Orthopedic Physicians Research Articles

Telemedicine Experiences of Athletic Trainers and Orthopaedic Physicians for Patients With Musculoskeletal Conditions.

Telemedicine is the delivery of medical care from a distance using technology. The integration of telemedicine as a supplement to musculoskeletal-based patient encounters may be feasible in sports medicine. To investigate health care professionals' perceptions of and experiences with telemedicine. Cross-sectional explanatory sequential mixed-methods study. A purposeful sample of 17 athletic trainers from a National Collegiate Athletic Association Division I institution and 5 orthopaedic physicians from a sports medicine clinic located 92 miles from the campus. Participants were trained on the telemedicine platform and used it over 5 months for initial, follow-up, and discharge patient encounters. Participants completed a preintervention survey containing the Theory of Planned Behavior and Technology Acceptance Model tool. Responses were analyzed using descriptive statistics and an independent-samples t test. After the intervention period, participants completed individual semistructured interviews that we coded using the consensual qualitative research tradition. From the interviews, the clinicians were characterized as telemedicine adopters (n = 14) or nonadopters (n = 8). The adopters reported higher levels of agreement on the Theory of Planned Behavior and Technology Acceptance Model tool as compared with nonadopters for all constructs. When comparing adoption status, we identified a difference (P < .01), with nonadopters reporting a low level of agreement for the subjective norm construct. The interviews revealed 5 domains: integration challenges, integration opportunities, collaborative practice, anticipatory socialization to future use, and benefits of integration. The participants indicated that integration challenges centered on "buy in," whereas opportunities aligned with the patient's condition and technology ease of use. They reflected that the telemedicine encounters required more preparation and yet allowed for cooperative behaviors between clinicians. The benefits of telemedicine included convenience and scheduling preferences that encouraged future use. The integration of telemedicine in sports medicine brought about both challenges and opportunities for collaboration among athletic trainers and physicians that were heavily predetermined by the social pressures of colleagues.

Improving resident education through unstable chicken hips: a novel way to teach an infant hip examination.

Current clinical screening for infantile hip dysplasia relies on combined Ortolani and Barlow maneuvers, which have a quoted sensitivity and specificity of 74-98 and 84-99%, respectively. Teaching this delicate physical examination maneuver is difficult as it requires a distinct tactile feel. The purpose of this study is to validate a benchtop learning grocery-bought chicken simulator model of newborn hip instability through a pre- and post-test surveys. This model of hip dysplasia uses whole chickens. A posterior capsulotomy of the chicken's hip joint was performed to create instability. Provocative maneuvers to dislocate and relocate the hip were taught by a pediatric orthopedic surgeon. All participants completed an anonymous pre- and post-training surveys. A total of 58 participants were included in the study: 10 medical students, 13 pediatric residents, 15 orthopedic residents, and 20 orthopedic or pediatric attending physicians. The pediatric residents had performed the Barlow/Ortolani tests more than the orthopedic residents (96.15 ± 83.19 vs. 37.53 ± 60.89; P = 0.01); however, fewer pediatric residents reported feeling a positive examination (31 vs. 67%). The majority of the group agreed that the simulation felt and moved like an infant's hip (3.95 and 4.13; Likert five-point scale). The participants unanimously agreed that the model could be used to teach someone new to pediatrics the basic steps of the examination (4.91; Likert five-point scale) and should be implemented in the teaching curriculum (100%). The current study validates the benchtop model in teaching the clinical steps in detecting hip dysplasia. The model improved confidence and comfort level for all participants and proved to be a valuable tool for resident education in multiple specialties. By improving education with this model, we hope to improve early identification of hip dysplasia with increased accuracy across subspecialties.

Оцінка психоемоційного напруження, як фактору що впливає на використання повних знімних пластикових протезів

Вимірювання тривожності як властивості особистості має дуже важливе значення, тому що вона багато в чому обумовлює поведінку суб'єкта. Певний рівень тривожності – природна і обов'язкова особливість активної діяльної особистості. У кожної людини існує свій оптимальний, або бажаний рівень тривожності – це так звана корисна тривожність. Оцінка людиною свого стану в цьому відношенні є для неї істотним компонентом самоконтролю і самовиховання. Пацієнтам з відсутністю зубів (часткове, повне), які мають зубні протези і користуються ними, притаманні помірна особистісна й реактивна тривожність, а пацієнтам з відсутністю зубів (часткове, повне), що мають зубні протези, але не користуються ними, властиві висока особистісна й реактивна тривожність. Отже, ефективність ортопедичного лікування пацієнта значною мірою буде залежати від того, наскільки лікарем-стоматологом-ортопедом будуть враховані не тільки індивідуальні особливості, але й його психосоматичний статус. Лікарю-стоматологу-ортопеду окрім «протезного» досвіду треба знати та вміти використовувати психологічні тести.&#x0D;

Comparison of the Effect of Custom Insole With CAD-CAM and Conventional Insole on FAOS Questionnaire Subscales in Patients With Plantar Fasciitis

Objective: One of the significant causes of foot pain is plantar fasciitis. The use of medical insoles is a conventional treatment for this condition. The purpose of this study was to compare the effect of the customized insole with the CAD-CAM and conventional insole on pain, symptoms, daily activity, exercise and recreational activity, and quality of life in patients with PF. Materials &amp; Methods: This quasi-experimental study was performed on 14 patients with plantar fasciitis (five women and nine men) with the mean age of 40 years. Fourteen patients have been diagnosed with orthopedic pain after being diagnosed with plantar fasciitis according to inclusion criteria. Diagnosis of the complication of plantar fasciitis by orthopedic physician, Patients with flexible flat foot. No neurological disorders or any foot pathology such as diabetes and osteoarthritis. Patients were randomly assigned into two groups of 7 using customized insole with CAD-CAM and conventional (prefabricated) insole. From the outset it was found to be one of two types of insole to be studied: first the patient was given a CNC insole, and the other 13 patients received the same insole and divided into two groups. The instrument of this study was the FAOS questionnaire (foot and ankle outcomes) which measures the five variables of pain, symptoms, daily activities, sports and recreational activities, and quality of life. Both groups completed the questionnaire before using the insole and again after six weeks. Compressive scan of both groups was accomplished using EMED foot pressure system. The custom-made insole was designed using Rhino Cross software and then shaved using EVA foam blocks with 50% shore using a CNC machine. In the conventional insoles group, patients received conventional polyurethane insoles based on the length measurements of the single leg. Patients completed the questionnaire again after six weeks. Data were analyzed by SPSS software v. 22. After checking the normality of the data by Shapiro-Wilk test, non-parametric Mann-Whitney and Wilcoxon tests were used to analyze the data. Results: In the pre-intervention phase, there was no significant difference in pain, symptoms, daily activities, recreational-sports activities, and quality of life in the two groups, and the two groups were homogeneous. After six weeks, there was a significant difference between the two groups in the FAOS questionnaire (P&lt;0.05). There was no significant difference between the two groups in pain score, symptoms, daily activities, recreational-sport activities, and quality of life (P &lt;0.05). Conclusion: According to the results of this study, both customized insoles with CAD-CAM and conventional insoles are effective in improving FAOS questionnaire subscales. There was no significant difference in the impact between the two types of insoles in foot and ankle.

Effect of Melilotus Officinalis Oil on Knee Joint Pain and Stiffness in the Elderly With Primary Knee Osteoarthritis

Objectives: Osteoarthritis is one of the most common diseases among older people which is one the most important causes of disability and heavy socio-economic burden on the elderly and society. This study aimed to investigate the effect of melilotus officinalis oil on knee joint pain and stiffness among older adults with mild to moderate primary knee osteoarthritis. Methods &amp; Materials: This is a double-blind randomized controlled clinical trial (registration code: IRCT2016082129461N1). Participants were 61 eligible older adults (35 females and 26 males with a mean age of 78±7.79 years) residing in one of the nursing homes in Tehran, Iran who had mild to moderate knee osteoarthritis clinically diagnosed by an orthopedic physician. Then they were assigned randomly into two groups of intervention and control received melilotus officinalis oil and diclofenac gel, respectively, using a randomization table based on balance block randomization. The data were collected using a demographic form and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for evaluating knee joint pain and stiffness at baseline, 2 weeks and 4 weeks after the intervention. Collected data were analyzed in SPSS V. 23 software. Results: There was no statistically significant different between the intervention and control groups in terms of sociodemographic variables (age, education, marital status, occupation, smoking, physical activity, chronic illness, and medication) at baseline. Knee pain (F1,58=119.07, P&lt;0.001) and joint stiffness (F 1,58=19.9, P&lt;0.001) reduced significantly in both groups, where the effect size was higher in the intervention group. No considerable side effect reported during the study. Conclusion: Compared to diclofenac gel, melilotus officinalis oil can reduce knee joint pain and stiffness in older people with mild to moderate knee osteoarthritis. Therefore, it is suggested for treatment of people with knee osteoarthritis. Further studies are recommended to investigate the mechanism of melilotus oficinalis oil in reducing knee pain and stiffness and determine its effective dosage.

Establishing the learning curve for elbow arthroscopy: surgeon and trainee perspectives on number of cases needed and optimal methods for acquiring skill

Elbow arthroscopy has increased in frequency as its indications have widened. Despite this growth, a learning curve has not yet been defined. We hypothesized that there would be significant differences in perspective between trainees and established surgeons for the number of cases needed to reach each skill level and what they felt are the most valuable training tools. Orthopedic attending physicians and trainees were asked to complete a questionnaire assessing participant demographics, case volumes required to reach defined skill levels (novice, safe, competent, proficient, and expert), and the efficacy of various learning methodologies for elbow arthroscopy. The value of educational methods was assessed using a 5-point Likert scale (1 = not at all valuable; 5 = extremely valuable). The study population consisted of 323 total participants, of whom 224 (69.3%) were attending surgeons and 99 (30.7%) were trainees (resident or fellow physicians). According to the attending physicians, the mean numbers of cases needed to reach each skill level were19 to be safe, 42 to be competent, 93 to be proficient, and 230 to be expert. These case numbers were not significantly different from the perspectives of trainees. Across the respondents, there were no significant differences in the number of cases needed to reach each level of skill based on the respondents' level of training, years of experience, type of fellowship, or self-reported skill level.Although both groups highly valued live surgery (4.7 of 5) and cadaveric practice (4.6 of 5) for acquiring skill, attendings placed higher value on reading (4.0 vs. 3.3, P < .001), videos/live demos (4.2 vs. 3.6, P< .001), and formal courses (4.5 vs. 4.1, P< .001) than trainees. Both groups place relatively low value on surgical simulators (2.8-3.6). There was considerable agreement amongattending surgeons and trainees in terms of the number of cases needed to attain various skill levels of elbow arthroscopy, which was consistent regardless of fellowship background, self-reported skill level, career length, and elbow arthroscopy case volume. However, there was some disagreement between attending surgeons and trainees over the most valuable methods for acquiring surgical skill with trainees placing less value on textbooks, surgical videos, and formal courses compared with attending surgeons. An understanding of the elbow arthroscopy learning curve will help trainees and their training programs establish case volume targets before safe, independent practice. Future studies should aim to clinically validate this learning curve.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States

ObjectiveAdequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States.Study designEighteen institutions from the Children’s ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported.Results87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI.ConclusionAt large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 ‘rule-out’ MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution’s pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

An interprofessional teaching approach for medical and physical therapy students to learn functional anatomy and clinical examination of the lower spine and hip

IntroductionPain of the lower back is a frequent symptom and is treated by different health professions. Anatomical as well as clinical knowledge is utmost important for all professions involved in this field. Here, we present a model that brings together an interprofessional team of experts to teach functional and clinical anatomy of the lower spine and hip area to medical and physical therapy students. MethodsTwo groups of medical students (n=60) and physical therapy students (n=77) were designated to two interprofessional clusters, with each cluster of students participating in three workshops, each lasting 40min. Workshops were guided by university anatomists, an orthopedic physician and physical therapists, and each provided specialized training, such as the conduction of clinical, orthopedic functional tests, the identification and palpation of anatomical structures and demonstrations of human anatomical joint prosections. A questionnaire, consisting of 18 questions regarding subjective anatomical and clinical knowledge and application of clinical assessment techniques was used as the evaluation tool before and after participation in the course. Furthermore, the amount of knowledge gained from peer group participants from the other profession versus the knowledge gained from the instructors was assessed. Descriptive statistics of data as well as quantitative data analysis was carried out for pre–post analysis. ResultsA total of 148 students participated in the pre-course evaluation and self-assessment and 113 students completed the post-course evaluation and self-assessment. 11 of the students, who completed the pre-course evaluation, and five students who completed the post-course evaluation failed to reveal their affiliation and these were only included in the general and corresponding cluster analysis. A final 132 pre-questionnaire and 97 post-questionnaire results were included in the analyses due to a likely group response bias. Scores for all combined groups showed an increase in the pre–post evaluation of 11.7% (P<.001). Cluster 1 and 2 (pre–post) score comparisons showed an increase of 13.7% (P<.001) and 8.8% (P<.001) respectively. A subgroup pre–post-questionnaire analysis demonstrated that medical students from both clusters had the highest increase in scores (17.6% and 19.9%) in comparison to their physical therapy counterparts (9.1% and 5.8%) (P<.001). Specifically, medical students profited highly from the anatomy in vivo (palpation) as well as clinical, orthopedic assessment exercises. Sub-question analyses showed that students learned from each other as well as from an interprofessional team of guiding experts/instructors, though mostly from the latter. ConclusionsThis course offers an appropriate and effective model that brings together an interprofessional team of experts to teach functional and clinical anatomy to medical and physical therapy students. Study results demonstrated an increase in subject-specific competencies in functional and clinical anatomy of the lower spine and hip. Medical students demonstrated the highest increase in subjective knowledge, especially in regard to clinical examination and assessment, which highlights the usefulness of this course early in the medical education. All students learned from the exchange with interprofessional group members as well as the instructors.

A Case-Control Study of Fluoridation and Osteosarcoma

Public health policy decisions in the United States have resulted in 62.4% of the population having access to fluoridated water. The purpose of this study was to examine the association between community water fluoridation and osteosarcoma. A secondary data analysis was performed with data collected from 2 separate but linked studies. Patients for phase 1 and phase 2 were selected from US hospitals via a matched case-control study design. For both phases, cases included patients diagnosed with osteosarcoma, and controls were patients diagnosed with other bone tumors or nonneoplastic conditions. In phase 1, cases (n = 209) and controls (n = 440) were patients of record in the participating orthopedic departments from 1989 to 1993. In phase 2, cases (n = 108) and controls (n = 296) were incident patients who were identified and treated by orthopedic physicians from 1994 to 2000. This analysis included all patients who met eligibility criteria on whom we had complete data on covariates, exposures, and outcome. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% CIs for the association of community water fluoridation with osteosarcoma. A modestly significant interaction existed between fluoridation living status and bottled water use (P = 0.047). The adjusted OR for osteosarcoma and ever having lived in a fluoridated area for nonbottled water drinkers was 0.51 (95% CI, 0.31 to 0.84; P = 0.008). In the same comparison, the adjusted OR for bottled water drinkers was 1.86 (95% CI, 0.54 to 6.41; P = 0.326). Findings from this study demonstrated that community water fluoridation is not associated with an increased risk for osteosarcoma.

An Orthopaedic Department's Response to the COVID-19 Health-Care Crisis: Indirect and Direct Actions with Thoughts for the Future.

An Orthopaedic Department's Response to the COVID-19 Health-Care Crisis: Indirect and Direct Actions with Thoughts for the Future.

Experiences from the SARS-CoV-2 Pandemic: How One Orthopaedic Practice Pivoted to Serve Their Community.

Experiences from the SARS-CoV-2 Pandemic: How One Orthopaedic Practice Pivoted to Serve Their Community.

COVID-19 Response in the Global Epicenter: Converting a New York City Level 1 Orthopedic Trauma Service into a Hybrid Orthopedic and Medicine COVID-19 Management Team.

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

Image Distortion in Biplanar Slot Scanning: Part 2 Technology-specific Factors.

Biplanar digital slot scanning technology has become the standard of care in the treatment of scoliosis. Yet, the amount of distortion and reproducibility of this type of imaging modality has yet to be fully investigated. In our paper "Image distortion in biplanar slot scanning: part 1 patient-specific factors" we found that there was potentially clinically impactful interimage distortion. The purpose of this study was to evaluate the degree to which this image distortion was secondary to the image acquisition process. Four 25 mm radio-opaque markers were placed at C3, T1, T12, and L5 on a full-length skeleton model. The skeleton was imaged in 10 different positions within the scanner. Five posteroanterior and 5 lateral images were obtained in each position. Two orthopaedic attending physicians and 3 orthopaedic resident physicians measured the markers for a total of 3200 measurements. Intraclass correlation coefficients (ICCs) and 95% confidence intervals were used to examine image distortion. Average marker size was 24.77, with a standard error of measurement of 0.00493. Image distortion and standard error of measurement accounted for ∼0.5% to 1.5% of total the measurement. Overall, there was good reliability and consistency when looking at markers in different views (ICC 0.790), planes, and locations within the image. Horizontal measurements were found to be more consistent and have better reliability (ICC 0.881) than vertical measurements (ICC 0.386). Position within the scanner had minimal impact on the accuracy of the measurements. This study demonstrates that there is minimal error due to image acquisition and measurement when using a biplanar slot scanner. Biplanar slot scanning technology tended to underestimate the size of the marker; however, the least accurate measurements only erred by 1.5% from the true length. This indicates that unlike traditional radiographs the sources of error in biplanar slot scanning images are not due to parallax and are likely due to patient-specific factors and rather than the technology itself.

Concordance and Discordance of Orthopedicians with Revised National Tuberculosis Control Program with Reference to Musculoskeletal Tuberculosis: A Qualitative Inquiry.

Musculoskeletal tuberculosis (TB) continues to share the major burden of extrapulmonary TB. This burden up to some extent may be attributed to the implementation gap which is reasonably broadest at the level of the immediate point of care. As an orthopedic physician is an important stakeholder at this juncture, it is imperative to recognize their experiences, perceptions, and anticipations to fill this gap. This qualitative inquiry tries to explore these attributes in the context of the recent development at the policy level in Revised National Tuberculosis Control Program. Type of Study Qualitative inquiry with framework approach. Orthopedic surgeons working in different work settings. Purposive sampling. An iterative topic guide for an in-depth interview was prepared by reviewing the literature and expert opinions. The questions were contextual, diagnostic, evaluative, and strategic. This study adopted a framework approach as the issue was near to evaluative and strategic policy research. The recorded interviews were transcribed and coded into axial and serial codes. A framework matrix was created and thematic mapping was done to understand the phenomena and to offer the solution framework. The investigators detected an element of unawareness of the current context coupled with the perceived previous stringency of the program. This is in conjunction with already multifaceted diagnostic and prognostic complexity. This leads to mutual dissociation and skepticism. This qualitative inquiry explored an element of dissociation between programmatic objectives and individualistic concerns of the caregivers. An integrated ecosystem which may take care of synergistic reciprocation among the two is imperative for successful implementation.

Non-Orthopedic Encounters Increase Opioid Exposure in Joint Osteoarthritis: A Single-Institution Analysis

BackgroundThere has been little-to-no evidence to support the use of opioid analgesia as a treatment modality for osteoarthritis (OA). Chronic opioid use has been associated with peri-operative and post-operative complications with joint reconstruction. The purpose of this study is to compare opioid-prescribing habits for OA between orthopedic and non-orthopedic physicians to identify encounters that increase opioid exposure. MethodsA retrospective chart review was performed on opioid-naive adult patients with outpatient opioid prescriptions for OA at a single academic institution between 2013 and 2018. Patients with prior surgery or opioid prescriptions were excluded. Independent t-tests and analysis of variance were used to compare prescription characteristics among providers. ResultsA total of 9625 opioid prescriptions were identified. Non-orthopedic providers account for 92% of prescriptions vs 8% by orthopedic surgeons. The greatest number of prescriptions is written by Internal Medicine (37.1%) and Family Medicine physicians (36.0%). Non-orthopedic physicians prescribe a greater number of prescriptions per patient, dosages, and refills (P < .001 for all). Non-orthopedic encounters are associated with increased risk for prescription dosages ≥50 MME/d (odds ratio 5.81, 95% confidence interval 4.35-7.81, P < .001) and 90 MME/d (odds ratio 18.2, 95% confidence interval 4.43-35.70, P < .001). ConclusionThe majority of opioid prescriptions for OA are written by non-orthopedic providers, with higher prescription rates, dosages, and more refills than orthopedic surgeons. OA is a common condition that will benefit from multi-disciplinary awareness to minimize unnecessary opioid exposure and reduce potential complications with joint arthroplasty.

Malpractice Litigation for Compartment Syndrome

The aim of this study was to analyze litigation involving compartment syndrome to identify the causes and outcomes of such malpractice suits. A better understanding of such litigation may provide insight into areas where clinicians may make improvements in the delivery of care. Jury verdict reviews from the Westlaw database from January 1, 2010 to January 1, 2018 were reviewed. The search term "compartment syndrome" was used to identify cases and extract data on the specialty of the physician defendant, the demographics of the plaintiff, the allegation, and the verdict. A total of 124 individual cases involving the diagnosis of compartment syndrome were identified. Medical centers or the hospital was included as a defendant in 51.6% of cases. The most frequent physician defendants were orthopedic surgeons (45.96%) and emergency medicine physicians (20.16%), followed by cardiothoracic/vascular surgeons (16.93%). Failure to diagnose was the most frequently cited claim (71.8% of cases). Most plaintiffs were men, with a mean age of 36.7years, suffering injuries for an average of 5years before their verdict. Traumatic compartment syndrome of the lower extremity causing nerve damage was the most common complication attributed to failure to diagnose, leading to litigation. Forty cases (32.25%) were found for the plaintiff or settled, with an average award of $1,553,993.66. Our study offers a brief overview of the most common defendants, plaintiffs, and injuries involved in legal disputes involving compartment syndrome. Orthopedic surgeons were most commonly named; however, vascular surgeons may also be involved in these cases because of the large number of cases with associated arterial involvement. A significant percentage of cases were plaintiff verdicts or settled cases. Failure to diagnosis or delay in treatment was the most common causes of malpractice litigation. Compartment syndrome is a clinical diagnosis and requires a high level of suspicion for a timely diagnosis. Lack of objective criteria for diagnosis increases the chances of medical errors and makes it an area vulnerable to litigation.

Clinical application of the concept of enhanced recovery after surgery in perioperative nursing of patients with total hip replacement

Objective To explore the clinical effect of the concept of enhanced recovery after surgery (ERAS) in the perioperative nursing of patients with total hip replacement. Methods A total of 93 patients with hip osteoarthritis admitted from June 2017 to June 2018 were divided into routine nursing group and ERAS nursing group according to the random number table method. Patients in both groups were treated with unilateral total hip arthroplasty. Routine nursing group was treated with routine perioperative nursing, and ERAS nursing group was treated with ERAS concept. The ERAS nursing team was established, including a head nurse and an orthopedic physician, in addition to the regular nursing staff. The treatment, perioperative pain and nursing satisfaction of the two groups were compared. Results The first time of getting out of bed activity [(1.95 ± 0.45) days vs. (5.52 ± 2.52) days], the first time of defecation after operation [(1.34 ± 0.56) days vs. (2.15 ± 0.84) days], the time of hospitalization [(5.73 ± 1.65) days vs. (10.04 ± 2.14) days] in ERAS nursing group were shorter than those in routine nursing group, and the cost of hospitalization [(49 450.50 ± 880.52) yuan vs. (53 053.50 ± 780.50) yuan] was lower than that in routine nursing group, the differences were statistically significant (t=6.639-31.622, P < 0.05). The NRS scores of 24 hours [(3.35 ± 0.85) vs. (4.32 ± 1.05)], 48 hours [(2.65 ± 0.52) vs. (3.48 ± 0.54)] after operation and discharge [(1.74 ± 0.65) vs. (2.36 ± 0.53)] in the ERAS nursing group were lower than those of the routine nursing group, the differences were statistically significant (t=4.526, 4.856 and 4.456, P < 0.05). The nursing satisfaction rate of ERAS nursing group (95.7%, 45/47) was higher than that of routine nursing group (76.60%, 36/47), the difference was statistically significant (P<0.05). Conclusion The idea of ERAS has a good clinical effect in perioperative nursing of patients with total hip replacement. Key words: Enhanced recovery after surgery; Hip osteoarthritis; Hip replacement; Perioperative nursing

Comparing Relative Contrast in Three-dimensional Double-echo Steady State With Routine Sequences for a Better Diagnosis of Knee Cartilage Anomalies

Aims This study compared relative contrast values in three-dimensional Double Echo Steady State (DESS) sequences with two flip angles of 40 and 90 degrees and other routine sequences. The obtained data could help to prove the effects of this sequence, compared to the other routine sequences; accordingly, it could be applied for better detection of lesions resulting from cartilage abnormalities. Methods &amp; Materials Total, 15 patients, including 9 men (14-56 y) and 6 women (36-65 y) with knee pain symptoms were referred to us by an orthopedic physician. All of the investigated patients underwent Magnetic Resonance Imaging (MRI) using DESS sequences with two flip angles of 40 and 90 degrees, as well as STIR , PD, T2, and 3D FLASH. We analyzed the acquired images using the Radiant DICOM Viewer4.6.9 software. We calculated relative contrast values for the selected SAGITAL images per sequence for each patient. The obtained data were analyzed using SPSS. Findings Friedman and Wilcoxon statistical tests data revealed significant P values (&lt;0.05) for all the sequences examined in this study. The DESS sequence with a flip angle of 90° presented the most relative contrast value with the average score of 77.2667. The FLASH sequence provided the worst result of 3.733 for the relative contrast value. Conclusion The DESS sequence with 90° flip angle indicated the best relative contrast values and provided the best possible signal from the synovial fluid and the cartilage; therefore, it leads to the better examination of articular cartilage in terms of lesion. Accordingly, the DESS sequence with a flip angle of 90° was the optimal sequence to evaluate cartilage abnormalities among the examined sequences in this study.

Global Forum: Orthopaedic Physicians in the Winter and Summer Olympic Games.

In training for and performing in the sporting competitions of the Olympic Games, athletes endure a variety of injuries that can lead to the development of a chronic musculoskeletal condition. Injury surveillance studies are in place for each event to collect epidemiological data in an attempt to enhance injury prevention for future Winter and Summer Olympic Games. Periodic health evaluations also are used to screen for injuries and monitor athletes' health in order to take measures to reduce the risk of reinjury. Orthopaedic physicians work to improve sport-specific injury prevention protocols to create a safe environment for competition and ultimately reduce the occurrence of injuries throughout the Olympic Games.

An Unorthodox Skin Traction Technique for the Initial Management of Distal Femur Fractures in a High-volume Trauma Centre: A Technical Review.

Distal femur fractures account for 3% of femur fractures and require definitive fixation to allow for weight-bearing and return of functional capability. However, if these fractures must wait a period of time to be taken to theatre, skin traction is routinely applied in the pre-operative period to maximise pain management, prevent deformity and protect neurovascular status. Pre-made traction kits are usually widely available in emergency departments worldwide, allowing for the rapid application and stabilisation of the limb once analgesia in the form of a femoral block has been delivered. Unfortunately, as in many aspects of healthcare, demand can sometimes outweigh supply. In high-volume-trauma centres or mass-casualty incidents, the pre-made kits designed for skin traction such as Sterotrac (Steroplast Healthcare, Manchester, UK) or Tensoplast (BSN medical GmbH, Hamburg, Germany) kits can be rapidly depleted, leaving emergency and orthopaedic physicians with no means of providing the traction required. Hence, we propose and describe a modified technique that provides a simple and inexpensive way to achieve and maintain skin traction using readily available hospital supplies, which can provide adequate support in a safe manner until definitive surgical fixation. This method not only provides sufficient traction but protects the bony pressure areas around the foot and ankle, thereby reducing the risk of iatrogenic pressure sores.