Practice Of Orthopaedic Surgeons Research Articles

The thermal properties of bone and the effects of surgical intervention

Much is written about the mechanical properties of bone; we are aware of how bone responds to different modes and degrees of stress and can use this knowledge to influence the mechanical environment around bones and joints for therapeutic effect. The thermal properties of bone are less well documented, yet all orthopaedic interventions produce significant thermal effects. This paper explains basic material thermodynamics and how this relates to bone and impacts on an orthopaedic surgeon's practice. Much is written about the mechanical properties of bone; we are aware of how bone responds to different modes and degrees of stress and can use this knowledge to influence the mechanical environment around bones and joints for therapeutic effect. The thermal properties of bone are less well documented, yet all orthopaedic interventions produce significant thermal effects. This paper explains basic material thermodynamics and how this relates to bone and impacts on an orthopaedic surgeon's practice.

Long-Term Outcomes of Surgical and Nonsurgical Management of Lumbar Spinal Stenosis: 8 to 10 Year Results from the Maine Lumbar Spine Study

A prospective observational cohort study. To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically. The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments. Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years. Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients (including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved(53% vs. 50%, P = 0.8), their predominant symptom (either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment. Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.

Intoeing: a developmental norm.

Intoeing, often referred to as pigeon-toes, is a frequent reason for referral to the pediatric orthopaedic surgeon's practice. Parents and grandparents are concerned about the appearance of the legs and a history of frequent tripping and falling. Many of the "abnormalities" that these children present with are variations of normal development of the lower extremities and include flat footedness, and torsional or angular "deformity." The approach of the specialist team is to identify the source of the intoeing, to rule out neuromuscular dysfunction or other serious conditions, and to counsel the family on anticipatory guidance of the natural history of intoeing. The focus of this article is intoeing, associated examination techniques, and nursing considerations of education and treatment. An understanding of musculoskeletal developmental norms, the clinical examination for intoeing, and the current recommendations for treatment will enable the provider to educate and accurately inform families.

An international comparative study of total hip arthroplasty cost and practice patterns

The cost of total hip arthroplasty (THA) was assessed on a worldwide basis, with specific information obtained regarding implant type, cost, manufacturer, fixation method, as well as other clinical related practices. One hundred and ten orthopaedic surgeons representing 30 countries and 6 continents responded to the questionnaire. The average number of THAs per year per surgeon was 75 (range, 2–300). Surgeons reported using all cemented components in 35% of THAs at an average cost of $1,536 (U.S. dollars). Uncemented components were used in 31% at an average cost of $2,674, and hybrid reconstructions in 34% at an average cost of $2,114. Almost half (44%) of the respondents stated that the hospital negotiated the type and price of the implants. Most surgeons (80%) indicated they were under pressure to decrease the cost of THA and 68% were under pressure to reduce the length of patients' hospital stay. When asked for recommended ways to reduce costs, 30% stated that negotiating a reduced implant price from the supplier was the most important measure. On a worldwide basis, there is tremendous variation in the cost and availability of implants. The reported cost for identical implants from a single manufacturer can vary as much as 700%. The comments of those responding are similar to the findings of surgeons here in the United States regarding cost containment and the role of reducing the length of hospital stay as well as negotiating reduced prosthesis and supply costs. The orthopaedic surgeon's practice pattern is a major determinant of total costs.

Infection after joint replacement

Twenty years ago infection relating to a prosthesis was always treated by its removal leading to loss of function. Today revision surgery has a high success rate. In every orthopaedic surgeon's practice there will always be some patients who have not achieved the expected result from joint replacement because of infection. The aim of joint replacement is to restore function and improve quality of life, and this aim must not be lost when consideration is given to the treatment of infection, chronic osteomyelitis, about a joint prosthesis. The purpose of this article is to provide a consensus view of what are the currently recommended ways of treating such infections, as no single orthopaedic surgeon, or group of surgeons, has sufficient experience to address the multitude of clinical and financial questions about the treatment of infected joint prostheses. For this reason there is controversy about the most appropriate treatment. There is probably enough information now available to dispel that controversy and describe a rational method of treatment.

Stark II and Its Effect on Orthopaedic Practice

The Omnibus Budget Reconciliation Act (OBRA) of 1989, "Stark I," and OBRA 1993, "Stark II," contain provisions introduced by Rep. Fortney "Pete" Stark of California that limit certain referral and compensation arrangements for physicians. Since some of these restrictions affect the practice of orthopaedic surgeons and the nurses employed in these practice settings, this article provides general information related to the Stark self-referral legislation.

Orthopaedic operations in the United States, 1979 through 1983.

Data from the National Center for Health Statistics were used to analyze the number of orthopaedic operations that were performed in the United States in 1979, 1981, and 1983. During the study period there was an increase of 24 per cent in the total number of orthopaedic procedures. During the same five-year period, the number of orthopaedic surgeons increased 28 per cent. Orthopaedic surgeons performed 3,549,000 operations in 1983, the most common orthopaedic procedure being open reduction and internal fixation of a fracture (331,000). This was also the eleventh most common operation performed in this country in 1983. The number of arthroscopic procedures (260,000) increased 100 per cent during the period of study, and this procedure was the sixteenth most common operation performed in the United States. In 1983, orthopaedic operations comprised 19 per cent of the surgery performed in this country. These figures illustrate the dynamics of the operative practice of orthopaedic surgeons in the United States. The figures show that the number of orthopaedic operations has markedly increased over the five-year period, but this increase is not as great as the increase in the number of orthopaedic surgeons. Future individual operative workloads of orthopaedists will decrease if these trends continue.

Low-back impairment-rating practices of orthopaedic surgeons and neurosurgeons in West Virginia.

The inquiry on low-back impairment rating practices among physicians who treat or evaluate workers' compensation claimants replicates an earlier inquiry appearing in Spine by Brand and Lehmann (1983). Findings are essentially similar. Physicians consider factors other than those of physical impairment in assigning ratings, and ratings in two states are similar rather than different. The conclusion of the earlier inquiry and premise of this inquiry is that lacking widely accepted criteria for rating low-back impairment, physicians rate the disability of an individual as they perceive it. Based on findings from both inquiries, variance among ratings increases as ratings become higher. A second conclusion is that duration of time-loss disability from work before a permanent rating is made can be detrimental regarding return to work.

Low-back impairment rating practices of orthopaedic surgeons.

Physicians' impairment ratings are an integral part of disability determinations. There are major difficulties in rating impairments manifested principally by pain (such as low-back pain), primarily owing to the relative absence of objective findings. Since there are no universally accepted criteria for rating low-back impairment, the authors have attempted to establish a notion of the impairment rating practices of orthopaedists through a survey. It is clear that many criteria apart from the physical examination are considered in rating low-back impairment, in spite of the fact that in most compensation or legal systems such ratings are supposed to consider only objective physical findings. Ratings are ordinarily not given until an average of 8.9 months after an injury and 9.7 months after surgery. Many orthopaedists probably give ratings in the absence of objective physical findings. Rating practices vary widely from physician to physician.