The Official Journal of - ข่าวประชาสัมพันธ์ราชวิทยาลัยแพทย์ออร์โธปิดิกส์ [PDF]

The Official Journal of the Royal Cotlege of Orthopaedic Surgeons of Thailand

The Thai Journal Of Orthopaedic Surgery

The Official Journal of the Royal College of Orthopaedic Surgeons of Thailand

The Official Journal of Thai Hip & Knee Society The Official Journal of Spine Society of Thailand The Official Journal of Thai Orthopaedic Society for Sports Medicine The Official Journal of Thai Musculoskeletal Tumor Society The Official Journal of Thailand Orthopaedic Trauma The Official Journal of Thai Society for Hand Surgery of RCOST The Official Journal of Pediatric Orthopaedic Society The Official Journal of Thailand Orthopaedic Foot and Ankle Society The Official Journal of Metabolic Bone Disorder and Orthogeriatrics

ISSN 0125-7552 Volume 39 / Number 1-2 January-April 2015

The Council Members of the Royal College of Orthopaedic Surgeons of Thailand (RCOST) 2014-2016 President Immediate Past President President Elect 1st Vice-President 2nd Vice-President Registrar Treasurer Secretary General Assistant Secretary General Promotion Council Members

Advisory Board

Sukit Saengnipanthkul, MD Thavat Prasartritha, MD Banchong Mahaisavariya, MD Manoj Chantarasorn, MD Kanyika Chanmiprasas, MD Thana Turajane, MD Pornpavit Sriphirom, MD Charlee Sumettavanich, MD Saradej Khuangsirikul, MD Thipachart Bunyaratabandhu, MD Pornchai Mulpruek, MD Sumroeng Neti, MD Pijaya Nagavajara, MD Aree Tanavalee, MD Warat Tassanawipas, MD Wanchai Sirisereewan, MD Kitiwan Vipulakorn, MD Keerati Chareancholvanich, MD Vera Sathira-Angkura, MD Chanyut Suphachatwong, MD Theerachai Apivatthakakul, MD Thammanoon Srisa-Arn, MD Somkid Lertsinudom, MD Werayudth Chaopricha, MD Samak Bukkanasen, MD Natee Rukpollamuang, MD Direk Israngkul, MD Suprija Mokkhavesa, MD Charoen Chotigavanich, MD Vinai Parkpian, MD Pongsak Vathana, MD Prasit Gonggetyai, MD Chaithavat Ngarmukos, MD Thamrongrat Keokarn, MD Suthorn Bavonratanavech, MD Wichien Laohacharoensombat, MD Saranatra Waikakul, MD Adisorn Patradul, MD

The Thai Journal of Orthopaedic Surgery Current Editorial Board (2015-2016) Advisory Board Thamrongrat Keokarn, MD Charoen Chotigavanich, MD Vinai Parkpian, MD

Pongsak Vathana, MD Suthorn Bavonratanavech, MD Thavat Prasartritha, MD

Editor Pongsak Yuktanandana, MD Associate Editors Aree Tanavalee, MD

Sittisak Honsawek, MD

Managing Editor Supawinee Pattanasoon Editorial Board Chayanin Angthong, MD Theerachai Apivatthakakul, MD Apichart Asavamongkolkul, MD Sakda Chaikitpinyo, MD Pruk Chaiyakit, MD Sukrom Cheecharern, MD Thanainit Chotanaphuti, MD Bavornrit Chuckpaiwong, MD Thossart Harnroongroj, MD Pibul Itiraviwong, MD Polasak Jeeravipoolvarn, MD Kitti Jiraratanapochai, MD Weerachai kosuwon, MD Wichien Laohacharoensombat, MD Wiroon Laupattarakasem, MD Somsak Leechavengvongs, MD Supphamard Lewsirirat, MD Worawat Limthongkul, MD Sirichai Luevitoonvechkij, MD Banchong Mahaisavariya, MD Jakravoot Maneerit, MD Kittipon Naratikun, MD Adisorn Patradul, MD

Vajara Phiphobmongkol, MD Chathchai Pookarnjanamorakot, MD Niti Prasathaporn, MD Sattaya Rojanasthien, MD Sukit Saengnipanthkul, MD Nadhaporn Saengpetch, MD Thananit Sangkomkamhang, MD Panupan Songcharoen, MD Thawee Songpatanasilp, MD, PhD Phutsapong Srisawat, MD Nattapol Tammachote, MD Boonsin Tangtrakulwanich, MD, PhD Parichart Thiabratana, MD Satit Thiengwittayaporn, MD Prakit Tienboon, MD Yingyong Torudom, MD Chairoj Uerpairojkit, MD Thanut Valleenukul, MD Saranatra Waikakul, MD Thanapong Waitayawinyu, MD Wiwat Wajanavisit, MD Kiat Witoonchart, MD Patarawan Woratanarat, MD, PhD

Editorial office address: The Royal College of Orthopaedic Surgeons of Thailand 4 th Floor, Royal Golden Jubilee Building, 2 Soi Soonvijai, New Petchburi Road, Bangkapi, Huay Khwang, Bangkok 10310 E-mail: [email protected], [email protected] Telephone: +66 2 7165436-7 The Journal is free online at http://www.rcost.or.th, http://thailand.digitaljournals.org/index.php/JRCOST

The Thai Journal of Orthopaedic Surgery

Volume 39 Number 1-2 January-April 2015

Contents Page Editorial

1

Pongsak Yuktanandana, MD

Original Articles Increasing Road Traffic Injuries in Underage Motorcyclists Urawit Piyapromdee, MD, Varinthorn Adulyanukosol, MD, Supphamard Lewsirirat, MD

3

Innovative Design of Tumor Registry Database Program for Musculoskeletal Oncology Service Chris Charoenlap, MD, Chindanai Hongsaprabhas, MD

9

Blood Utilization for Elective Orthopaedic Surgeries at Maharat Nakhon Ratchasima Hospital Jumpotpong Wong-Aek, MD, Supphamard Lewsirirat, MD, Urawit Piyapromdee, MD

17

Comparison of Percutaneous K-wire and T-plate Fixation in Treatment of Distal Radius Fractures Somboon Wutphiriya-angkul, MD

25

Review Articles Bone Marrow-derived Mesenchymal Stem Cells for the Treatment of Knee Osteoarthritis Tulyapruek Tawonsawatruk, MD, PhD, Trai Promsang, MD, Paween Tangchiphisut, MD, Pongsak Yuktanandana, MD

35

Benefits of Arthroscopic Role in Osteoarthritis of the Knee Sorawut Thamyongkit, MD, Pongsak Yuktanandana, MD

43

Instruction to Authors

49

Appendix 2nd Annual CAOS Thailand Meeting 2015: Research Meeting Abstracts Comparison Study of Computer Assisted Surgery Total Knee Arthroplasty (CAS-TKA) Between Pinless Computer Assisted Surgery (Pinless-CAS) and Articular Surface Mounted Navigation System (ASM): Radiographic Results and Early Clinical Outcome Pruk Chaiyakit, MD, Anupab Imsumran, MD

57

Comparison of 10-Year Patient Satisfaction Between Computer Assisted Navigation and Conventional Technique in Minimally Invasive Surgery Total Knee Arthroplasty Kreangsak Lekkreusuwan, MD, Saradej Khuangsirikul, MD, Thanainit Chotanaphuti, MD

58

Learning Curve in UKA Robotic Computer Assisted Surgery Methawut Thonginta, MD

59

The Accuracy of Limb Length Measurement with Navigated Total Hip Arthroplasty in Osteonecrosis of Femoral Head Patients Yingyong Suksathien, MD, Jithayut Sueajui, MD

60

Comparison of Clinical Outcomes between Parallel Joint Line to The Floor and Oblique Joint Line after Computer Assisted Total Knee Arthroplasty: Preliminary Study Pornpavit Sripirom, MD, Pawit Yuangngoen, MD, Sorawut Sirisak, MD, Chaiyaporn Siramanakul, MD, Thakrit Chompoosang, MD, Anuchit Vejjaijiva, MD

61

วารสารราชวิทยาลัยแพทย์ออร์โธปิดิกส์แห่งประเทศไทย

ปีที่ ๓๙ ฉบับที่ ๑-๒ มกราคม-เมษายน ๒๕๕๘

สารบัญ หน้า บทบรรณาธิการ พงศ์ศักดิ์ ยุกตะนันทน์, พบ นิพนธ์ต้นฉบับ ปัญหาการเพิ่มขึ้นของการบาดเจ็บจากอุบัติเหตุจราจรของเด็กก่อนวัยที่อนุญาตให้มีใบขับขี่ อุรวิศ ปิยะพรมดี, พบ, , พบ, ศุภมาส ลิว่ ศิริรตั น์, พบ การพัฒนาโปรแกรมจัดเก็บฐานข้อมูลทะเบียนโรคมะเร็งสาหรับการดูแลรักษาผู้ป่วยเนื้องอกกระดูก และระบบเนื้อเยื่อเกี่ยวพัน กฤษณ์ เจริญลาภ, พบ, ชินดนัย หงสประภาส, พบ การศึกษาความคุ้มค่าของการจองเลือดสาหรับผ่าตัดทางออร์โธปิดิกส์ที่ไม่ฉุกเฉินของ โรงพยาบาลมหาราชนครราชสีมา จุมภฏพงษ์ วงษ์เอก, พบ, ศุภมาศ ลิว่ ศิริรัตน์, พบ, อุรวิศ ปิยะพรมดี, พบ การศึกษาเปรียบเทียบระหว่าง percutaneous K-wire และ T-plate ในการรักษาผู้ป่วยที่มีกระดูกเรเดียส ส่วนปลายหัก สมบูรณ์ วุฒิพิริยะอังกูร, พบ บทความปริทรรศน์ การใช้เซลล์ต้นกาเนิดชนิดเมสเซลไคมอลจากไขกระดูกในการรักษาโรคเข่าเสื่อม ตุลยพฤกษ์ ถาวรสวัสดิ์รักษ์, พบ, ไตร พรหมแสง, พบ, ปวีณ ตั้งจิตต์พิสุทธิ์, พบ, พงศ์ศักดิ์ ยุกตะนันทน์, พบ ประโยชน์ของการผ่าตัดแบบส่องกล้องในผู้ป่วยโรคข้อเข่าเสื่อม สรวุฒิ ธรรมยงค์กิจ, พบ, พงศ์ศักดิ์ ยุกตะนันทน์, พบ คาแนะนาสาหรับผู้ส่งบทความเพื่อลงตีพิมพ์

1

3 9

17

25

35 43

49

ภาคผนวก การประชุมวิชาการ 2nd Annual CAOS Thailand Meeting 2015: Research Meeting Abstracts Comparison Study of Computer Assisted Surgery Total Knee Arthroplasty (CAS-TKA) Between Pinless Computer Assisted Surgery (Pinless-CAS) and Articular Surface Mounted Navigation System (ASM): Radiographic Results and Early Clinical Outcome

พฤกษ์ ไชยกิจ, พบ, อานุภาพ อิ่มสาราญ, พบ

57

วารสารราชวิทยาลัยแพทย์ออร์โธปิดิกส์แห่งประเทศไทย

ปีที่ ๓๙ ฉบับที่ ๑-๒ มกราคม-เมษายน ๒๕๕๘

สารบัญ Comparison of 10-Year Patient Satisfaction Between Computer Assisted Navigation and Conventional Technique in Minimally Invasive Surgery Total Knee Arthroplasty

58

เกรียงศักดิ์ เล็กเครือสุวรรณ, พบ, สารเดช เขื่องศิริกุล, พบ, ธไนนิธย์ โชตนภูติ, พบ Learning Curve in UKA Robotic Computer Assisted Surgery

59

เมธาวุธ ทองอินต๊ะ, พบ The Accuracy of Limb Length Measurement with Navigated Total Hip Arthroplasty in Osteonecrosis of Femoral Head Patients

60

ยิ่งยง สุขเสถียร, พบ, จิธายุทธ เสือจุ้ย, พบ Comparison of Clinical Outcomes between Parallel Joint Line to The Floor and Oblique Joint Line after Computer Assisted Total Knee Arthroplasty: Preliminary Study

พรภวิษญ์ ศรีภิรมย์, พบ, ปวิทย์ ยวงเงิน, พบ, สรวุฒิ ศิริศักดิ,์ พบ, ชัยพร ศิระมานะกุล, พบ, ฐกฤต ชมภูแสง, พบ, อนุชิต เวชชัยชีวะ, พบ

61

Editorial In recent years, a number of academic journals are being published in Thailand. Publications of research articles in journals and citations play essential roles in academic promotion and grant funding. Moreover, these have become key indicators of research output and quality. The main policy of the current executive board of the Royal College of Orthopaedic Surgeons (RCOST) of Thailand is to improve the quality of our journal to achieve national level of Thai Journal Citation Index (TCI) and ultimately international level of Scopus and PubMed. We plan to submit our data for approval by the Commission for Higher Education. The TCI center database includes journals published regularly for at least 3 years, with articles in Thai or English, including reviews, research articles, short reports, which are reviewed by at least 2 readers, have Thai or English abstracts and cited reference lists. Thus far, the Thailand Research Fund and the Commission for Higher Education have established criteria for classifying national and international journals. Hopefully, our journal will receive approval for national standards sooner or later. This volume of the Thai Journal of Orthopaedic Surgery contain 6 articles, 4 original articles and 2 review articles, published: 1. Increasing road traffic injuries in underage motorcyclists 2. Innovative design of tumor registry database program for musculoskeletal oncology service 3. Blood utilization for elective orthopedic surgeries at Maharat Nakhon Ratchasima Hospital 4. Comparison of percutaneous k-wire and t-plate fixation in treatment of distal radius fractures 5. Bone marrow-derived mesenchymal stem cells for treatment of knee osteoarthritis 6. Benefits of arthroscopy in osteoarthritis of the knee In the upcoming volume, which will be distributed in the 37th RCOST annual meeting during the 22nd-24th October 2015, we assure that more original articles, review articles, and case reports will be incorporated. Last but not least, we would like to express our sincere gratitude to all authors, all members of the editorial board, all peer reviewers and editorial office staffs, especially Ms. Supawinee Pattanasoon. They all work very hard to improve the quality of this journal.

Pongsak Yuktanandana, MD Aree Tanavalee, MD Sittisak Honsawek, MD

Increasing Road Traffic Injuries in Underage Motorcyclists Urawit Piyapromdee, MD, Varinthorn Adulyanukosol, MD, Supphamard Lewsirirat, MD Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand Purpose: Traffic accident is the second most common pediatric injury in Thailand. Children aged less than 15 years old are not allowed to get a motorcycle driving license. But the number of underage motorcyclists is still high. The purpose of this study is to evaluate the number of traffic injuries in underage motorcyclists and the trend of this problem. Methods: A retrospective review of traffic accident cases at Maharat Nakhon Ratchasima Hospital from October 2009 to September 2013 was performed. Motorcyclists aged less than 15 years old were included in the study. The number of patients per year, risk behaviors, the diagnosis, complications and incidence rate were collected from the traffic injury surveillance database. Results: In total, 44,335 patients were referred to Maharat Nakhon Ratchasima Hospital. There were 5,320 injured children, 1,373 (25.81%) patients were underage motorcyclists. There were 291, 318, 391 and 373 underage motorcyclists each year, respectively. Only 225 (16.54%) were wearing a helmet, 55 cases (4.04%) had consumed alcohol before the accident. The number of severe cases, such as head injuries, abdominal injuries, or fractures increased year on year, especially the fractures; the incident rate ratio of the fracture case was 10.23% per year (P=0.005). Death cases per year were 2, 4, 7 and 6, respectively. The most common cause of death was head injury. Conclusion: Traffic accidents involving an underage motorcyclist are high and increasing every year. If we can strictly control underage motorcyclists not to ride motorcycles, the accidents may decrease. Keywords: Pediatric, Road traffic accident, Motorcycle, Thailand, Injury, Underage motorcyclist The Thai Journal of Orthopaedic Surgery: 39 No.1-2: 3-7 Full text. e journal: http://www.rcost.or.th, http://thailand.digitaljournals.org/index.php/JRCOST

Introduction In Thailand, motorcycles are the most popular form of transportation because of their affordability. The number of motorcyclists is increasing every year and the number of accidents is also increasing. In 2004, traffic accidents caused 567,000 victims in Thailand. There were 24,800 deaths or 40 deaths per 100,000 populations(1). In children, traffic accidents are the second most common unintentional injury and there are over 20,000 hospital admissions each year (2). The injuries from traffic accidents cause mortality and long term disability that increase the national burden. Thailand loses over 600,000 disability-adjusted life years (DALYs) from road traffic injuries every year. The majority (88%) of DALYs lost were due to premature mortality(3). If a child’s accident results in long-term disability, a large burden will be placed on their family, and as a bigger picture, the country. Correspondence to: Piyapromdee U, Department of Orthopedic surgery, Maharat Nakhon Ratchasima hospital, Nakhon Ratchasima, 30000, Thailand E-mail: [email protected]

JRCOST VOL.39 NO.1-2 January-April 2015

Children aged less than 15 years old do not have permission to obtain a motorcycle driving license, but it is common to see these underage motorcyclists on the road. The purposes of this study are to show the number of traffic injuries among underage motorcyclists and the trend of this problem.

Patients and Methods A retrospective analysis study was conducted at the Maharat Nakhon Ratchasima Hospital, the referral trauma center in the Northeast of Thailand that covers 32 amphoes in Nakhon Ratchasima and 3 surrounding provinces; Chaiyaphum, Surin and Buriram. The traffic injury surveillance database (IS database) from October 2009 to September 2013 at Maharat Nakhon Ratchasima Hospital was reviewed. Maharat Nakhon Ratchasima Hospital established the injury surveillance system in 1995 according to the model of Epidemiology Division, Ministry of Public Health. Surveillance data include demographic data, cause of injuries and risk behaviors such as alcohol consumption, helmet use, and psychoactive drugs. The IS database was recorded by welltrained nurses at the emergency room.

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From the IS database, we collected the data of children under 15 years old who came to the emergency room as a result of traffic accidents. The passengers, pedestrians and incomplete data were excluded. The demographic data and details of injury were reviewed. Statistical analysis was performed using STATA, version 12.0 (College Station, TX). The number of underage motorcyclists per year, risk behaviors, diagnosis, complications, and mortality patients per year were summarized. The Poisson regression analysis was used to determine the incidence rate ratio of underage motorcyclist patients adjusted with Nakhon Ratchasima children population data(4). The incidence rate ratios of severe cases; extremity fractures, head injuries, intra-abdominal injuries and spine fractures, are

also reported. A P-value of less than 0.05 was considered statistically significant. This study was approved by the Institutional Review Board of Maharat Nakhon Ratchasima Hospital.

Results During the study period, 44,335 traffic accident patients were treated at Maharat Nakhon Ratchasima Hospital in which 5,320 of them were age less than 15 years old. 1,373 (25.81%) patients were classified as a rider, 3,559 (66.9%) as passenger or pedestrian and 388 (7.29%) patients were unable to be classified. The proportions of underage motorcyclists related to pediatric populations of the same geographic area are demonstrated in Table 1.

Table 1 Underage motorcyclist patients at Maharat Nakhon Ratchasima Hospital from October 2009 to September 2013.

Year

No. of traffic accident patients

No. of underage motorcyclists

Nakhon Ratchasima children population*

Rate of underage motorcyclist patients per 100,000 population

2009-10 2010-11 2011-12 2012-13

10,233 11,057 11,753 11,292

291 318 391 373

506,078 497,769 489,645 481,574

58 64 80 77

Total

44,335

1,371

* Annual epidemiology surveillance report 2013, Bureau of Epidemiology, Ministry of Public Health, Thailand (4).

A Poisson regression model showed that the prevalence of underage motorcyclists per 100,000 population being treated increased over the study period by an average of 11.53% per year

(95% CI, 0.36%-23.95%; P=0.04). The trend of road traffic injuries among underage motorcyclists and the children population is shown in Fig. 1.

Fig. 1 Trend of road traffic injuries among underage motorcyclists and the children population in Nakhon Ratchasima area

THE THAI JOURNAL OF ORTHOPAEDIC SURGERY

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Patient demographic data are shown in Table 2. The majority of the patients were from Nakhon Ratchasima. Fifty-five patients (4.04%) consumed alcohol before the accident, 1,135 patients (83.46%) did not wear a helmet, and one case used psychoactive drugs.

A number of cases with associated severe injuries are shown in Table 3. Concomitant extremity fractures increased every year over the study period with an incidence rate ratio of 10.23% per year (P=0.005). Mortality cases per year were 2, 4, 7 and 6, respectively. The most common cause of death was head injury.

Table 2 Demographic data of the underage motorcyclists at Maharat Nakhon Ratchasima Hospital. Characteristic

No. of underage motorcyclists

Boy (%) Girl (%)

978(71.23) 395(28.77)

Age (years) Mean (SD) Range

13.23(1.01) 8-14

Place of the accident Nakhon Ratchasima (%) Chaiyaphum (%) Buriram (%) Others (%)

1,336(97.31) 29(2.11) 6(0.44) 2(0.14)

Total

1,373

Table 3 Numbers of underage motorcyclist accidents associated with severe injuries by year

Extremity fractures Head injuries Intra-abdominal injuries Spine fractures Death

2009-10

2010-11

2011-12

2012-13

Total IRR*(%) P-value

141 84 10 1

151 79 11 0

189 86 9 2

182 106 17 3

663 355 47 6

10.23 8.59 17.69 79.15

0.005 0.08 0.21 0.14

2

4

7

6

19

38.42

0.12

*IRR = Incidence rate ratio from Poisson regression analysis over the study period.

Discussion Traffic accidents, the second most common cause of unintentional injury in children, are a major public health problem in Thailand. According to our results conducted at the tertiary trauma care center there were over five thousand traffic-injured children and a quarter of these patients were underage motorcyclists. Although the size of the population aged less than 15 years old has decreased, the incidences of injuries in an underage motorcyclist group have been increasing by over 11% per year. This problem is also of concern in other countries such as Australia and the USA(1,5). The severity of an associated injury is also increasing, nearly half of underage motorcyclist patients suffered from extremity fractures with an increasing average of 10.23% every year.

JRCOST VOL.39 NO.1-2 January-April 2015

Due to inconvenient public transportation in Nakhon Ratchasima, motorcycle is the best available option for most children. From this study, we found that the most motorcyclists were adolescents, approximately 15 years old which is below the legal age of 18 years old to obtain a motorcycle driving license. Physically, this age group might be able to handle a motorcycle and thus their parents or guardians allowed them to ride. On the other hand, many studies have confirmed that young age and poor riding skills contribute to motorcycle accidents(6-9). Moreover, we found that only 16.54% of patients wore a helmet and 4% of patients consumed alcohol before the accident. These factors have previously been associated with morbidity and mortality in road traffic injuries(10-15). So the government’s policy must be strictly enforced in the underage motorcyclist group and promote the use of helmets to reduce the severity of

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injuries. Furthermore, a good public transportation and school bus system must be established in order to provide affordable transportation so that children do not need to use a motorcycle before an appropriate age. This study has several limitations. First, data included only patients referred to Maharat Nakhon Ratchasima Hospital. The incidence reported could be lower due to the fact that some patients were treated at a local hospital or were cases with fatality. Second, some information in the IS database was provided by parents or witnesses at the scene, such as the details of injury, riding person, and helmet use from which information bias could have occurred. We conducted this study not only to report the information but also to reflect this issue to all related parties such as parents, the government, and organizations enforcing the law. We believe that collaborating with each other to solve the problem will help many children who will be the future of the nation.

Conclusion The number of traffic accidents involving underage motorcyclists is high and increasing every year. If we can strictly control underage motorcyclists not to ride motorcycles, the accidents may decrease.

Acknowledgements The authors would Rojtinnakorn, chief nurse department, who provided database at the Maharat Hospital.

like to thank Nitaya at the emergency traffic the injuries Nakhon Ratchasima

References 1. Bevan CA, Babl FE, Bolt P, Sharwood LN. The increasing problem of motorcycle injuries in children and adolescents. Med J Aust [Internet]. 2008 [cited 2013 Oct 26];189(1). Available from: https://www.mja.com.au/journal/2008/ 189/1/increasing-problem-motorcycle-injurieschildren-and-adolescents 2. Weraarchakul W, Weraarchakul W, Jetsrisuparb A, Thepsuthammarat K, Sutra S. Unintentional injury among Thai children and adolescents in 2010. J Med Assoc Thai 2012; 95 Suppl 7: S114-22. 3. Ditsuwan V, Veerman LJ, Barendregt JJ, Bertram M, Vos T. The national burden of road traffic injuries in Thailand. Popul Health Metr 2011; 9: 2.

4. Bureau of Epidemiology. Annual Epidemiological Surveillance Report. Thailand: Ministry of Public Health. 2013. 5. Centers for Disease Control and Prevention (CDC). Nonfatal injuries from off-road motorcycle riding among children and teens-United States, 2001-2004. MMWR Morb Mortal Wkly Rep 2006; 55: 621-4. 6. Stella J, Cooke C, Sprivulis P. Most head injury related motorcycle crash deaths are related to poor riding practices. Emerg Med (Fremantle) 2002; 14: 58-61. 7. Woratanarat P, Ingsathit A, Chatchaipan P, Suriyawongpaisal P. Safety riding program and motorcycle-related injuries in Thailand. Accid Anal Prev 2013; 58: 115-21. 8. Siman-Tov M, Jaffe DH; Israel Trauma Group, Peleg K. Bicycle injuries: a matter of mechanism and age. Accid Anal Prev 2012; 44: 135-9. 9. Sirathranont J, Kasantikul V. Mortality and injury from motorcycle collisions in Phetchaburi Province. J Med Assoc Thai 2003; 86: 97-102. 10. Siviroj P, Peltzer K, Pengpid S, Morarit S. Helmet use and associated factors among Thai motorcyclists during Songkran festival. Int J Environ Res Public Health 2012; 9: 3286-97. 11. Kasantikul V, Ouellet JV, Smith T, Sirathranont J, Panichabhongse V. The role of alcohol in Thailand motorcycle crashes. Accid Anal Prev 2005; 37: 357-66. 12. Sriussadaporn S, Sirichindakul B, Pak-Art R, Tharavej C. Pelvic fractures: experience in management of 170 cases at a university hospital in Thailand. J Med Assoc Thai 2002; 85: 200-6. 13. Pitaktong U, Manopaiboon C, Kilmarx PH, Jeeyapant S, Jenkins R, Tappero J, et al. Motorcycle helmet use and related risk behaviors among adolescents and young adults in Northern Thailand. Southeast Asian J Trop Med Public Health 2004; 35: 232-41. 14. Pakula A, Shaker A, Martin M, Skinner R. The association between high-risk behavior and central nervous system injuries: analysis of traffic-related fatalities in a large coroner’s series. Am Surg 2013; 79: 1086-8. 15. Jung S, Xiao Q, Yoon Y. Evaluation of motorcycle safety strategies using the severity of injuries. Accid Anal Prev 2013; 59: 357-64.

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ปัญหาการเพิ่มขึ้นของการบาดเจ็บจากอุบัติเหตุจราจรของเด็กก่อนวัยที่อนุญาตให้มีใบขับขี่ อุรวิศ ปิยะพรมดี, พบ,

, พบ,

, พบ

วัตถุประสงค์: อุบัติเหตุจราจรเป็นปัญหาที่พบได้บ่อยในประเทศไทยซึ่งถูกจัดเป็นอันดับที่สองของสาเหตุของอุบัติเหตุ ใน เด็กไทย ปัญหาอุบัติเหตุจราจรในเด็กที่ขับขี่รถจักรยานยนต์ในขณะที่ยังไม่ถึงวัยที่สามารถมีใบขับขี่ได้ ก็เป็นปัญหาหนึ่งที่ยัง พบได้ทั่วไป แม้กฎหมายไทยห้ามเด็กที่มีอายุต่ากว่า 15 ปีขับขี่จักรยานยนต์ การศึกษานี้มีจุดมุ่งหมายเพื่อแสดงถึงปริมาณ และแนวโน้มของการเพิ่มขึ้นของการบาดเจ็บจากอุบัติเหตุจราจรของเด็ก ที่ขับขี่รถจักรยานยนต์ในขณะที่ยังไม่มีใบขับขี่ วิธีการศึกษา: การศึกษารวบรวมข้อมูลย้อนหลังจากฐานข้อมูลผู้ป่วยอุบัติเหตุที่มารักษาที่โรงพยาบาลมหาราชนครราชสีมา ระหว่าง เดือนตุลาคม พ.ศ. 2552 ถึง เดือน กันยายน พ.ศ. 2556 ผู้ป่วยเด็กที่อายุต่ากว่า 15 ปี และได้รับการบาดเจ็บขณะเป็นผู้ ขับขี่จั กรยานยนต์ ถูกเก็ บข้อมู ล เพื่ อวิเคราะห์ จ่านวนการบาดเจ็บ ค่ าวินิจ ฉัยโรค ผลข้างเคียงขณะรัก ษา จ่ านวนผู้ป่วยที่ เสียชีวิต ปัจจัยร่วมที่ก่อให้เกิดอุบัติเหตุ และแนวโน้มการเพิ่มขึ้นของปัญหานี้ในอนาคต ผลการศึกษา: จากผู้ป่วยอุบัติเหตุ 44,335 รายที่มารักษาที่ โรงพยาบาลมหาราชนครราชสีมา พบว่ามีอุบัติเหตุจราจรที่เกิดใน เด็ก (อายุต่ากว่า 15 ปี) 5,320 ราย และพบว่า 1,373 ราย หรือคิดเป็นร้อยละ 25.81 เป็นการบาดเจ็บจากอุบัติเหตุจราจรจากการ ขับขี่รถจักรยานยนต์ในขณะที่ยั งไม่มีใบขับ ขี่ เมื่ อเปรี ยบเที ยบรายปีพบว่า มี การบาดเจ็ บ 291, 318, 391 และ 373 ราย ตามล่าดับ ในจ่านวนนี้พบว่า มีเพียงร้อยละ 16.54 ที่สวมหมวกนิรภัย และ ร้อยละ 4.04 ดื่มสุราก่อนเกิดเหตุ จ่านวนผู้ป่วยที่ ได้รับบาดเจ็บรุนแรง เช่นการบาดเจ็บที่ศีรษะ การบาดเจ็บในช่องท้อง และกระดูกหักมีจ่านวนที่เพิ่มมากขึ้น โดยเฉพาะ ผู้ป่วยที่มีกระดูกหักมีอัตราส่วนร้อยละการเพิ่มขึ้นถึง 10.23 (P=0.005) และมีผู้ป่วยที่เสียชีวิต 2, 4, 7 และ 6 รายต่อ ปี ตามล่าดับซึ่งสาเหตุหลักของการเสียชีวิตคือ การบาดเจ็บที่ศีรษะ สรุป: ปัญหาอุบัติเหตุจราจรของเด็ก ที่ขับขี่รถจักรยานยนต์ในขณะที่ยังไม่มีใบขับขี่ยังเป็นปัญหาที่มีแนวโน้มเพิ่มมากขึ้น อย่ างต่อ เนื่ อ ง ส่งผลให้ มีผู้ที่ ได้ รับ บาดเจ็ บ พิก ารและเสี ย ชีวิ ตเพิ่มขึ้ น ทุ กปี หากมีมาตรการที่ เ หมาะสมเพื่ อ ลดการขั บ ขี่ รถจักรยานยนต์ในขณะที่ยังไม่มีใบขับขี่ของเด็กอายุต่ากว่า 15 ปี ก็จะสามารถลดการเกิดอุบัติเหตุในผู้ป่วยกลุ่มนี้ได้

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Innovative Design of Tumor Registry Database Program for Musculoskeletal Oncology Service Chris Charoenlap, MD, Chindanai Hongsaprabhas, MD Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Purpose: To demonstrate an innovative program design which combines tumor registration and electronic health records that suit Thai orthopedic oncologist practice. Methods: The Thai Musculoskeletal Tumor Society (TMTS) database program is a Microsoft Access database created for bone and soft tissue tumor services. Only significant parameters are recorded and all data forms are based on user-friendly concepts. Apart from exporting data to a web-based tumor registration, all input data will be utilized to facilitate complex oncology work such as printing out patient records or patient transfer forms, showing disease demographic data, retrieving particular case series, and post-operative time calculations with management planning. Results: The TMTS database program was designed for new emerging orthopedic oncology units with limited resources to possess a standard tumor database for clinical use and to promote research collaboration between small and large tumor centers. Conclusion: By adopting the specialty-specific TMTS database, we expected increases both in efficiency of tumor patient care and collaborative multi-institutional research. Keywords: Thai Musculoskeletal Tumor Society, Tumor registry, Tumor Database, Electronic Health Record The Thai Journal of Orthopaedic Surgery: 39 No.1-2: 9-15 Full text. e journal: http://www.rcost.or.th, http://thailand.digitaljournals.org/index.php/JRCOST

Introduction Tumor registration is very useful in orthopedic oncology. It can provide information about quality of treatment and facilitate clinicians in choosing proper management. National or multinational musculoskeletal databases have been initiated in many countries for more than two decades. Tumor records retrieved from national databases were applied to conduct clinical research and publish treatment guidelines based on their collective data(1,2). In 2011, the first version of the Thai Musculoskeletal Tumor Society (TMTS) registration system using case report forms commenced. Corresponding surgeons had to fill out the forms after their operation and send all of the papers to the RCOST (Royal College of Orthopedic Surgeons of Thailand) tumor subspecialty secretary by fax or email once a month. But after 6 months, there were very poor responses from participating institutes and the project was eventually canceled. Correspondence to: Charoenlap C, Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand E-mail: [email protected]

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The causes of the first version failure were reviewed and it was found that many problems were related to the Thai orthopedic oncologists working context. There were thirty active members in 2011, of which twenty surgeons had completed their training less than five years previously and were obligated to establish musculoskeletal tumor services with insufficient support. They were in charge of all bone and soft tissue tumor cases in hospitals that resulted in long surgical waiting lists. To conclude, most of subspecialty tumor members had no time for extra paper work, no assistance and limited funding. The second version of the TMTS tumor registry (Fig. 1), developed in early 2014, is a webbased registration system which aims to reduce time for sending reports and improves availability. Nevertheless, the other difficulties still remained, so database program development was proposed as a resolution. The main concept of the program is to create a database application which integrates the registration process into daily orthopedic oncology services without increasing any burden from additional paper work and also improve patient care efficiency.

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Fig. 1 The second version of the TMTS tumor registry

Materials and Methods The TMTS database program is a Microsoft Access database which combines EHR (Electronic Health Records) and the registry system to work on the same platform. The program can be used for sending tumor data for registration on the web-based TMTS tumor registry and conducting clinical research. Overall features of the program were designed from orthopedic oncologists’ working pattern which involves out-patient care, surgery, and multi-disciplinary conferences. Having the requirement to input several parameters means a workload that needs more time or personnel to fill in. On the other hand, small clinical benefit can be gained from a database if there is little information in it. The TMTS database program contains only essential variables which were carefully selected; any issues or documents which are already recorded somewhere else in the hospital system and require a request to retrieve were not included. The physician can input a patient’s clinical information similarly to standard clinical notes by following the on-screen textboxes and all necessary parameters will be collected. All input data will be utilized for supporting clinical

care so that the user will realize the advantages of the program and value of data completion. The program has a user-friendly interface and can be operated by a single user. In general, there are only four textboxes that need to be filled out including date of visit, follow-up notes, diagnosis, and tumor location then other details can be completed later. It usually took less than 5 minutes to complete the form depending on the user’s typing skills. If significant data is missing, it can be corrected on the next visit or while doing a case review. In the orthopedic oncology field, there are two types of treatment outcome assessment, oncologic and functional. An oncologic outcome is the main result determined by disease progression status and survival time such as localized recurrence, distant metastasis, and disease-specific mortality. Oncologic outcomes can be recorded in the follow-up section of the program which can be turned into a dataset for further analysis. Functional score assessment is the secondary outcome which represents patient’s quality of life and advantages of surgical reconstruction techniques. If functional outcomes are not assessed at specific times and functional data is missing, analysis of results may be difficult and unreliable. In contrast, collecting functional scores on every visit causes unnecessary paper work and wastes time. To solve this issue, the automatic tumor-type specific scheduling function of the program can remind both the physician and patient what and when should be done on each visit and avoid missing evaluations and early revisits because of incomplete investigation.

Results Patient identification section This section contains patient identification data including patient name, hospital number, national identification number, gender, birth date, registration date, healthcare plan, contact number, and corresponding doctor. The national identification number is an important detail because it can be used to check alive/dead status from central civil registrations and for referring patients between medical centers. (Fig. 2)

Fig. 2 Patient identification section

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Medical records section The medical record section has three modules. (Fig. 3) The first module is the follow-up record including date of record, patient disease status [no evidence of disease (NED), alive with

disease (AWD), and died of disease (DOD)], and a free-style clinical record. The tumor board comment window is located below this section to display opinions from multidisciplinary meetings.

Fig. 3 Medical record section The second module is the diagnosis record which contains various tools for classifying a tumor and its location. In this part, there are both free-text records and a systematic international classification of disease (ICD) registration combo box for both pathology (ICD-O-3) and diseases (ICD-10CM) which automatically pop-up for selection when typing. Because of the complexity of ICD-10CM registration, an ICD helper button was created to assist inexperienced registrars to identify the appropriate ICD description for the disease by navigating through a different window which illustrates a list of tumor type-specific diagnoses. In addition, a staging tools button provides automatic TNM staging classification for bone and soft tissue tumors which is difficult to remember due to classification complexity. Other tools include Functional outcome

Fig. 4 Functional scores

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automated Tomita and Tokuhashi’s scores for prognostic prediction in cases of spinal metastasis. The last module is treatment data which is used to record surgical treatment and select appropriate postoperative plans. The postoperative time will automatically be calculated from the date of operation. Treatment plan toggle buttons are located at the top. These buttons determine different plans of treatment (investigation, surgery, followup, and discharge). The names of patients and their information will be listed in surgical waiting or investigation lists according to their treatment plan. Patient names and contacts will be listed in the loss of follow-up list if they are on follow-up status, but do not come to the clinic for more than 365 days. Patients who have a discharge status will be excluded from the loss of follow-up list.

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Two types of functional scores are available in the program for archiving. The MSTS score (Musculo-Skeletal Tumor Society score) is a clinician-oriented subjective score which assess pain, function and emotional acceptance. A Thaitranslation of the TESS score (Toronto Extremity

Salvage Score) for upper or lower extremities are available in an electronic and paper form by clicking on the button beside an electronic form to print questionnaires to be given to the patient for self-assessment just before coming back on following visits. (Fig. 4)

Post-operative protocol

Fig. 5 Post-operative protocol Specific protocols for benign, intermediate-grade, or malignant tumors will be demonstrated according to postoperative plan selection in the operative treatment section. (Fig. 5) The estimated date for the current visit will be highlighted in yellow to notify the clinician what

investigation and clinical evaluation should be carried out in the current visit and what should be expected for the next one. With this strategy, incomplete investigation which unnecessarily wastes time and also delays the proper treatment will be minimized.

Tumor board setup application

Fig. 6 Tumor board setup application

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A multidisciplinary approach is a crucial part of cancer management. The tumor board setup section can help the listing of patients for the conference by just entering the meeting date, hospital number, and then clicking the update button. Suggestions from the meeting can be noted in the tumor board comment box on the same window and all opinions will be viewed in the patient’s medical record form. (Fig. 6) Exporting data and printing reports One function of the TMTS database program is to export data for TMTS tumor registration and clinical research. A Microsoft Excel file can be created for research purposes by selecting the type and behavior of tumor and then clicking the export button. The program will automatically select relevant data and send it to the TMTS tumor registry manager via e-mail by clicking ‘sending data to TMTS registry’ on the main menu screen. Printing documents can save a lot of time compared with paper forms. Several reports can be printed such as out-patient notes, referral documents, tissue request forms, surgical waiting lists, investigation lists, loss of follow-up lists, and patient inform sheets. The latter one contains the diagnosis and stage of disease in a comprehensive style which is easy to understand for patients, so they will know important information about their disease and plan of treatment. Equipment and expenditure The TMTS database program supports simultaneous operating using a split database technique for up to 10 users, but every computer unit must be in the same local area network (LAN). Free cloud data storage services (e.g. Dropbox, One drive, Google drive) enable users to connect to the database from remote locations, however only a single user can operate at a time because cloud applications cannot merge the same file from two different locations. The budget for establishing a database system includes a desktop computer or notebook with a Microsoft Office installation which has a total cost of around 15,000 Baht (300$) per unit and 1,500 Baht (30$) for a LAN switcher if simultaneous multi-users (up to 10 users) is required. The program is free-licensed for TMTS members.

Discussion The electronic health record (EHR) has been widely adopted by many hospitals in the U.S. since 2009, and proven itself by providing benefits in overall patient care(3). EHR also allows multicenter research to be conducted which is a crucial approach especially for orthopedic oncology which has very low prevalences of disease in the general

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population. However, a favorable outcome of EHR is relying on the quality of the information in terms of completeness and accuracy. Therefore, only good medical records can result in better patient care, while lacking information by inaccuracy or missing data will make no difference(4). Currently, more than seventy percent of Thai hospitals are using paper-based clinical records for data collecting systems with partially implemented electronic records for some specific tasks such as scheduling surgical operations and ordering medication. So far, paper documents are the most convenient method for collecting clinical data; however, paper-based medical records are usually scattered among hospital information systems and difficult to gather and update. Most of the electronic health record systems that are used in Thai hospitals are not design for special clinics which need more specific details to make data clinically useful. One problem of EHR implementation into clinical practice is personal acceptance by the user. Some clinicians may not realize the true benefits of EHR, have a poor attitude toward EHR because of the burden, and deny using it. The program should motivate users by identifying specific requirements and solving their problems(5). In addition, there are demanding features for specialty specific EHR such as redundant data input elimination, research support applications, reporting tools for quality indicators, and an interface with institutional software(6). Treating sarcoma patients is complicated and involves multiple specialties to achieve the best outcome. Improper management and follow-ups can lead to patient mortality. By creating a program for Thai orthopedic oncologists, we can expect an increase in quality of patient care and collaborative research between small and large medical centers. If patient records are properly registered and classified, an accurate data of specific diseases can be sought out by the TMTS database program and be ready for reviewing in a minute. Continuous improvement of the program through user comments will reassure usability and sustainability of the database. If the second version of the TMTS registry is successful, this project can be a model for other subspecialties in the RCOST or other national sarcoma groups that have a similar context.

Acknowledgements We are grateful to all of the members of the Thai Musculoskeletal Tumor Society for the great inspiration in the way of both service and academic in orthopaedic oncology. We also appreciate Napat Thanakornvathana for her dedicated work on database registration.

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References 1. Alvegård TA, Bauer H, Blomqvist C, Rydholm A, Smeland S. The Scandinavian Sarcoma Group--background, organization and the SSG Register--the first 25 years. Acta Orthop Scand Suppl 2004; 75: 1-7. 2. Iwamoto Y, Tanaka K. The activity of the Bone and Soft Tissue Tumor Study Group of the Japan Clinical Oncology Group. Jpn J Clin Oncol 2012; 42: 467-70. 3. King J, Patel V, Jamoom EW, Furukawa MF. Clinical benefits of electronic health record use: national findings. Health Serv Res 2014; 49: 392-404.

4. Hayrinen K, Saranto K, Nykanen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int J Med Inform 2008; 77: 291-304. 5. Jensen TB. Design principles for achieving integrated healthcare information systems. Health Informatics J 2013; 19: 29-45. 6. Hollin I, Griffin M, Kachnowski S. How will we know if it's working? A multi-faceted approach to measuring usability of a specialtyspecific electronic medical record. Health Informatics J 2012; 18: 219-32.

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การพัฒนาโปรแกรมจัดเก็บฐานข้อมูลทะเบียนโรคมะเร็งสาหรับการดูแลรักษาผู้ป่วยเนื้องอกกระดูกและ ระบบเนื้อเยื่อเกี่ยวพัน กฤษณ์ เจริญลาภ, พบ, ชินดนัย หงสประภาส, พบ วัตถุประสงค์: เพื่อนำเสนอโปรแกรมที่พัฒนำขึ้นมำใหม่โดยเป็นกำรจัดเก็บฐำนข้อมูลทะเบียนโรคมะเร็งในรู ปแบบเอกสำร อิเล็กทรอนิกส์ ทำให้ง่ำยต่อกำรสืบค้นข้อมูล และเหมำะสมในทำงปฏิบัติสำหรับแพทย์ออร์โธปิดิกส์ด้ำนเนื้องอกกระดูก และระบบเนื้อเยื่อเกี่ยวพัน วิธีการศึกษา: โปรแกรมจัดเก็บฐำนข้อมูลของอนุสำขำเนื้องอกกระดูกและระบบเนื้อเยื่อเกี่ยวพัน รำชวิทยำลัยแพทย์ออร์โธปิ ดิกส์แห่งประเทศไทย เป็นโปรแกรมที่พัฒนำขึ้นโดยใช้โปรแกรมพื้นฐำนของ ไมโครซอฟท์แอคเซส โดยเลือกจัดเก็บข้อมูล ที่สำคัญในรูปแบบที่ง่ำยต่อกำรลงข้อมูล โปรแกรมนี้สำมำรถเลือกส่งข้อมูลบำงส่วนไปยังฐำนข้อมูลทะเบียนโรคมะเร็ ง ส่วนกลำงผ่ำนกำรเชื่อมต่อทำงอินเตอร์เนตได้โดยง่ำ ย นอกจำกนั้นยังสำมำรถเลือกคำสั่งในกำรพิมพ์แบบลงบันทึกผู้ป่วย นอก ใบส่งตัวกำรรักษำ บอกข้อมูลพื้นฐำนของผู้ป่วย บอกระยะเวลำภำยหลังกำรผ่ำตัด รวมถึงแนะนำแนวทำงกำรรักษำใน กำรตรวจติดตำมแต่ละครั้งได้อีกด้วย ผลการศึกษา: โปรแกรมจัดเก็บฐำนข้อมูลของอนุสำขำฯ เหมำะสำหรับกำรเริ่มต้นเก็บข้อมูลของสถำบันที่ก่อตั้งขึ้นมำใหม่ และยังมีทรัพยำกรจำกัด เพื่อให้มีกำรจัดเก็บฐำนข้อมูลที่มีประสิทธิภำพ สำมำรถนำข้อมูลที่ได้ ไปใช้พัฒนำกำรดูแลรักษำ ผู้ป่วยรวมถึงเสริมสร้ำงควำมร่วมมือด้ำนงำนวิจัยจำกหลำยสถำบันได้เป็นอย่ำงดี สรุป: คณะผู้จัดทำมีควำมคำดหวังว่ำกำรนำโปรแกรมจัดเก็บฐำนข้อมูลของอนุสำขำฯ ไปใช้ จะช่วยเพิ่มประสิทธิภำพในกำร ดูแลรักษำผู้ป่วยเนื้องอกกระดูกและระบบเนื้อเยื่อเกี่ยวพันและเสริมสร้ำงควำมร่วมมือด้ำนข้อมูลในกำรทำวิจัยจำกหลำย สถำบันต่อไปในอนำคต

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Blood Utilization for Elective Orthopaedic Surgeries at Maharat Nakhon Ratchasima Hospital Jumpotpong Wong-Aek, MD, Supphamard Lewsirirat, MD, Urawit Piyapromdee, MD Department of Orthopaedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand Background: Elective orthopaedic surgeries incur unavoidable blood loss and may need blood replacement. Over preoperative blood requesting results in unnecessary crossmatching. Aim: To audit blood ordering and utilization in elective orthopaedic surgeries at Maharat Nakhon Ratchasima hospital for a one year period and recommend guidelines for blood orders. Materials and Methods: A 1 year retrospective analysis of patients who underwent elective orthopaedic surgeries. Patients’ age, sex, type of operative procedure, pre- and postoperative hematocrit (Hct) levels, number of units crossmatched, transfusion, crossmatch to transfusion ratio (C:T), transfusion probability, transfusion indices, and the actual and predicted fall in Hct were reviewed and a blood ordering schedule proposed based on a surgical blood ordering equation. Results: 1,417 patients underwent 25 kinds of elective orthopaedic procedures. 1987 units of blood were crossmatched, but only 296 units were transfused. Transfusions were never used in seven procedures. All of the 25 procedures had C:T >2.0. Nineteen of the 25 procedures had transfusion probabilities of 30 is considered as indicative of significant blood usage(19-22). These parameters are used to calculate a blood ordering schedule using the SBOE. Many such SBOEs are in use; however, this study calculated blood ordering to create a guideline by using an equation modified from Nuttall et al(23,24) for the purpose of simplicity.

Number of packed red blood cell units required = [predicted Hct fall(%) – patient Hct capacity(%)] 3 The predicted Hct fall is calculated based on the amount of blood lost during each surgical procedure and in the first 24 hour postoperative period to reduce the risk of severe blood loss and developing shock after surgery, assuming by the difference between preoperative and postoperative Hct that is taken at 24 hours post-surgery. The difference in the mean preoperative and mean postoperative Hct levels of the patients for each procedure gives the predicted Hct fall for any surgical procedure. The patient’s Hct capacity is calculated based on postoperative Hct which should not be less than the normal threshold at 33 percent(25), so the differential between preoperative Hct and 33 is a capacity of the amount of blood loss from the surgical procedure. For example, the preoperative Hct is 36, so the capacity of the amount of blood loss from the surgical procedure is 3 percent. If the predicted Hct fall is 6 percent, the number of packed red blood cell (PRC) units required = [6 – 3]/3 which equals one unit.

Result A total of 1,417 patients were included in this study with 1,065 patients cross-matched. These patients underwent 25 common different elective procedures of orthopaedic surgery at Maharat Nakhon Ratchasima hospital. There were 646 males (60.7 percent) and 419 females (39.4 percent). The mean age was 46.9 years old. Out of the total 1,987 PRC units crossmatched from 1,065 cases, only 296 units (14.9 percent) were transfused to 243 patients. This means 85.1 percent of the total crossmatched units were not transfused. The number of patients and units cross-matched and transfused is tabulated in Table 1. A majority of the patients (75.2 percent) underwent elective operations with cross-matching (1,065 patients cross-matched from 1,417 cases). The C:T ratio, transfusion probability, and transfusion index were formulated for each of the elective procedures and are shown in Table 2. The overall C:T ratio was 6.7 (1,987/296 units). Seven out of the 25 elective procedures namely, lumbar discectomy, forearm and ankle plating, patella tension band wiring (TBW), below knee amputation (BKA), knee, and shoulder arthroscopy never had blood transfused and these cannot be used to calculate the C:T ratio. None of the 25 elective procedures had C:T ratio < 2; the lowest C:T ratio was for posterolateral interbody fusion (PLIF) with a C:T ratio of 2.3. The highest C:T ratio was for anterior cervical discectomy and fusion (ACDF) with a C:T ratio of 61.5.

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The overall transfusion probability was only 22.8 percent. There were eight procedures with significant blood usage in which the transfusion probability was > 30 percent, namely posterior lumbar fusion (PLF) 1-2 levels, PLF 3-4 levels, PLIF 1-2 levels, PLIF 3-4 levels, femoral cephalomedullary nailing, femoral plating, acetabular fixation, and distal femoral plating. However, the transfusion index was > 0.5 in PLF 34 levels, PLIF 1-2 levels, PLIF 3-4 levels, acetabulum fixation, and distal femoral plating. Many elective operations were performed with meticulous care of bleeding or were quickly completed and so resulted in minimal or uncountable blood loss during surgery. However, postoperative bleeding is unavoidable and may cause the fall in postoperative Hct until a need for blood infusion was necessary after surgery. The amount of Hct loss between preoperative and postoperative measurements of each procedure was calculated in Table 3. There is an accepted guideline for postoperative infusions at Maharat Nakhon

Ratchasima Hospital to infuse blood if Hct drops below 30 percent(25). The predicted Hct fall is indicated the blood consumption and it should be the amount of units of blood prepared for a procedure and can be a protocol for preoperative cross-matched or surgical blood operative schedules (SBOS). However, patients with Hct levels which are high preoperatively and remain normal after the surgery was performed do not need the blood infusion and the preoperative cross-matching is wasted. Therefore, if the difference between preoperative Hct and the predicted Hct fall was more than 30 percent the preoperative crossmatching is unnecessary. The SBOS was drafted based on the SBOE. When the number of units calculated is less than 0.9 units, a type and screen (T&S) policy is recommended. When it is more than 0.9 units, the number of PRC units is rounded off to the nearest integer. The Hct capacity, predicted Hct loss, and the SBOS are tabulated in Table 4.

Table 1 Blood cross-matched and transfusion patterns for different elective orthopedic surgeries Operation Type

Patients(n)

Anterior cervical discectomy and fusion 1 level Anterior cervical discectomy and fusion 2 levels Anterior cervical discectomy and fusion 3 levels Corpectomy Lumbar discectomy Posterior lumbar fusion 1-2 levels Posterior lumbar fusion 3-4 levels Posterior lumbar interbody fusion 1-2 levels Posterior lumbar interbody fusion 3-4 levels Arthroscopic knee Arthroscopic shoulder Total hip arthroplasty Total knee arthroplasty Hip hemiarthroplasty Plate and screw humerus Plate and screw forearm Multiple screw neck femur Dynamic hip screw Cephalomedullary nail femur Intramedullary nail femur Kuncher nail femur Distal plate femur Plate and screw femur Intramedullary nail tibia Plate and screw tibia Plate and screw ankle Acetabulum fixation Patella tension band wiring Below knee amputation Total

42 14 4 10 48 73 40 23 5 105 12 92 91 68 30 170 12 80 61 56 8 22 72 65 92 62 15 37 8 1,417

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Crossmatched Transfused Patients(n) Units(n) Patients(n) Units(n) 42 87 2 2 14 27 0 0 4 9 0 0 10 21 2 2 48 66 0 0 73 147 23 26 40 103 24 35 23 56 14 23 5 14 4 6 2 2 0 0 1 0 0 0 92 182 27 31 91 182 5 5 68 136 20 22 30 49 8 11 48 63 0 0 12 17 1 1 79 146 18 18 61 115 21 22 56 111 15 20 8 16 1 1 22 53 15 18 72 150 27 31 48 56 4 4 61 88 4 4 18 21 0 0 15 44 8 14 10 13 0 0 12 13 0 0 1,065 1,987 243 296

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Table 2 Blood utilization for different elective orthopedic operations Operation Type Anterior cervical discectomy and fusion Corpectomy Lumbar discectomy * Posterior lumbar fusion 1-2 Posterior lumbar fusion 3-4 Posterior lumbar interbody fusion 1-2 Posterior lumbar interbody fusion 3-4 Arthroscopic knee * Arthroscopic shoulder * Total hip arthroplasty Total knee arthroplasty Hip hemiarthroplasty Plate and screw humerus Plate and screw forearm * Multiple screw neck femur Dynamic hip screw Cephalomedullary nail femur Intramedullary nail femur Kuncher nail femur Distal plate femur Plate and screw femur Intramedullary nail tibia Plate and screw tibia Plate and screw ankle * Acetabulum fixation Patella tension band wiring * Below knee amputation *

C:T ratio 61.5 11 5.7 2.9 2.4 2.3 5.9 36 6.2 4.5 17 8.1 5.2 5.6 16 2.9 4.8 14 22 3.1 -

%T 3.3 20 31.5 60 60.8 80 29.3 5.49 29.4 26.7 8.3 22.8 34.4 26.8 12.5 68.2 37.5 8.33 6.55 53.3 -

Ti 0.03 0.2 0.36 0.88 1 1.2 0.34 0.05 0.32 0.37 0.08 0.22 0.36 0.36 0.13 0.82 0.43 0.08 0.07 0.93 -

*Packed red blood cells (PRC) was not transfused in this procedure

Table 3 Predicted hematocrit loss for different orthopaedic procedures Type of surgery Plate and screw forearm Plate and screw ankle Patella tension band wiring Multiple screw neck femur Plate and screw tibia Below knee amputation Dynamic hip screw Cephalomedullary nail femur Plate and screw humerus Intramedullary nail femur Intramedullary nail tibia Distal plate femur Plate and screw femur Kuncher nail femur Acetabulum fixation Arthroscopic shoulder Arthroscopic knee Anterior cervical discectomy and fusion Lumbar discectomy Total knee arthroplasty Hip hemiarthroplasty Corpectomy Total hip arthroplasty Posterior lumbar fusion 1-2 Posterior lumbar interbody fusion 1-2 Posterior lumbar fusion 3-4 Posterior lumbar interbody fusion 3-4

Predicted hematocrit loss (percent) 0.47 0.4 0.4 1.95 2.31 1.57 3.37 2.91 3.53 3.7 3.63 5.14 5.31 6.28 7.28 0.3 0 1.99 2.12 3.18 3.01 4.06 5.57 4.65 7.85 7 12.24

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Table 4 Predicted hematocrit loss and surgical blood ordering schedule Type of surgery Plate and screw forearm Plate and screw ankle Patella tension band wiring Arthroscopic shoulder Arthroscopic knee Multiple screw neck femur Plate and screw tibia Below knee amputation Anterior cervical discectomy and fusion

Lumbar discectomy Dynamic hip screw Cephalomedullary nail femur Total knee arthroplasty Hip hemiarthroplasty Plate and screw humerus Intramedullary nail femur Intramedullary nail tibia Corpectomy distal plate femur Plate and screw femur Posterior lumbar fusion 1-2 Kuncher nail femur Total hip arthroplasty Acetabulum fixation Posterior lumbar interbody fusion 1-2

Posterior lumbar fusion 3-4 Posterior lumbar interbody fusion 3-4

Predicted Hct loss 30 2 1 2 1 2 1 2 1 2 1 3 2 3 2 3 2 3 2 4 2 4 2 4 2 4 2 5 2 5 2 5 2 6 3 6 3 7 3 7 3 8 3 12 5

Discussion Blood is a valuable commodity and its proper usage certainly promotes the management efficiency of the blood bank resource and hospital. The results from the present study shows highly improper blood ordering in this hospital according to the overall C:T ratio, transfusion probability, and transfusion index, and that some operations, namely, lumbar discectomy, forearm and ankle plating, patella tension band wiring, below knee amputation, knee, and shoulder arthroscopy, never needed blood infusions at all . So the C:T ratio parameter could not be calculated due to dividing by zero. Many operative procedures in this study have a low risk for intraoperative bleeding because of the use of a tourniquet for bleeding control, but bleeding still might continue in the postoperative period. Therefore, the surgeons cannot predict the necessary preoperative cross-matching because the surgeons might not have the estimate data for the amount of blood to be used or blood loss which leads to improper blood ordering. The elective orthopedic procedures in which the tourniquet was used intraoperatively, but still had a postoperative Hct loss of more than 3 percent were total knee arthroplasty and intramedullary nailing tibia.

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31 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 4

32 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 4

Preoperative hematocrit (%) 33 34 35 36 37 -

38 -

39 -

40 -

T&S

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However, these procedures showed the insignificant blood usage with transfusion probabilities of 5.49 and 8.33, respectively. There are some operative procedures in which the tourniquet cannot be used. The routine preoperative cross-matching without the guideline for this group had never been reviewed and might lead to improper blood ordering. In the present study, none of the 48 patients who underwent lumbar discectomy used any blood that was crossmatched. Also, only 2 ACDF patients recieved infusions out of the total 60 patients. The operations which used significant amounts of blood as calculated by the transfusion probability were PLIF, PLF, acetabulum fixation, femur and distal femoral plating, and femoral cephalomedullary nailing. Although these procedures had significant blood usage the C:T ratio was still high. It means that the preoperative cross-matching was much higher than what was actually needed. The appropriate blood usage can be achieved by a blood ordering schedule which will result in a decreased fee from unnecessary cross-matching(26,27). The appropriate blood ordering can be achieved by using guidelines or schedules and many schedules have been developed for this purpose. Bhutia et al. (28) evaluated the

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preoperative blood ordering and transfusion practices for common elective general surgical procedures and found that 40 percent of the crossmatches performed were unnecessary. Vibhute et al.(19) used MSBOS to analyze the blood evaluation and transfusion practices for 500 elective general surgical procedures. It was shown that MSBOS definitely improved the blood utilization and reduced the wastage rate. However, it does not take into consideration the individual differences in transfusion needs between different patients undergoing the same surgery. The SBOE is created from this concern. The risk factors have been analyzed and found to be useful in predicting blood transfusions(17,18). Some of them include low preoperative Hb/hematocrit, surgical blood loss, and the type of surgery. This study drafted the schedule which was formulated using the modified SBOE from Nuttall et al.(23) and operations with less bleeding, but the patients had low hematocrit capacity, preoperative cross-matching in this situation might or might not be necessary. The concept of type and screen will then be used by performing grouping and screening antibodies without cross-matching. Type and screen is suggested to be 99 percent effective in preventing incompatible transfusions(29-31). This is due to the high efficacy of antibody screening in the detection of potentially clinically significant antibodies. According to the American Association of Blood Banks’ recommendations(25), if the antibody screening is negative and there are no previous records of detecting such antibodies, serological testing to detect ABO incompatibility is adequate and antiglobulin testing is performed, crossmatching may be skipped. Benefits of a type and screen (T&S) include reduced costs of reagents (used for crossmatching), improved turnaround time, and decreased workload of the laboratory personnel. Most importantly, it helps reduce unnecessary loss of blood supply due to the outdating of blood. However, the necessity of crossmatched infusions of some patients cannot be achieved by using the ratio. The surgical team needs to assess the need of crossmatching by assessing the rapidity of blood loss and the sign indications of blood loss. However, sometimes it appears that the amount of hematocrit is not high enough to fall into the blood replacement need category. In addition, the use of hematocrit may be varied due to other factors such as dehydration or technical errors in the sample collecting process which can lead to an inaccuracy in the interpretation of the results. There are many factors that are associated with blood loss during and after each surgical procedure regardless of the kind of procedure. Hence, the results obtained from this study are meant to be a guideline rather than a rule. People associated with the use of this guideline need to

determine the appropriateness of its use. Nevertheless, the implementation of such schedules requires a careful assessment of blood utilization practices of the hospital and regular reviews to improve the accuracy of the guideline.

Conclusion Blood is a valuable resource. There is the cost associated with the supply and the storage process of blood. An excess ordering of blood burdens in a significant waste of time, resources, and money. However, a proper and an appropriate amount of blood ordering is difficult to determine and there is a significant risk to patients. The assessment of blood ordering and utilization can be performed by a quantitative review and reflected in the form of C:T ratios, transfusion probabilities and transfusion indexes. If the result is higher than the mean, the surgical team should consider the case because it can lead to an improvement of the utilization. The guideline and the follow up of the guideline’s result can lead to a more accurate guideline. This will lead to a reduction in the waste of crossmatching, costs associated with the over ordering of crossmatching and the time consumed in the ordering process of the blood bank. Most importantly, it will reduce the risk of insufficient blood supply for the patient in the necessary situation or emergency surgical procedure.

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7. Singh JK, Singh P. Routine pre-operative crossmatch for elective colorectal resections: An appropriate use of resources? The Surgeon 2011; 9: 8-12. 8. Voak D, Napier JAF, Boulton FE, Cann R, Finney RD, Fraser ID, et al. British Committee for Standards in haematology blood transfusion task force guidelines for implementation of a maximum surgical blood order schedule. Clin Lab Haematol 1990; 12: 321-7. 9. Jayaranee S, Prathiba R, Vasanthi N, Lopez CG. An analysis of blood utilization for elective surgery in a tertiary medical centre in Malaysia. Malays J Pathol 2002; 24: 59-66. 10. Komatsu H, Mitsuhata H, Hasegawa J, Matsumoto S. Evaluation of efficacy of maximum surgical blood order schedule (MSBOS) in the operating room. Masui 1992; 41: 914-8. 11. Mahattanobon S, Sunpaweravong S. Blood order guideline for elective surgery: impact of a guideline. Songkla Med J 2008; 26: 491-500. 12. Wanasuwannakul T, Vasinanukorn M, Lim A. Appropriate blood order for elective surgical procedures in Songklanagarind hospital. Thai J Anesthesiol 2005; 31: 271-80. 13. Sakurai Y, Okada C. Comparison by simulation of the efficiency of surgical blood order equation with that of maximum surgical blood order schedule. Masui 2001; 50: 69-75. 14. Friedman BA, Oberdman HA, Chandnick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in United States. Transfusion 1976; 16: 380-7. 15. Friedman BA. An analysis of Surgical Blood use in United States hospitals with application to the maximum surgical blood order schedule. Transfusion 1979; 19: 268-78. 16. Murphy WG, Phillips P, Gray A, Heatley L, Palmer J, Hopkins D, et al. Blood use for surgical patients: a study of Scottish hospital transfusion practices. J R Coll Surg Edinb 1995; 40: 10-3. 17. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999; 81: 2-10. 18. Use of blood products for elective surgery in 43 European hospitals. The Sanguis Study Group. Transfus Med 1994; 4: 251-68. 19. Vibhute M, Kamath SK, Shetty A. Blood utilization in elective general surgery cases:

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Requirements, ordering and transfusion practices. J Postgrad Med 2000; 46: 13-4. 20. Guidelines for implementation of a maximum surgical blood order system schedule. The British Committee for Standards in Haematology Blood Transfusion Task Force. Clin Lab Haematol 1990; 12: 321-7. 21. Mead JH, Anthony CD, Sattler M. Hemotherapy in elective surgery: an incidence report, review of literature and alternatives for guideline appraisal. Am J Clin Path 1980; 74: 223-7. 22. Knowles S. Blood transfusion: challenges and limitations. TransfusAlternTransfus Med 2007; 9: 2-9. 23. Nuttall GA, Santrach PJ, Oliver WC, Ereth MH, Horlocker TT, Cabanela ME, et al. Possible guidelines for autologous red blood cell donations before total hip arthroplasty based on the surgical blood order equation. Mayo Clin Poc 2000; 75: 10-7. 24. Nuttall GA, Horlocker TT, Santrach PJ, Oliver WC, Dekutoski MB, Bryant S. Use of the surgical blood order equation in spinal instrumentation and fusion surgery. Spine (Phila Pa 1976) 2000; 25: 602-5. 25. Petrides M, Stack G. Practical guide to transfusion medicine. Bethesda, Maryland: American Association of Blood Banks; 2001. 26. ผกาวรรณชนะชั ย สุ ว รรณ . Blood Utilization in Elective Surgery at Police General Hospital. วารสารโลหิตวิทยาและเวชศาสตร์บริการโลหิต 2553; 20: 93-104. 27. Chawla T, Kakepoto GN, Khan MA. An audit of blood cross-match ordering practices at the Aga Khan University Hospital: first step towards a Maximum Surgical Blood Ordering Schedule. J Pak Med Assoc 2001; 51: 251-4. 28. Bhutia SG, Srinivasan K, Ananthakrishnan N, Jayanthi S, RavishankarM.Blood utilization in elective surgery–requirements, ordering and transfusionpractices. Natl Med J India 1997; 10: 164-8. 29. Wong L, Cheng G. Type and screen of blood units at a teaching hospital. Hong Kong Med J 1995; 1: 27-30. 30. Boral LI, Henry JB. The type and screen: a safe alternative and supplement in selected surgical procedures. Transfusion 1977; 17: 163-8. 31. Subramanian A, Rangarajan K, Kumar S, Sharma V, Farooque K, Chandra MM. Reviewing the blood ordering schedule for elective orthopedic surgeries at a level one trauma care center . J Emerg Trauma Shock. 2010; 3: 225-30.

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การศึกษาความคุ้มค่าของการจองเลือดสาหรับผ่าตัดทางออร์โธปิดิกส์ที่ไม่ฉุกเฉินของโรงพยาบาลมหาราช นครราชสีมา จุมภฏพงษ์ วงษ์เอก, พบ, ศุภมาศ ลิ่วศิริรัตน์, พบ, อุรวิศ ปิยะพรมดี, พบ หลักการและวัตถุประสงค์: การจองเลือดก่อนการผ่าตัดที่เกินการใช้ ทาให้เกิดผลเสียและค่ าใช้จ่ายที่ไม่จาเป็น จากรายงาน ของคลังเลือดระหว่างปี 2553-2555 พบว่าอัตราส่วนของการจองเลือดก่อนผ่าตัดกับการใช้เลือดจริง (C/T ratio) ไม่เหมาะสม คิดเป็น 2.58, 2.82, 3.02 วัตถุประสงค์ของการศึกษานี้เพื่อศึกษาความคุ้มค่าในการเตรียมเลือดเพื่อการผ่าตัดทางกระดูกและ ข้อกรณีไม่ฉุกเฉินและจัดทาแนวทางการจองเลือดที่เหมาะสม วิธีการศึกษา: เป็นการศึกษาเชิงพรรณนาแบบย้อนหลังโดยเก็บข้อมูลการเตรียมเลือดและใช้เลือดจริงของการผ่าตัดกระดูก และข้อที่ไม่ฉุกเฉินในระยะเวลา 12 เดือน โดยเก็บข้อมูล อายุ, เพศ, ชนิดการผ่าตัด, ฮีมาโตคริตก่อนและหลังผ่าตัด, ระดับฮี มาโตคริตที่ลดลงจริงของชนิดการผ่าตัด จานวนเลือดที่เตรียมและใช้ และคานวณตัวชี้วัดความคุ้มค่า (C:T ratio, Transfusion probability, Transfusion index) และจัดทาแนวทางการจองเลือดจากสูตร ผลการศึกษา: พบผู้ป่วยที่เข้ารับการผ่าตัด 1,417 ราย จากการผ่าตัด 25 ชนิด ได้รับการเตรียมเลือด 1,987 ยูนิต ใช้เพียง 296 ยู นิต มีการผ่าตัด 7 ชนิด ที่ไม่มีการใช้เลือดทั้ง 25 ชนิด การผ่าตัดมี C:Tratio มากกว่า 2 การผ่าตัด 19 ชนิด มี transfusion probability