Venous thromboembolism prophylaxis after total hip or knee arthroplasty: a survey of Canadian orthopedic surgeons.
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OBJECTIVE: To determine the pharmacologic and physical modalities used by orthopedic surgeons in Canada to prevent venous thromboembolism (deep venous thrombosis and pulmonary embolism) after total hip or knee arthroplasty. DESIGN: Mail survey sent to all members of the Canadian Orthopaedic Association. SETTING: A nation-wide study. METHODS: A total of 828 questionnaires, designed to identify the type and frequency of prophylaxis against venous thromboembolism that were used after hip and knee arthroplasty were mailed to orthopedic surgeons. OUTCOME MEASURES: Demographic data and the frequency and type of thromboprophylaxis. RESULTS: Of the 828 surveys mailed 445 (54%) were returned, and 397 were included in this analysis. Of the respondents, 97% used prophylaxis routinely for patients who undergo total hip or knee arthroplasty. Three of the 397 (0.8%) did not use any method ofprophylaxis. Warfarin was the most common agent used (46%), followed by low-molecular-weight heparin (LMWH) (36%). Combination therapy with both mechanical and pharmacologic methods were used in 39% of patients. Objective screening tests were not frequently performed before discharge. Extended prophylaxis beyond the duration of hospitalization was used by 36% of physicians. CONCLUSION: Prophylaxis for venous thromboembolism with warfarin or LMWH has become standard care after total hip or knee arthroplasty in Canada. (+info)
A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments.
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OBJECTIVE: To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments. DESIGN: Randomised controlled trial. SETTING: Orthopaedic outpatient departments in two hospitals. SUBJECTS: 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion. INTERVENTIONS: Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists). MAIN OUTCOME MEASURES: Patient centred measures of pain, functional disability and perceived handicap. RESULTS: A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238). CONCLUSIONS: On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs. (+info)
How long should patients be followed-up after total hip replacement? Current practice in the UK.
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Some 1000 postcard questionnaires were sent to Fellows of the British Orthopaedic Association (BOA) to establish current follow-up practice of primary total hip replacement (THR) patients. For cemented THRs, 50% of surgeons saw their patients for under 1 year, 78% under 5 years with indefinite follow-up being performed by 14%. There was significantly more follow-up of uncemented and hybrid prostheses with the proportions being 25%, 56% and 30% respectively (chi 2, P < 0.0001). This study has revealed a wide variation in practice between individual surgeons and has shown over one-third of surgeons feel they are prevented from performing as much follow-up as they would wish by the availability of clinic resources. Higher follow-up rates of uncemented components may reflect a lack of confidence in their long-term performance. (+info)
Health economics and orthopaedics.
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It is becoming widely accepted that research which considers only the outcome and not the costs associated with new technologies in health care, is of limited value in making decisions about the use of scarce resources. Economic evaluation is becoming a standard feature of clinical research but many published economic evaluations fall short of best practice in their methodology. We have described the essential features of economic evaluation, using published studies in orthopaedics, in order to try to improve the ability of orthopaedic surgeons to read, understand and appraise such studies critically, and to encourage them to consider including economic evaluation in future investigations. (+info)
The medial approach for operative release of post-traumatic contracture of the elbow.
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We treated post-traumatic contracture of the elbow in 13 consecutive patients (14 elbows) by operative release. Through a single medial approach, the posterior oblique bundle of the medial collateral ligament was resected, followed by posterior and anterior capsulectomies. An additional lateral release through a separate incision was required in only four elbows. The results were assessed at a mean interval of 57 months after operation. Before surgery active extension lacked 43 degrees which improved to 17 degrees after operation. Active flexion before operation was 89 degrees, which improved to 127 degrees. The mean arc of movement increased from 46 degrees to 110 degrees. All 14 elbows showed scarring of the posterior oblique bundle of the medial collateral ligament. Neither the interval from injury to operative release nor the age of the patient affected the results. A medial approach is useful to reveal and excise the pathological changes in the medial collateral ligament. It is a safe and effective route through which to correct post-traumatic contracture of the elbow. (+info)
Current attitudes to total hip replacement in the younger patient: results of a national survey.
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A postal questionnaire was sent to all practicing consultant orthopaedic surgeons in the UK seeking information regarding their usual total hip replacement practice, the age at which they would define a patient as falling into the 'young hip group' and whether this might modify their practice. In particular, in the 'younger' age group, we were interested in the frequency of usage of uncemented implants, the choice of implant and the bearing surfaces. Of 1242 surgeons surveyed, we had a response from 935 who currently undertake total hip arthroplasty. Their responses confirm that approximately 60,645 total hip replacements are performed annually in the UK of which 9,376 are performed in the younger age group (mean age 57.5 years). As with our previous survey, the most popular prosthesis in the 'older' age group overall was the Charnley (51%) followed by the Exeter (15%). These implants also proved to be the most popular in the 'younger' age group (40% Charnley, 18% Exeter), with 75% of surgeons choosing a cemented stem, and 65% also opting to cement the socket. 23% of surgeons used hydroxy-apatite coated implants on both the femoral and acetabular sides of the joint. Stainless steel remained the most popular choice of femoral head bearing surface (42%) followed by chrome-cobalt (33%) and ceramic (25%). On the acetabular side, high density polyethylene predominated--accounting for 95%, with only 3% using chrome cobalt and 2% ceramic. There would appear to be a remarkably conservative attitude among British surgeons, the majority of whom prefer to stick with tried and tested cemented femoral implants when dealing with the younger patient. There are a small number of uncemented acetabulae and the hybrid configuration. Hydroxy-apatite coatings seem to be the most popular choice for the non-cemented prostheses. Ceramic femoral heads are used more frequently than the ceramic acetabular bearing, and equally metal/metal bearings remain infrequently used. (+info)
Watson Jones Lecture. The organisation of trauma services in the UK.
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To provide a high level of orthopaedic trauma care, education and research, across the country, trauma services in the UK require modification. Good information is necessary prior to formulating ideas and proposals. Trauma care provision must be considered comprehensively at both the national and local levels. As a first step, it is important to know just how many acute hospitals there are in the country. It is also important to know about the distribution of surgical specialities and the number of consultant orthopaedic surgeons staffing those hospitals. (+info)
Influence of clinical information on the detection of wrist fractures in children.
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The purpose of this investigation is to assess the importance of clinical information for the detection of non-displaced wrist fractures in children. Twenty non-displaced fractures of the distal radius in children younger than 15 years of age and twenty age-matched controls were evaluated by five blinded observers before and after giving clinical data, and a receiver operating characteristic (ROC) analysis using a continuous rating scale with a line-marking method was performed. The detection of the fractures was significantly improved with clinical information, and the main reason for this was an increase in true positive fraction. Availability of adequate clinical data should be emphasized for interpreting radiography. (+info)