The electronic medical office: optimizing solutions.

Optimizing the care for patients in the orthopaedic clinical setting involves a wide range of issues. Surgical techniques, preoperative and postoperative care, long-term outcomes follow-up, continuing education, and patient communication are a few of the important areas that surgeons deal with on a regular basis. Successful management of this information has an impact on clinical outcomes, direct patient care, financial decisions, and management of the surgeon's time. The development of a comprehensive electronic medical office is a powerful and probably necessary tool to successfully manage such information and achieve the goals of an effective and safe orthopaedic practice.

Repair of obstetric vesicovaginal fistulas in Africa.

OBJECTIVE: The purpose of this study was to show the outcomes of primary surgical repair of obstetric vesicovaginal fistula repairs in Niger, Africa. STUDY DESIGN: From October 2003 to April 2005, 90 patients were examined with vesicovaginal fistulas and no previous repair. Fistulas were variable in location and degree of scarring and ranged up to 7 cm in size. All patients were offered surgical repair. Primary repair was performed in 73 women. RESULTS: Successful primary closure was achieved in 41 patients (56%); 19 patients were lost to follow up, and 13 patients had a persistent fistula. Incontinence, despite fistula closure, was present in 9 patients. Common features of failure and/or incontinence included larger size, involvement of the urethrovesical junction, and scarring. CONCLUSION: The initial repair of vesicovaginal fistulas has the highest probability of success. The successful closure is dependent on size, site, and associated scarring.

Traumatic absence of the proximal urethra.

OBJECTIVE: Traumatic absence of the proximal urethra is an obstetrical vesicovaginal fistula resulting from obstructed labors in Niger, Africa. Repair by direct reanastomosis was evaluated. STUDY DESIGN: A prospective case series of 25 women with traumatic absence of the proximal urethra underwent a direct layered reanastomosis of the distal urethra to the urethrovesical junction. Results are based on 21 patients (84%) examined at follow-up. RESULTS: Seventeen patients (81%) had complete healing of their fistulas. After direct reanastomosis alone, 48% (10 of 21) were dry. An additional 7 patients (33%) suffered from urinary incontinence despite closure of their fistulas. Four patients (19%) had a persistent fistula. CONCLUSION: Direct layered reanastomosis is an acceptable primary repair procedure for traumatic absence of the proximal urethras.

Surgical management of complex obstetric fistula in Eritrea.

OBJECTIVES: To evaluate the incidence of and demographic characteristics associated with obstetric fistula in Eritrea. To determine the outcomes of surgical repair of complex fistula in Eritrea by a visiting surgical team. METHODS: A surgical team comprising expert gynecologic surgeons traveled to Eritrea in September 2004. We evaluated 50 patients with genitourinary fistula and performed surgical repairs of these fistulas on 37 women via both vaginal and abdominal approaches. Demographic and basic medical data were obtained at the time of evaluation, and follow-up questionnaires were completed at 4 weeks postoperative. RESULTS: The majority of the women had fistulas related to obstructed labor at their first pregnancy unattended by any healthcare professional. The average duration of labor was 3 days, and more than half had resulted in stillbirths. The rate of successful repair in women with primary vesicovaginal fistulas (VVF) was 63%, and that in women with recurrent vesicovaginal fistulas was 61%. Two women required urinary diversion procedures because of the severity of the damage to the genital tract. Urethral reconstruction in women with urethrovaginal fistulas (UVFs) was successfully accomplished in 77% of patients. The rate of successful repair of rectovaginal fistulas (RVFs) was 87%. CONCLUSIONS: We have demonstrated that a team of specialized surgeons can successfully accomplish surgical procedures and repairs of very complex urinary tract fistulas in a very short mission to a resource-poor nation.

Internet-based learning.

The Internet, with established and newly appearing websites, is becoming a more integral part of orthopaedic education every day. We review some of the well-known resources on the Internet (Orthogate, OrthoNet, American Academy of Orthopaedic Surgeons site, Orthopedic Hyperguide, WorldOrtho, Wheeless's Textbook of Orthopaedics, Orthoteers, AO North America site, University of Iowa Virtual Hospital texts, and South Australian Orthopaedic Registrars' Notebook) and reports the results of a survey of 35 orthopaedic surgery residents and 24 attending orthopaedic surgeons on the use of orthopaedic knowledge resources on the World Wide Web. The top three most commonly used online sites by the residents were Wheeless's Textbook of Orthopaedics, the American Academy of Orthopaedics Surgeons website, and Orthopedics Hyperguide. According to the survey, all 35 residents used online resources for learning, giving preference to online textbooks when looking for clinical information and online practice examinations when preparing for the in-training (OITE) or board examinations. Among the attending physicians, 19 (79%) used the Internet. Their most commonly used online sites were the American Academy of Orthopaedics Surgeons website, AO North America site, and Wheeless's Textbook of Orthopaedics. The attending physicians also preferred online textbooks to other online resources. Also provided in this article is a discussion of our idea for a future comprehensive, accurate, and constantly updated orthopaedic online resource that uses already available technology.