. The mean number of door openings during primary TJA was 71.1 (range 35-176) with a mean operative time of 111.9 (range 53-220) minutes, for an average of 0.64 (range 0.36-1.05) door openings/min. Nursing staff were responsible for 52.2% of total door openings, followed by anesthesia staff at 23.9% and orthopedic staff at 12.7%. In the preincision period, we observed an average of 0.84 door openings/ min, with nursing and orthopedic personnel responsible for most of the door openings. The postincision period yielded an average of 0.54 door openings/min, with nursing and anesthesia personnel being responsible for most of the door openings. There is a high incidence of door openings during TJA. Because we observed a range in the number of door openings per surgery, we believe it is possible to reduce this number during TJA.

Damage control orthopaedics: Variability of construct design for external fixation of the lower extremity and implications on cost

IntroductionTo evaluate relative cost of external fixator constructs applied for damage control purposes in a cohort of advanced orthopaedic trainees and orthopaedic staff traumatologists. We also sought to evaluate physicians’ understanding of component cost. Materials and methodsParticipants were asked to apply an external fixator for three separate fracture patterns in damage control fashion. A total of 19 physicians (nine PGY-4 residents, five PGY-5 residents, two orthopaedic trauma fellows and three orthopaedic staff traumatologists) participated. Total construct cost was calculated. Participants provided an estimate of the cost of each component in a fill-in format survey. Main outcome measures included cost of external fixator construct applied and the estimated cost of external fixator components. ResultsAverage whole sale cost of an external fixator construct was $5252 (±$1798). Of the three fracture types examined, the tibial plafond fracture external fixator construct on average cost the most, followed by the tibial plateau fracture and the femur fracture construct. The large ex-fix combination clamp was the major contributor to cost for each construct. The combination clamp may be substituted for a multi-pin clamp, resulting in significant cost savings. The self-drilling Schanz pin and the large ex-fix combination clamp were most highly underestimated (25% and 22% of their actual cost, respectively). ConclusionInnumerous construct designs exist and even small changes can significantly impact cost. Knowledge of component cost is low among staff and trainees. Education of component cost is vital to allow adequate consideration of construct design prior to fixator application.