For Residents

Since its development in 1981, the Accreditation Council for Graduate Medical Education (ACGME) has served as a non-profit, private coun­cil to monitor and evaluate resi­dent training programs across 133 disciplines in the United States. In 2003, the ACGME imple­mented codified work-hour restrictions, largely in response to a number of troubling factors including escalating resident work demands, increased public concern, the possibility of governmental intervention, and published research on the con­sequences of sleep deprivation. In doing so, it has significantly changed the face of orthopedic residency training programs.

As residents, I’m certain we have encountered varying levels of resis­tance to work-hour restrictions in our respective residency programs. At times, clinical conversation with attending surgeons has progressed to more peripheral topics like the ACGME restrictions. Speculation about the “shift-worker” mentality that these guidelines cultivate inevitable segues to broader questions about the rigors of current orthopedic training.

While there was a time when I might have eschewed this point of view, I have become more disconcerted with the paradigm shift in residency training. In response to a report on resident work hours from the Institute of Medicine (IOM), the ACGME released more stringent regulations in July 2011. Further discussions are underway to evaluate broadening the reductions to a possible 56-hour workweek. Current ACGME work-hour guidelines dictate that interns and junior residents can now only continuously work 16- and 24-hours shifts, respectively, and at least 8-10 hours must be allotted for rest before returning to duty. “Strategic napping” is “strongly encouraged” after 16-hours of duty; 80-hour limitations are mandated; and 1 in 7 days must be devoid of any clinical duties. In our hospital setting, interns can no longer take traditional 24-hour hospital call; limited coverage of the home-call pager is also not permitted, even with back-up assistance readily available.

In the interest of full-disclosure, I am a product of the contempo­rary work-hour restrictions and have never known the unregulated age of 48-hour shifts or weeks filled with q3 calls. However, as an intern and junior resident, I frequently exceeded my allotted work hours to complete my patient care duties and more importantly, operate post-call. I do not dispute that the ACGME work-hour regulations have improved qual­ity of life among residents.^1-3 I also believe that the majority of residents support the intentions of these guide­lines, but I have significant concerns about its downstream effects. There is limited evidence to support its questionable role in mitigating poor patient outcomes, in-house mortal­ity, or preventable medical error.⁴ Ultimately, my wider concerns lie in the compromise of our postgradu­ate training and what has aptly been referred to as “the erosion of medical professionalism.”⁵

As an intern, I once covered a Friday and Sunday call in late April for one of the junior residents who needed to go on emergency leave. With a chief resident available for backup, I had one of my busiest weekends of call to date, including 27 consults, 6 hip fractures, 5 open femoral and tibial shaft fractures, 3 comminuted elbows, and a C5 com­plete spinal cord injury. Exhausted from my attempts to manage this exclusively, I was struck by the value of this hard-nosed experience. That weekend, I learned the importance of preparation, calmness under pressure, prioritization, and ultimately, medi­cal decision-making. Given current constraints, this experience would be impossible, and in my opinion, ortho­pedic training suffers as a result of that lack of practical knowledge.

Compromised Training Experience. Increasingly, orthopedic faculty and program directors are concerned about the preparedness of their current train­ees and I believe this will only be exacerbated by more stringent work-hour restrictions such as those currently under debate.

In one recent study,⁶ only 17% of program directors believed that resi­dents were adequately prepared for clinical practice as an attending ortho­pedic surgeon, while 20% believed that residents had sufficient outpatient clinic exposure. In contrast, residents expressed contrary points of view, with 56% and 60% claiming sufficient prep­aration and clinical exposure, respec­tively. However, more recent data sug­gest worsening educational value with the increased work-hour restrictions imposed in 2011.⁷ In a national survey of US residents,⁷ nearly half of respon­dents believed that the new ACGME regulations negatively impacted prepa­ration for a more supervisory, senior resident role. More importantly, 41% of residents perceived a lower quality of resident education since implemen­tation of new work-hour restrictions.

Candidates’ performance on American Board of Orthopaedic Surgery Part I written examination have also shown a corresponding decrease, with failure rates approaching 20% in 2010. While there have been conflicting studies regarding the effect of work-hour restrictions on operative experi­ence,^8-10 diminished clinical practice may hasten a decision towards fellow­ship specialization in order to extend training exposure.¹¹ When surveyed, approximately a quarter of residents and 45% of program directors cited the impact of the 80-hour workweek on operative case loads as the impetus for fellowship training.⁶

Erosion of Medical Professional. Many have expressed concerns that resident work–hour restrictions would herald the adoption of a “shift worker” mentality among orthopedic residents.

Numerous programs are increasingly reliant on a night float system in which frequent hand-offs and disruptions in continuity of care are considered the norm. Patient care is often fragmented during the transition from the emer­gency setting to definitive surgical treatment and postoperative care, and the resident’s ability to develop strong doctor-patient relationships is impaired.

With the limitations on interns and junior residents, there has been a steady migration of the workload up the chain of command. Increasingly, senior residents and attendings are left to shoulder the burden of unabsorbed floor work, and quality of life among senior residents has declined.7 Many clinical teams are heavily dependent on physician extenders to meet patient care needs. In discussing this trend, Pellegrini5 stated that, “Absent hard data regarding favorable changes in medical errors and patient safety, and without a competency-based education­al program to test and implement, we find ourselves left only with the abstract and intuitive sense that mandated limits to work hours for medical trainees defy the ethos that engenders professional­ism in the practice of medicine.”

Call to Action. Current ACGME work-hour guidelines have successfully restored a certain quality of life to residency training and decreased the burnout rate previously common to orthopedics.¹² However, it has also imposed some unintended consequences that threaten the over­all quality of our residency educa­tion and the comprehensiveness of our patient care. We must be proactive in our attempts to preserve the caliber of graduate medical education and improve our collective residency train­ing experience through the implemen­tation of core competencies and train­ing simulation models. We should sup­port the proposed increase of allotted orthopedic training from 3 to 6 months during the intern year and encourage the pursuit of additional clinical and operative exposure. Most important­ly, we must strongly question further work-hour restrictions that threaten to dilute our clinical experience and extend the duration of residency train­ing, particularly in the absence of more conclusive, evidence-based literature regarding its benefits.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article. The opinions or assertions con­tained herein are the private views of the author and are not to be construed as official or reflecting the views of the Department of Defense or the US gov­ernment. The author is an employee of the US government.

References
1. Kusuma SK, Mehta S, Sirkin M, et al. Measuring the attitudes and impact of the eighty-hour workweek rules on orthopedic surgery resi­dents. J Bone Joint Surg Am. 2007;89(3):679-685.
2. Immerman I, Kubiak EN, Zuckerman JD. Resident work-hour rules: a survey of resi­dents’ and program directors’ opinions and attitudes. Am J Orthop (Belle Mead, NJ). 2007;36(12):E172-E179.
3. Zuckerman JD, Kubiak EN, Immerman I, Dicesare P. The early effects of code 405 work rules on attitudes of orthopaedic residents and attending surgeons. J Bone Joint Surg Am. 2005;87(4):903-908.
4. Baldwin K, Namdari S, Donegan D, Kamath AF, Mehta S. Early effects of resident work-hour restrictions on patient safety: a systematic review and plea for improved studies. J Bone Joint Surg Am. 2011;93(2):e5.
5. Pellegrini VD Jr. Considering educational work-hour guidelines in the global orthopaedic com­munity. J Bone Joint Surg Am. 2010;92(7):e1.
6. Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM. Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am. 2011;93(23):e1421-e1429.
7. Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulations—A follow-up national survey. New Eng J Med. 2012 May 30. [ePub ahead of print]
8. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg. 2008;206(5):804-811.
9. Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman JD, Egol KA. Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions. J Bone Joint Surg Am. 2008;90(4):924-927.
10. Pappas AJ, Teague DC. The impact of the accreditation council for graduate medical edu­cation work-hour regulations on the surgical experience of orthopaedic surgery residents. J Bone Joint Surg Am. 2007;89(4):904-909.
11. Herndon JH. The future of specialization within orthopedics. J Bone Joint Surg Am. 2004;86-A(11):2560-2566.
12. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice. Part 1: ortho­paedic surgery residents and faculty. J Bone Joint Surg Am. 2007;91(10):2395-2405.

Since its development in 1981, the Accreditation Council for Graduate Medical Education (ACGME) has served as a non-profit, private coun­cil to monitor and evaluate resi­dent training programs across 133 disciplines in the United States. In 2003, the ACGME imple­mented codified work-hour restrictions, largely in response to a number of troubling factors including escalating resident work demands, increased public concern, the possibility of governmental intervention, and published research on the con­sequences of sleep deprivation. In doing so, it has significantly changed the face of orthopedic residency training programs.

As residents, I’m certain we have encountered varying levels of resis­tance to work-hour restrictions in our respective residency programs. At times, clinical conversation with attending surgeons has progressed to more peripheral topics like the ACGME restrictions. Speculation about the “shift-worker” mentality that these guidelines cultivate inevitable segues to broader questions about the rigors of current orthopedic training.

While there was a time when I might have eschewed this point of view, I have become more disconcerted with the paradigm shift in residency training. In response to a report on resident work hours from the Institute of Medicine (IOM), the ACGME released more stringent regulations in July 2011. Further discussions are underway to evaluate broadening the reductions to a possible 56-hour workweek. Current ACGME work-hour guidelines dictate that interns and junior residents can now only continuously work 16- and 24-hours shifts, respectively, and at least 8-10 hours must be allotted for rest before returning to duty. “Strategic napping” is “strongly encouraged” after 16-hours of duty; 80-hour limitations are mandated; and 1 in 7 days must be devoid of any clinical duties. In our hospital setting, interns can no longer take traditional 24-hour hospital call; limited coverage of the home-call pager is also not permitted, even with back-up assistance readily available.

In the interest of full-disclosure, I am a product of the contempo­rary work-hour restrictions and have never known the unregulated age of 48-hour shifts or weeks filled with q3 calls. However, as an intern and junior resident, I frequently exceeded my allotted work hours to complete my patient care duties and more importantly, operate post-call. I do not dispute that the ACGME work-hour regulations have improved qual­ity of life among residents.^1-3 I also believe that the majority of residents support the intentions of these guide­lines, but I have significant concerns about its downstream effects. There is limited evidence to support its questionable role in mitigating poor patient outcomes, in-house mortal­ity, or preventable medical error.⁴ Ultimately, my wider concerns lie in the compromise of our postgradu­ate training and what has aptly been referred to as “the erosion of medical professionalism.”⁵

As an intern, I once covered a Friday and Sunday call in late April for one of the junior residents who needed to go on emergency leave. With a chief resident available for backup, I had one of my busiest weekends of call to date, including 27 consults, 6 hip fractures, 5 open femoral and tibial shaft fractures, 3 comminuted elbows, and a C5 com­plete spinal cord injury. Exhausted from my attempts to manage this exclusively, I was struck by the value of this hard-nosed experience. That weekend, I learned the importance of preparation, calmness under pressure, prioritization, and ultimately, medi­cal decision-making. Given current constraints, this experience would be impossible, and in my opinion, ortho­pedic training suffers as a result of that lack of practical knowledge.

Compromised Training Experience. Increasingly, orthopedic faculty and program directors are concerned about the preparedness of their current train­ees and I believe this will only be exacerbated by more stringent work-hour restrictions such as those currently under debate.

In one recent study,⁶ only 17% of program directors believed that resi­dents were adequately prepared for clinical practice as an attending ortho­pedic surgeon, while 20% believed that residents had sufficient outpatient clinic exposure. In contrast, residents expressed contrary points of view, with 56% and 60% claiming sufficient prep­aration and clinical exposure, respec­tively. However, more recent data sug­gest worsening educational value with the increased work-hour restrictions imposed in 2011.⁷ In a national survey of US residents,⁷ nearly half of respon­dents believed that the new ACGME regulations negatively impacted prepa­ration for a more supervisory, senior resident role. More importantly, 41% of residents perceived a lower quality of resident education since implemen­tation of new work-hour restrictions.

Candidates’ performance on American Board of Orthopaedic Surgery Part I written examination have also shown a corresponding decrease, with failure rates approaching 20% in 2010. While there have been conflicting studies regarding the effect of work-hour restrictions on operative experi­ence,^8-10 diminished clinical practice may hasten a decision towards fellow­ship specialization in order to extend training exposure.¹¹ When surveyed, approximately a quarter of residents and 45% of program directors cited the impact of the 80-hour workweek on operative case loads as the impetus for fellowship training.⁶

Erosion of Medical Professional. Many have expressed concerns that resident work–hour restrictions would herald the adoption of a “shift worker” mentality among orthopedic residents.

Numerous programs are increasingly reliant on a night float system in which frequent hand-offs and disruptions in continuity of care are considered the norm. Patient care is often fragmented during the transition from the emer­gency setting to definitive surgical treatment and postoperative care, and the resident’s ability to develop strong doctor-patient relationships is impaired.

With the limitations on interns and junior residents, there has been a steady migration of the workload up the chain of command. Increasingly, senior residents and attendings are left to shoulder the burden of unabsorbed floor work, and quality of life among senior residents has declined.7 Many clinical teams are heavily dependent on physician extenders to meet patient care needs. In discussing this trend, Pellegrini5 stated that, “Absent hard data regarding favorable changes in medical errors and patient safety, and without a competency-based education­al program to test and implement, we find ourselves left only with the abstract and intuitive sense that mandated limits to work hours for medical trainees defy the ethos that engenders professional­ism in the practice of medicine.”

Call to Action. Current ACGME work-hour guidelines have successfully restored a certain quality of life to residency training and decreased the burnout rate previously common to orthopedics.¹² However, it has also imposed some unintended consequences that threaten the over­all quality of our residency educa­tion and the comprehensiveness of our patient care. We must be proactive in our attempts to preserve the caliber of graduate medical education and improve our collective residency train­ing experience through the implemen­tation of core competencies and train­ing simulation models. We should sup­port the proposed increase of allotted orthopedic training from 3 to 6 months during the intern year and encourage the pursuit of additional clinical and operative exposure. Most important­ly, we must strongly question further work-hour restrictions that threaten to dilute our clinical experience and extend the duration of residency train­ing, particularly in the absence of more conclusive, evidence-based literature regarding its benefits.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article. The opinions or assertions con­tained herein are the private views of the author and are not to be construed as official or reflecting the views of the Department of Defense or the US gov­ernment. The author is an employee of the US government.

References
1. Kusuma SK, Mehta S, Sirkin M, et al. Measuring the attitudes and impact of the eighty-hour workweek rules on orthopedic surgery resi­dents. J Bone Joint Surg Am. 2007;89(3):679-685.
2. Immerman I, Kubiak EN, Zuckerman JD. Resident work-hour rules: a survey of resi­dents’ and program directors’ opinions and attitudes. Am J Orthop (Belle Mead, NJ). 2007;36(12):E172-E179.
3. Zuckerman JD, Kubiak EN, Immerman I, Dicesare P. The early effects of code 405 work rules on attitudes of orthopaedic residents and attending surgeons. J Bone Joint Surg Am. 2005;87(4):903-908.
4. Baldwin K, Namdari S, Donegan D, Kamath AF, Mehta S. Early effects of resident work-hour restrictions on patient safety: a systematic review and plea for improved studies. J Bone Joint Surg Am. 2011;93(2):e5.
5. Pellegrini VD Jr. Considering educational work-hour guidelines in the global orthopaedic com­munity. J Bone Joint Surg Am. 2010;92(7):e1.
6. Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM. Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am. 2011;93(23):e1421-e1429.
7. Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulations—A follow-up national survey. New Eng J Med. 2012 May 30. [ePub ahead of print]
8. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg. 2008;206(5):804-811.
9. Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman JD, Egol KA. Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions. J Bone Joint Surg Am. 2008;90(4):924-927.
10. Pappas AJ, Teague DC. The impact of the accreditation council for graduate medical edu­cation work-hour regulations on the surgical experience of orthopaedic surgery residents. J Bone Joint Surg Am. 2007;89(4):904-909.
11. Herndon JH. The future of specialization within orthopedics. J Bone Joint Surg Am. 2004;86-A(11):2560-2566.
12. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice. Part 1: ortho­paedic surgery residents and faculty. J Bone Joint Surg Am. 2007;91(10):2395-2405.

Since its development in 1981, the Accreditation Council for Graduate Medical Education (ACGME) has served as a non-profit, private coun­cil to monitor and evaluate resi­dent training programs across 133 disciplines in the United States. In 2003, the ACGME imple­mented codified work-hour restrictions, largely in response to a number of troubling factors including escalating resident work demands, increased public concern, the possibility of governmental intervention, and published research on the con­sequences of sleep deprivation. In doing so, it has significantly changed the face of orthopedic residency training programs.

As residents, I’m certain we have encountered varying levels of resis­tance to work-hour restrictions in our respective residency programs. At times, clinical conversation with attending surgeons has progressed to more peripheral topics like the ACGME restrictions. Speculation about the “shift-worker” mentality that these guidelines cultivate inevitable segues to broader questions about the rigors of current orthopedic training.

While there was a time when I might have eschewed this point of view, I have become more disconcerted with the paradigm shift in residency training. In response to a report on resident work hours from the Institute of Medicine (IOM), the ACGME released more stringent regulations in July 2011. Further discussions are underway to evaluate broadening the reductions to a possible 56-hour workweek. Current ACGME work-hour guidelines dictate that interns and junior residents can now only continuously work 16- and 24-hours shifts, respectively, and at least 8-10 hours must be allotted for rest before returning to duty. “Strategic napping” is “strongly encouraged” after 16-hours of duty; 80-hour limitations are mandated; and 1 in 7 days must be devoid of any clinical duties. In our hospital setting, interns can no longer take traditional 24-hour hospital call; limited coverage of the home-call pager is also not permitted, even with back-up assistance readily available.

In the interest of full-disclosure, I am a product of the contempo­rary work-hour restrictions and have never known the unregulated age of 48-hour shifts or weeks filled with q3 calls. However, as an intern and junior resident, I frequently exceeded my allotted work hours to complete my patient care duties and more importantly, operate post-call. I do not dispute that the ACGME work-hour regulations have improved qual­ity of life among residents.^1-3 I also believe that the majority of residents support the intentions of these guide­lines, but I have significant concerns about its downstream effects. There is limited evidence to support its questionable role in mitigating poor patient outcomes, in-house mortal­ity, or preventable medical error.⁴ Ultimately, my wider concerns lie in the compromise of our postgradu­ate training and what has aptly been referred to as “the erosion of medical professionalism.”⁵

As an intern, I once covered a Friday and Sunday call in late April for one of the junior residents who needed to go on emergency leave. With a chief resident available for backup, I had one of my busiest weekends of call to date, including 27 consults, 6 hip fractures, 5 open femoral and tibial shaft fractures, 3 comminuted elbows, and a C5 com­plete spinal cord injury. Exhausted from my attempts to manage this exclusively, I was struck by the value of this hard-nosed experience. That weekend, I learned the importance of preparation, calmness under pressure, prioritization, and ultimately, medi­cal decision-making. Given current constraints, this experience would be impossible, and in my opinion, ortho­pedic training suffers as a result of that lack of practical knowledge.

Compromised Training Experience. Increasingly, orthopedic faculty and program directors are concerned about the preparedness of their current train­ees and I believe this will only be exacerbated by more stringent work-hour restrictions such as those currently under debate.

In one recent study,⁶ only 17% of program directors believed that resi­dents were adequately prepared for clinical practice as an attending ortho­pedic surgeon, while 20% believed that residents had sufficient outpatient clinic exposure. In contrast, residents expressed contrary points of view, with 56% and 60% claiming sufficient prep­aration and clinical exposure, respec­tively. However, more recent data sug­gest worsening educational value with the increased work-hour restrictions imposed in 2011.⁷ In a national survey of US residents,⁷ nearly half of respon­dents believed that the new ACGME regulations negatively impacted prepa­ration for a more supervisory, senior resident role. More importantly, 41% of residents perceived a lower quality of resident education since implemen­tation of new work-hour restrictions.

Candidates’ performance on American Board of Orthopaedic Surgery Part I written examination have also shown a corresponding decrease, with failure rates approaching 20% in 2010. While there have been conflicting studies regarding the effect of work-hour restrictions on operative experi­ence,^8-10 diminished clinical practice may hasten a decision towards fellow­ship specialization in order to extend training exposure.¹¹ When surveyed, approximately a quarter of residents and 45% of program directors cited the impact of the 80-hour workweek on operative case loads as the impetus for fellowship training.⁶

Erosion of Medical Professional. Many have expressed concerns that resident work–hour restrictions would herald the adoption of a “shift worker” mentality among orthopedic residents.

Numerous programs are increasingly reliant on a night float system in which frequent hand-offs and disruptions in continuity of care are considered the norm. Patient care is often fragmented during the transition from the emer­gency setting to definitive surgical treatment and postoperative care, and the resident’s ability to develop strong doctor-patient relationships is impaired.

With the limitations on interns and junior residents, there has been a steady migration of the workload up the chain of command. Increasingly, senior residents and attendings are left to shoulder the burden of unabsorbed floor work, and quality of life among senior residents has declined.7 Many clinical teams are heavily dependent on physician extenders to meet patient care needs. In discussing this trend, Pellegrini5 stated that, “Absent hard data regarding favorable changes in medical errors and patient safety, and without a competency-based education­al program to test and implement, we find ourselves left only with the abstract and intuitive sense that mandated limits to work hours for medical trainees defy the ethos that engenders professional­ism in the practice of medicine.”

Call to Action. Current ACGME work-hour guidelines have successfully restored a certain quality of life to residency training and decreased the burnout rate previously common to orthopedics.¹² However, it has also imposed some unintended consequences that threaten the over­all quality of our residency educa­tion and the comprehensiveness of our patient care. We must be proactive in our attempts to preserve the caliber of graduate medical education and improve our collective residency train­ing experience through the implemen­tation of core competencies and train­ing simulation models. We should sup­port the proposed increase of allotted orthopedic training from 3 to 6 months during the intern year and encourage the pursuit of additional clinical and operative exposure. Most important­ly, we must strongly question further work-hour restrictions that threaten to dilute our clinical experience and extend the duration of residency train­ing, particularly in the absence of more conclusive, evidence-based literature regarding its benefits.

Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article. The opinions or assertions con­tained herein are the private views of the author and are not to be construed as official or reflecting the views of the Department of Defense or the US gov­ernment. The author is an employee of the US government.

References
1. Kusuma SK, Mehta S, Sirkin M, et al. Measuring the attitudes and impact of the eighty-hour workweek rules on orthopedic surgery resi­dents. J Bone Joint Surg Am. 2007;89(3):679-685.
2. Immerman I, Kubiak EN, Zuckerman JD. Resident work-hour rules: a survey of resi­dents’ and program directors’ opinions and attitudes. Am J Orthop (Belle Mead, NJ). 2007;36(12):E172-E179.
3. Zuckerman JD, Kubiak EN, Immerman I, Dicesare P. The early effects of code 405 work rules on attitudes of orthopaedic residents and attending surgeons. J Bone Joint Surg Am. 2005;87(4):903-908.
4. Baldwin K, Namdari S, Donegan D, Kamath AF, Mehta S. Early effects of resident work-hour restrictions on patient safety: a systematic review and plea for improved studies. J Bone Joint Surg Am. 2011;93(2):e5.
5. Pellegrini VD Jr. Considering educational work-hour guidelines in the global orthopaedic com­munity. J Bone Joint Surg Am. 2010;92(7):e1.
6. Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM. Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am. 2011;93(23):e1421-e1429.
7. Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulations—A follow-up national survey. New Eng J Med. 2012 May 30. [ePub ahead of print]
8. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg. 2008;206(5):804-811.
9. Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman JD, Egol KA. Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions. J Bone Joint Surg Am. 2008;90(4):924-927.
10. Pappas AJ, Teague DC. The impact of the accreditation council for graduate medical edu­cation work-hour regulations on the surgical experience of orthopaedic surgery residents. J Bone Joint Surg Am. 2007;89(4):904-909.
11. Herndon JH. The future of specialization within orthopedics. J Bone Joint Surg Am. 2004;86-A(11):2560-2566.
12. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice. Part 1: ortho­paedic surgery residents and faculty. J Bone Joint Surg Am. 2007;91(10):2395-2405.

The unprecedented rising cost of health­ care in the United States has been at the forefront of national debate for the past decade and represents a seri­ous threat to the infrastructure of our society. Health care costs are currently following an unsustainable growth rate and are projected to constitute 34% of the US gross domestic prod­uct by 2040. Commercial and government payers have become increasingly interested in improved resource utilization through regulation, price fixing, and assigning value levels to physician care as a means of cutting costs and improving quality of care. A key component of transitioning from a volume-driven to a value-driven model is individual surgeon accountability to make use of effective, inexpensive solutions supported by cost-effectiveness data. Groups such as the Social and Economic Value of Orthopaedic Surgery Project Team, lead by current AAOS president Dr. John R. Tongue, represent a modern, proactive approach by surgeons to take personal responsibility for reducing health care spending. However, while we often think of technological innovation as the primary means to provide improved health care solutions, these answers are often expensive and impracti­cal when applied large-scale. Recent findings in the field of perioperative infec­tions show us that we cannot forget to look at past discoveries in other medical disciplines that may offer cost-effective adaptations in orthopedic surgery.^1-3

Perioperative infections after orthopedic procedures can be devastating complications for patients, families, and physicians alike, with an enor­mous cost to the health care system. The morbidity from surgical site infec­tions includes pain, loss of function, increased hospitalization, prolonged rehabilitation, and higher rates of reoperation.⁴ Research has shown that certain orthopedic operations have a significantly greater risk of infection such as revision total knee arthroplasty, ankle fusion, and subtalar fusion.⁵ Specialty areas, such as foot and ankle surgery in particular, have been shown to have higher infection rates, compared with other procedures.⁶ The resource allocation and financial costs of treating perioperative infec­tions in orthopedic surgery can often rise 3-13 times more than the cost of the index procedure, thus mak­ing perioperative infections an ideal target for cost-effective solutions in a value-driven health care model.^7,8 There is a tremendous need for effec­tive, low-cost, safe, and easy to use methods of preventing perioperative infections after orthopedic proce­dures, and dilute Betadine lavage is an example of such a solution.

Povidone-iodine is a stable chemi­cal complex of polyvinylpyrrolidone and elemental iodine (9-12%) that was first sold in 1955 and is now one of the most widely used antiseptics for skin, mucous membranes, and wounds. Betadine is a brand name for a range of povidone-iodine topi­cal antiseptics and has been shown to have bactericidal activity against multiple pathogens, including meth­icillin-resistant Staphlococcus aure­us.⁹ It is cheap ($1), safe, fast, widely used, and easy to alter into various concentrations. The earliest study by Sindelar and Mason¹⁰ investigating the potential decreases in periopera­tive infection rates with dilute povi­done-iodine irrigation in general and urologic surgery date back as early as 1977. Since then, there have been 14 studies conducted in multiple coun­tries, involving the fields of general, cardiovascular, and urologic surgery. Many of these studies showed similar decreases in infection rates before the idea of using a dilute Betadine lavage was implemented in orthopedic sur­gery 3 decades later.¹¹

In 2005, Cheng and colleagues¹² prospectively studied the effect of a dilute 3.5% Betadine 3-minute lavage on the incidence of postoperative spine infections. They found a significant decrease in infection rate, compared with saline lavage alone, without adverse effects on clinical outcomes. Recently, a research group led by Dr. Craig Della Valle¹³ demonstrated that a 0.35% Betadine lavage for 3 minutes significantly lowered the rate of acute postoperative infection after total hip and knee arthroplasty from 0.97% to 0.15% in a group of 2550 patients.

Using inexpensive tools that cur­rently exist and applying them in new and innovative ways, represents an area of orthopedic research that should be further pursued and that may pro­vide the cost-effective solutions that the current healthcare environment demands. Parvizi² recently showed that levels of synovial C-reactive pro­tein (CRP) could help differentiate between infected and uninfected revi­sion total knee arthroplasties with a sensitivity of 70% and specificity of 100%. CRP is a relatively inexpen­sive ($15), widely used laboratory test that has been known to rise in response to acute inflammation since its discovery in 1930 by Tillett and Francis.¹⁴ The use of serum CRP has changed the management of ortho­pedic perioperative infections, and specifically, the diagnosis algorithm for periprosthetic joint infections.13 CRP represents another example of how using old tools in new ways can address both orthopedic and resource management needs. The use of intra­wound vancomycin powder ($12) to decrease postsurgical wound infec­tion in instrumented thoracolumbar fusions may also represent a cost-effective method of infection pre­vention that is applicable to other orthopedic specialties and should be explored further.³

The price of innovation does not need to be high and with the current economic environment and rising costs of health care, it is doubtful that expen­sive solutions to common orthopedic problems will be feasible or sustain­able when increased in scale. We need to focus more attention on how to improve our resourcefulness and col­laboration with other medical disci­plines to foster creative and innovative low-cost solutions to challenging prob­lems. The examples discussed here of dilute Betadine lavage, CRP assays, and vancomycin powder are recent and relevant examples in the orthopedic literature that show that these solutions can and do exist. Furthermore, these existing technologies warrant further research across additional orthopedic specialties to improve the quality of patient care without the additional cost. Translational research has become a cornerstone of modern medicine and is often described as the synthesis of basic and applied research in order to take basic science advancements and turn them into clinical treatments in a “bench-to-bedside” model. What we should not forget is that translation can take many forms and that discovering new applications to existing technolo­gies may represent a form of transla­tional research in orthopedics that can improve our field within the framework of healthcare reform. Future solutions may exist by looking at the past, but only if we keep our eyes open for them.

Author's Disclosure Statement. The author reports no actual or poten­tial conflict of interest in relation to this article.

REFERENCES
1. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postop­erative deep periprosthetic joint infection. J Arthroplasty. 2012;27:27-30.
2. Parvizi J, Jacovides C, Adeli B, Jung KA, Hozack WJ. Mark B. Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clin Orthop Relat Res. 2012;470:54-60.
3. Sweet FA, Roh M, Sliva C. Intrawound applica­tion of vancomycin for prophylaxis in instru­mented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (PhilaPa 1976). 2011;36:2084-2088.
4. Garvin KL, Konigsberg BS. Infection following total knee arthroplasty: prevention and management. J Bone Joint Surg Am. 2011;93:1167-1175.
5. Taylor GJ, Bannister GC, Calder S. Perioperative wound infection in elective orthopaedic surgery. J Hosp Infect. 1990;16:241-247.
6. Miller WA. Postoperative wound infection in foot and ankle surgery. Foot Ankle. 1983;4:102-104.
7. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23:984-991.
8. Calderone RR, GarlandDE, Capen DA, Oster H. Cost of medical care for postoperative spinal infec­tions. Orthop Clin North Am. 1996;27:171-182.
9. McLure AR, Gordon J. In-vitro evaluation of povidone-iodine and chlorhexidine against methicillin-resistant Staphylococcus aureus. J Hosp Infect. 1992;21:291-229.
10. Sindelar WF, Mason GR. Efficacy of povidone-iodine irrigation in prevention of surgical wound infections. Surg Forum. 1977;28:48-51.
11. Chundamala J, Wright JG. The efficacy and risks of using povidone-iodine irrigation to pre­vent surgical site infection: an evidence-based review. Can J Surg. 2007;50:473-481.
12. Cheng MT, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Efficacy of dilute betadine solu­tion irrigation in the prevention of postopera­tive infection of spinal surgery. Spine (PhilaPa 1976). 2005;30:1689-1693.
13. Della Valle C, Parvizi J, Bauer TW, et al. AmericanAcademy of Orthopaedic Surgeons clinical prac­tice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93:1355-1357.
14. Tillett WS, Francis T. Serological reactions in pneumonia with a non-protein somatic fraction of pneumococcus. J Exp Med.1930;52:561-571.

The unprecedented rising cost of health­ care in the United States has been at the forefront of national debate for the past decade and represents a seri­ous threat to the infrastructure of our society. Health care costs are currently following an unsustainable growth rate and are projected to constitute 34% of the US gross domestic prod­uct by 2040. Commercial and government payers have become increasingly interested in improved resource utilization through regulation, price fixing, and assigning value levels to physician care as a means of cutting costs and improving quality of care. A key component of transitioning from a volume-driven to a value-driven model is individual surgeon accountability to make use of effective, inexpensive solutions supported by cost-effectiveness data. Groups such as the Social and Economic Value of Orthopaedic Surgery Project Team, lead by current AAOS president Dr. John R. Tongue, represent a modern, proactive approach by surgeons to take personal responsibility for reducing health care spending. However, while we often think of technological innovation as the primary means to provide improved health care solutions, these answers are often expensive and impracti­cal when applied large-scale. Recent findings in the field of perioperative infec­tions show us that we cannot forget to look at past discoveries in other medical disciplines that may offer cost-effective adaptations in orthopedic surgery.^1-3

Perioperative infections after orthopedic procedures can be devastating complications for patients, families, and physicians alike, with an enor­mous cost to the health care system. The morbidity from surgical site infec­tions includes pain, loss of function, increased hospitalization, prolonged rehabilitation, and higher rates of reoperation.⁴ Research has shown that certain orthopedic operations have a significantly greater risk of infection such as revision total knee arthroplasty, ankle fusion, and subtalar fusion.⁵ Specialty areas, such as foot and ankle surgery in particular, have been shown to have higher infection rates, compared with other procedures.⁶ The resource allocation and financial costs of treating perioperative infec­tions in orthopedic surgery can often rise 3-13 times more than the cost of the index procedure, thus mak­ing perioperative infections an ideal target for cost-effective solutions in a value-driven health care model.^7,8 There is a tremendous need for effec­tive, low-cost, safe, and easy to use methods of preventing perioperative infections after orthopedic proce­dures, and dilute Betadine lavage is an example of such a solution.

Povidone-iodine is a stable chemi­cal complex of polyvinylpyrrolidone and elemental iodine (9-12%) that was first sold in 1955 and is now one of the most widely used antiseptics for skin, mucous membranes, and wounds. Betadine is a brand name for a range of povidone-iodine topi­cal antiseptics and has been shown to have bactericidal activity against multiple pathogens, including meth­icillin-resistant Staphlococcus aure­us.⁹ It is cheap ($1), safe, fast, widely used, and easy to alter into various concentrations. The earliest study by Sindelar and Mason¹⁰ investigating the potential decreases in periopera­tive infection rates with dilute povi­done-iodine irrigation in general and urologic surgery date back as early as 1977. Since then, there have been 14 studies conducted in multiple coun­tries, involving the fields of general, cardiovascular, and urologic surgery. Many of these studies showed similar decreases in infection rates before the idea of using a dilute Betadine lavage was implemented in orthopedic sur­gery 3 decades later.¹¹

In 2005, Cheng and colleagues¹² prospectively studied the effect of a dilute 3.5% Betadine 3-minute lavage on the incidence of postoperative spine infections. They found a significant decrease in infection rate, compared with saline lavage alone, without adverse effects on clinical outcomes. Recently, a research group led by Dr. Craig Della Valle¹³ demonstrated that a 0.35% Betadine lavage for 3 minutes significantly lowered the rate of acute postoperative infection after total hip and knee arthroplasty from 0.97% to 0.15% in a group of 2550 patients.

Using inexpensive tools that cur­rently exist and applying them in new and innovative ways, represents an area of orthopedic research that should be further pursued and that may pro­vide the cost-effective solutions that the current healthcare environment demands. Parvizi² recently showed that levels of synovial C-reactive pro­tein (CRP) could help differentiate between infected and uninfected revi­sion total knee arthroplasties with a sensitivity of 70% and specificity of 100%. CRP is a relatively inexpen­sive ($15), widely used laboratory test that has been known to rise in response to acute inflammation since its discovery in 1930 by Tillett and Francis.¹⁴ The use of serum CRP has changed the management of ortho­pedic perioperative infections, and specifically, the diagnosis algorithm for periprosthetic joint infections.13 CRP represents another example of how using old tools in new ways can address both orthopedic and resource management needs. The use of intra­wound vancomycin powder ($12) to decrease postsurgical wound infec­tion in instrumented thoracolumbar fusions may also represent a cost-effective method of infection pre­vention that is applicable to other orthopedic specialties and should be explored further.³

The price of innovation does not need to be high and with the current economic environment and rising costs of health care, it is doubtful that expen­sive solutions to common orthopedic problems will be feasible or sustain­able when increased in scale. We need to focus more attention on how to improve our resourcefulness and col­laboration with other medical disci­plines to foster creative and innovative low-cost solutions to challenging prob­lems. The examples discussed here of dilute Betadine lavage, CRP assays, and vancomycin powder are recent and relevant examples in the orthopedic literature that show that these solutions can and do exist. Furthermore, these existing technologies warrant further research across additional orthopedic specialties to improve the quality of patient care without the additional cost. Translational research has become a cornerstone of modern medicine and is often described as the synthesis of basic and applied research in order to take basic science advancements and turn them into clinical treatments in a “bench-to-bedside” model. What we should not forget is that translation can take many forms and that discovering new applications to existing technolo­gies may represent a form of transla­tional research in orthopedics that can improve our field within the framework of healthcare reform. Future solutions may exist by looking at the past, but only if we keep our eyes open for them.

Author's Disclosure Statement. The author reports no actual or poten­tial conflict of interest in relation to this article.

REFERENCES
1. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postop­erative deep periprosthetic joint infection. J Arthroplasty. 2012;27:27-30.
2. Parvizi J, Jacovides C, Adeli B, Jung KA, Hozack WJ. Mark B. Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clin Orthop Relat Res. 2012;470:54-60.
3. Sweet FA, Roh M, Sliva C. Intrawound applica­tion of vancomycin for prophylaxis in instru­mented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (PhilaPa 1976). 2011;36:2084-2088.
4. Garvin KL, Konigsberg BS. Infection following total knee arthroplasty: prevention and management. J Bone Joint Surg Am. 2011;93:1167-1175.
5. Taylor GJ, Bannister GC, Calder S. Perioperative wound infection in elective orthopaedic surgery. J Hosp Infect. 1990;16:241-247.
6. Miller WA. Postoperative wound infection in foot and ankle surgery. Foot Ankle. 1983;4:102-104.
7. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23:984-991.
8. Calderone RR, GarlandDE, Capen DA, Oster H. Cost of medical care for postoperative spinal infec­tions. Orthop Clin North Am. 1996;27:171-182.
9. McLure AR, Gordon J. In-vitro evaluation of povidone-iodine and chlorhexidine against methicillin-resistant Staphylococcus aureus. J Hosp Infect. 1992;21:291-229.
10. Sindelar WF, Mason GR. Efficacy of povidone-iodine irrigation in prevention of surgical wound infections. Surg Forum. 1977;28:48-51.
11. Chundamala J, Wright JG. The efficacy and risks of using povidone-iodine irrigation to pre­vent surgical site infection: an evidence-based review. Can J Surg. 2007;50:473-481.
12. Cheng MT, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Efficacy of dilute betadine solu­tion irrigation in the prevention of postopera­tive infection of spinal surgery. Spine (PhilaPa 1976). 2005;30:1689-1693.
13. Della Valle C, Parvizi J, Bauer TW, et al. AmericanAcademy of Orthopaedic Surgeons clinical prac­tice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93:1355-1357.
14. Tillett WS, Francis T. Serological reactions in pneumonia with a non-protein somatic fraction of pneumococcus. J Exp Med.1930;52:561-571.

The unprecedented rising cost of health­ care in the United States has been at the forefront of national debate for the past decade and represents a seri­ous threat to the infrastructure of our society. Health care costs are currently following an unsustainable growth rate and are projected to constitute 34% of the US gross domestic prod­uct by 2040. Commercial and government payers have become increasingly interested in improved resource utilization through regulation, price fixing, and assigning value levels to physician care as a means of cutting costs and improving quality of care. A key component of transitioning from a volume-driven to a value-driven model is individual surgeon accountability to make use of effective, inexpensive solutions supported by cost-effectiveness data. Groups such as the Social and Economic Value of Orthopaedic Surgery Project Team, lead by current AAOS president Dr. John R. Tongue, represent a modern, proactive approach by surgeons to take personal responsibility for reducing health care spending. However, while we often think of technological innovation as the primary means to provide improved health care solutions, these answers are often expensive and impracti­cal when applied large-scale. Recent findings in the field of perioperative infec­tions show us that we cannot forget to look at past discoveries in other medical disciplines that may offer cost-effective adaptations in orthopedic surgery.^1-3

Perioperative infections after orthopedic procedures can be devastating complications for patients, families, and physicians alike, with an enor­mous cost to the health care system. The morbidity from surgical site infec­tions includes pain, loss of function, increased hospitalization, prolonged rehabilitation, and higher rates of reoperation.⁴ Research has shown that certain orthopedic operations have a significantly greater risk of infection such as revision total knee arthroplasty, ankle fusion, and subtalar fusion.⁵ Specialty areas, such as foot and ankle surgery in particular, have been shown to have higher infection rates, compared with other procedures.⁶ The resource allocation and financial costs of treating perioperative infec­tions in orthopedic surgery can often rise 3-13 times more than the cost of the index procedure, thus mak­ing perioperative infections an ideal target for cost-effective solutions in a value-driven health care model.^7,8 There is a tremendous need for effec­tive, low-cost, safe, and easy to use methods of preventing perioperative infections after orthopedic proce­dures, and dilute Betadine lavage is an example of such a solution.

Povidone-iodine is a stable chemi­cal complex of polyvinylpyrrolidone and elemental iodine (9-12%) that was first sold in 1955 and is now one of the most widely used antiseptics for skin, mucous membranes, and wounds. Betadine is a brand name for a range of povidone-iodine topi­cal antiseptics and has been shown to have bactericidal activity against multiple pathogens, including meth­icillin-resistant Staphlococcus aure­us.⁹ It is cheap ($1), safe, fast, widely used, and easy to alter into various concentrations. The earliest study by Sindelar and Mason¹⁰ investigating the potential decreases in periopera­tive infection rates with dilute povi­done-iodine irrigation in general and urologic surgery date back as early as 1977. Since then, there have been 14 studies conducted in multiple coun­tries, involving the fields of general, cardiovascular, and urologic surgery. Many of these studies showed similar decreases in infection rates before the idea of using a dilute Betadine lavage was implemented in orthopedic sur­gery 3 decades later.¹¹

In 2005, Cheng and colleagues¹² prospectively studied the effect of a dilute 3.5% Betadine 3-minute lavage on the incidence of postoperative spine infections. They found a significant decrease in infection rate, compared with saline lavage alone, without adverse effects on clinical outcomes. Recently, a research group led by Dr. Craig Della Valle¹³ demonstrated that a 0.35% Betadine lavage for 3 minutes significantly lowered the rate of acute postoperative infection after total hip and knee arthroplasty from 0.97% to 0.15% in a group of 2550 patients.

Using inexpensive tools that cur­rently exist and applying them in new and innovative ways, represents an area of orthopedic research that should be further pursued and that may pro­vide the cost-effective solutions that the current healthcare environment demands. Parvizi² recently showed that levels of synovial C-reactive pro­tein (CRP) could help differentiate between infected and uninfected revi­sion total knee arthroplasties with a sensitivity of 70% and specificity of 100%. CRP is a relatively inexpen­sive ($15), widely used laboratory test that has been known to rise in response to acute inflammation since its discovery in 1930 by Tillett and Francis.¹⁴ The use of serum CRP has changed the management of ortho­pedic perioperative infections, and specifically, the diagnosis algorithm for periprosthetic joint infections.13 CRP represents another example of how using old tools in new ways can address both orthopedic and resource management needs. The use of intra­wound vancomycin powder ($12) to decrease postsurgical wound infec­tion in instrumented thoracolumbar fusions may also represent a cost-effective method of infection pre­vention that is applicable to other orthopedic specialties and should be explored further.³

The price of innovation does not need to be high and with the current economic environment and rising costs of health care, it is doubtful that expen­sive solutions to common orthopedic problems will be feasible or sustain­able when increased in scale. We need to focus more attention on how to improve our resourcefulness and col­laboration with other medical disci­plines to foster creative and innovative low-cost solutions to challenging prob­lems. The examples discussed here of dilute Betadine lavage, CRP assays, and vancomycin powder are recent and relevant examples in the orthopedic literature that show that these solutions can and do exist. Furthermore, these existing technologies warrant further research across additional orthopedic specialties to improve the quality of patient care without the additional cost. Translational research has become a cornerstone of modern medicine and is often described as the synthesis of basic and applied research in order to take basic science advancements and turn them into clinical treatments in a “bench-to-bedside” model. What we should not forget is that translation can take many forms and that discovering new applications to existing technolo­gies may represent a form of transla­tional research in orthopedics that can improve our field within the framework of healthcare reform. Future solutions may exist by looking at the past, but only if we keep our eyes open for them.

Author's Disclosure Statement. The author reports no actual or poten­tial conflict of interest in relation to this article.

REFERENCES
1. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postop­erative deep periprosthetic joint infection. J Arthroplasty. 2012;27:27-30.
2. Parvizi J, Jacovides C, Adeli B, Jung KA, Hozack WJ. Mark B. Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clin Orthop Relat Res. 2012;470:54-60.
3. Sweet FA, Roh M, Sliva C. Intrawound applica­tion of vancomycin for prophylaxis in instru­mented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (PhilaPa 1976). 2011;36:2084-2088.
4. Garvin KL, Konigsberg BS. Infection following total knee arthroplasty: prevention and management. J Bone Joint Surg Am. 2011;93:1167-1175.
5. Taylor GJ, Bannister GC, Calder S. Perioperative wound infection in elective orthopaedic surgery. J Hosp Infect. 1990;16:241-247.
6. Miller WA. Postoperative wound infection in foot and ankle surgery. Foot Ankle. 1983;4:102-104.
7. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23:984-991.
8. Calderone RR, GarlandDE, Capen DA, Oster H. Cost of medical care for postoperative spinal infec­tions. Orthop Clin North Am. 1996;27:171-182.
9. McLure AR, Gordon J. In-vitro evaluation of povidone-iodine and chlorhexidine against methicillin-resistant Staphylococcus aureus. J Hosp Infect. 1992;21:291-229.
10. Sindelar WF, Mason GR. Efficacy of povidone-iodine irrigation in prevention of surgical wound infections. Surg Forum. 1977;28:48-51.
11. Chundamala J, Wright JG. The efficacy and risks of using povidone-iodine irrigation to pre­vent surgical site infection: an evidence-based review. Can J Surg. 2007;50:473-481.
12. Cheng MT, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Efficacy of dilute betadine solu­tion irrigation in the prevention of postopera­tive infection of spinal surgery. Spine (PhilaPa 1976). 2005;30:1689-1693.
13. Della Valle C, Parvizi J, Bauer TW, et al. AmericanAcademy of Orthopaedic Surgeons clinical prac­tice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93:1355-1357.
14. Tillett WS, Francis T. Serological reactions in pneumonia with a non-protein somatic fraction of pneumococcus. J Exp Med.1930;52:561-571.