Evidence suggests that the alleviation of pain is enhancedby a strong patient-clinician relationship and attending to a patient’s social and mental health. There is a limited role for medication, opioids in particular. Orthopaedic surgeons can use comprehensive biopsychosocial strategies to help people recover and can work with colleagues who have the appropriate expertise in order to maximize pain alleviation with optimal opioid stewardship. Preparing patients for elective surgery and caring for them after unplanned injury or surgery can benefit from planned and practiced strategies based in communication science. Cite this article:
The United States and Canada are in the midst
of an epidemic of the use, misuse and overdose of opioids, and deaths
related to overdose. This is the direct result of overstatement
of the benefits and understatement of the risks of using opioids
by advocates and pharmaceutical companies. Massive amounts of prescription
opioids entered the community and were often diverted and misused.
Most other parts of the world achieve comparable pain relief using
fewer opioids. The misconceptions about opioids that created this epidemic are
finding their way around the world. There is particular evidence
of the increased prescription of strong opioids in Europe. Opioids are addictive and dangerous. Evidence is mounting that
the best pain relief is obtained through resilience. Opioids are
often prescribed when treatments to increase resilience would be
more effective. Cite this article:
As residency training programmes around the globe
move towards competency-based medical education (CBME), there is
a need to review current teaching and assessment practices as they
relate to education in orthopaedic trauma. Assessment is the cornerstone
of CBME, as it not only helps to determine when a trainee is fit
to practice independently, but it also provides feedback on performance
and guides the development of competence. Although a standardised
core knowledge base for trauma care has been developed by the leading
national accreditation bodies and international agencies that teach
and perform research in orthopaedic trauma, educators have not yet established
optimal methods for assessing trainees’ performance in managing
orthopaedic trauma patients. This review describes the existing knowledge from the literature
on assessment in orthopaedic trauma and highlights initiatives that
have recently been undertaken towards CBME in the United Kingdom,
Canada and the United States. In order to support a CBME approach, programmes need to improve
the frequency and quality of assessments and improve on current
formative and summative feedback techniques in order to enhance
resident education in orthopaedic trauma. Cite this article:
Intravenous tranexamic acid (TXA) has been shown
to be effective in reducing blood loss and the need for transfusion
after joint replacement. Recently, there has been interest in applying
it topically before the closure of surgical wounds. This has the
advantages of ease of application, maximum concentration at the
site of bleeding, minimising its systemic absorption and, consequently,
concerns about possible side-effects. We conducted a systematic review and meta-analysis which included
14 randomised controlled trials (11 in knee replacement, two in
hip replacement and one in both) which investigated the effect of
topical TXA on blood loss and rates of transfusion. Topical TXA
significantly reduced the rate of blood transfusion (total knee
replacement: risk ratio (RR) 4.51; 95% confidence interval (CI):
3.02 to 6.72; p <
0.001 (nine trials, I2 = 0%); total
hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)).
The rate of thromboembolic events with topical TXA were similar
to those found with a placebo. Indirect comparison of placebo-controlled
trials of topical and intravenous TXA indicates that topical administration
is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of
reducing the need for blood transfusion after total knee and hip
replacement. Further research is required to find its optimum dose
for topical use. Cite this article:
