Low agreement among 24 doctors using the Neer-classification; only moderate agreement on displacement, even between specialists.
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Twenty-four orthopaedic surgeons classified 42 pairs of radiographs according to the Neer system for proximal humeral fractures. Mean kappa value for inter-observer agreement was 0.27 (95% CI 0.26-0.28) with no clinically significant difference between orthopaedic residents ( n=9), fellows ( n=6) and specialists ( n=9). Mean kappa for agreement of displacement versus non-displacement was 0.41 (95% CI 0.39-0.43) overall, and 0.50 (95% CI 0.45-0.56) within the specialist group. The agreement found in our study is unsatisfactory from a clinical perspective. (+info)
Quality improvement for patients with hip fracture: experience from a multi-site audit.
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PROBLEM: The first East Anglian audit of hip fracture was conducted in eight hospitals during 1992. There were significant differences between hospitals in 90-day mortality, development of pressure sores, median lengths of hospital stay, and in most other process measures. Only about half the survivors recovered their pre-fracture physical function. A marked decrease in physical function (for 31%) was associated with postoperative complications. DESIGN: A re-audit was conducted in 1997 as part of a process of continuing quality improvement. This was an interview and record based prospective audit of process and outcome of care with 3 month follow up. Seven hospitals with trauma orthopaedic departments took part in both audits. Results from the 1992 audit and indicator standards for re-audit were circulated to all orthopaedic consultants, care of the elderly consultants, and lead audit facilitators at each hospital. KEY MEASURES FOR IMPROVEMENT: Processes likely to reduce postoperative complications and improve patient outcomes at 90 days. STRATEGY FOR CHANGE: As this was a multi-site audit, the project group had no direct power to bring about changes within individual NHS hospital trusts. RESULTS: Significant increases were seen in pharmaceutical thromboembolic prophylaxis (from 45% to 81%) and early mobilisation (from 56% to 70%) between 1992 and 1997. There were reduced levels of pneumonia, wound infection, pressure sores, and fatal pulmonary embolism, but no change was recorded in 3 month functional outcomes or mortality. LESSONS LEARNT: While some hospitals had made improvements in care by 1997, others were failing to maintain their level of good practice. This highlights the need for continuous quality improvement by repeating the audit cycle in order to reach and then improve standards. Rehabilitation and long term support to improve functional outcomes are key areas for future audit and research. (+info)
Severe necrotising soft tissue infections in orthopaedic surgery.
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PURPOSE: To review all cases of necrotising infection managed in the Department of Orthopaedic Surgery of Dunedin Hospital in New Zealand between 1989 and 1998. METHODS: Hospital records were analysed for predisposing factors, clinical features, diagnostic results, treatment strategies, and outcomes. RESULTS: 13 cases (9 males and 4 females) of necrotising infection were identified. The mean age was 48 years (range, 8-76 years). Presenting symptoms included painful swelling, erythema, and necrosis. Most patients had predisposing factors and had received nonsteroidal anti-inflammatory drugs before presentation. 12 patients underwent surgical debridement including a total of 4 amputations. Septic shock developed in 9 patients who required dialysis for renal failure. Four patients died. The most common organisms identified were group A beta-haemolytic streptococci. CONCLUSION: Severe necrotising infections require a high index of suspicion and rapid medical and surgical intervention to reduce the mortality and morbidity. (+info)
Research output of a cohort of orthopaedic consultants in Great Britain.
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There has been renewed emphasis on research following the Calman recommendations for higher training. It is often considered essential for progression in training to have participated in research projects and to have some publications to one's credit. Orthopaedic surgery is usually thought to lag behind other disciplines in this respect. It was decided to conduct a review of the research output of a cohort of orthopaedic consultants in Great Britain to obtain baseline information for future comparisons. A group of surgeons who graduated at least 25 years ago was chosen as it was felt this would provide the pattern of research output throughout the surgical career of the cohort. The type of publication and the various factors that may affect research output were studied. There was a significant difference in the output of consultants working in teaching hospitals and large centres compared to those in district general hospitals. Is the soil as important as the seed? (+info)
Involving users in the implementation of an imaging order entry system.
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Physician order entry is a powerful function of a computerized hospital information system. Although designed to be clinician-driven, the imaging section of the order entry system may not be designed optimally to engage the clinician with imaging procedures logically organized for the clinician's typical work patterns. There also may be resistance among overburdened clinicians in having to take the time to learn a new computer system and to assume "clerk's duties" of entering imaging orders. A potential means to address clinician opposition is to cooperatively engage each clinical service in the design of an imaging order entry system with customized menus for each service. This article reports a step-by-step process for the implementation of an imaging order entry system with specialized menus for an orthopedic service. This implementation process includes (1) identification of key personnel, (2) familiarization with the system, (3) discussion and dialogue between key personnel, (4) addressing specific problems, (5) education and orientation of the target group, (6) initial implementation, (7) feedback and improvement, (8) demonstration project (time study) to foster acceptance, and (9) ongoing enhancement. (+info)
Low molecular weight heparin in prevention of perioperative thrombosis.
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OBJECTIVE: To determine whether prophylactic treatment with low molecular weight heparin reduces the incidence of thrombosis in patients who have had general or orthopaedic surgery. DESIGN: Meta-analysis of results from 52 randomised, controlled clinical studies (29 in general surgery and 23 in orthopaedic surgery) in which low molecular weight heparin was compared with placebo, dextran, or unfractionated heparin. SUBJECTS: Patients who had had general or orthopaedic surgery. INTERVENTION: Once daily injection of a low molecular weight heparin compared with placebo, dextran, or unfractionated heparin. MAIN OUTCOME MEASURES: Incidence of deep venous thrombosis, pulmonary embolism, major haemorrhages, and death. RESULTS: The results confirm that low molecular weight heparins are more efficacious for the prophylactic treatment of deep venous thrombosis than placebo (common odds ratio 0.31, 95% confidence interval 0.22 to 0.43; p < 0.001) and dextran (0.44, 0.30 to 0.65; p < 0.001). The results suggest that low molecular weight heparins are also more efficacious than unfractionated heparin (0.85, 0.74 to 0.97; p = 0.02), with no significant difference in the incidence of major haemorrhages (1.06, 0.93 to 1.20; p = 0.62). CONCLUSIONS: Low molecular weight heparins seem to have a higher benefit to risk ratio than unfractionated heparin in preventing perioperative thrombosis. However, it remains to be shown in a suitably powered clinical trial whether low molecular weight heparin reduces the risk of fatal pulmonary embolism compared with heparin. (+info)
What questions do patients undergoing lower extremity joint replacement surgery have?
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BACKGROUND: The value of the Internet to deliver preoperative education would increase if there was variability in questions patients want answered. This study's goal was to have patients consulting an orthopedic surgeon about undergoing either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA) rate the importance of different questions concerning their care. METHODS: We assembled questions patients might have about joint replacement surgery by analyzing the literature and querying a pilot group of patients and surgeons. Twenty-nine patients considering undergoing THA and 19 patients considering TKR completed a written survey asking them to rate 30 different questions, with a 5 point Likert scale from 1 (least important)--5 (most important). RESULTS: For patients considering THA or TKR, the 4 highest rated questions were: Will the surgery affect my abilities to care for myself?, Am I going to need physical therapy?, How mobile will I be after my surgery?, When will I be able to walk normally again? The mean percentage disagreement was 42% for questions answered by TKR patients and 47% for the THA group. Some patients gave a high rating to questions lowly rated by the rest of the group. CONCLUSIONS: Although there was enough agreement to define a core set of questions that should be addressed with most patients considering THA or TKA, some of the remaining questions were also highly important to some patients. The Web may offer a flexible medium for accommodating this large variety of information needs. (+info)
An analysis of orthopaedic residency selection criteria.
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The lack of literature on residency selection criteria used by orthopaedic program directors has left medical students in the position of relying on rumor and anecdotal information as to what program directors value most highly when sorting through large candidate pools. The purpose of this study was to compare the perspectives on resident selection criteria solicited from orthopaedic program directors and residency applicants. A power analysis was done to determine adequate sample size. A 26-item questionnaire was mailed to 98 residency applicants who interviewed at our program and 156 orthopaedic program directors. The program directors were also asked to elaborate on those factors that were most important in their selection process. A two-tailed Student's t-test was employed to compare the two groups. Significance was set at p < 0.05. Statistically significant differences between applicant and program director ratings were found in 12 of the 26 questionnaire items. Applicants (n = 91) ranked the following criteria as most important: a letter of recommendation from an orthopaedic surgeon (8.6 on a scale of 1 to 10, 10 being most important), USMLE I score (7.7), and rank in medical school (7.6). The most important criteria for the directors (n = 109) were: the applicant performed a rotation at the director's program (7.9), USMLE I score (7.8), and rank in medical school (7.8). This study provides the most comprehensive empirical data to date as to the factors which orthopaedic program directors consider most important during the residency selection process. To our knowledge, this is the first study in the orthopaedic literature that compares the program directors 'and residency applicants' views on resident selection criteria. Significant differences were found between applicant and program director views on resident selection criteria. (+info)