Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS.
The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor.
Up to 20 percent of patients remain dissatisfied after primary total knee arthroplasty (TKA) surgery. Understanding the reasons for dissatisfaction post TKA may allow for better patient selection and optimized treatment for those who remain dissatisfied. The association between function, mobility and satisfaction are not well understood. The purpose of this study was to investigate the association between post-TKA satisfaction and i) pre-operative, ii) post-operative, and iii) change in knee joint function during gait. Thirty-one patients scheduled to receive primary TKA for knee osteoarthritis (OA) diagnosis were recruited and visited the Dynamics of Human Motion laboratory for instrumented walking gait analysis (using a synchronized NDI Optotrak motion capture system and AMTI force platforms in the walkway) at two time points, first within the week prior to their surgery, and second at approximately one year after surgery. At their post-operative visit, patients were asked to indicate their satisfaction with their knee prosthesis on a scale from zero to 100, with zero being totally unsatisfied and 100 being completely satisfied. Knee joint mechanics during gait at both time points were characterized by discriminant scores, the projection of their three-dimensional knee angles and moments during gait onto an existing discriminant model that was created to optimize separation of severe knee OA and healthy asymptomatic gait patterns. This discriminant model was created using data from 73 healthy participants and 73 with severe knee OA, and includes the magnitude and pattern features (captured with principal component analysis) of the knee adduction and flexion moment, and the magnitude of the knee flexion angle during gait. Larger discriminant scores indicate improved function toward healthy patterns, and smaller scores indicate more severe function. Associations between post-operative satisfaction and pre, post and change in discriminant scores were examined using Pearson correlation analyses. We also examined associations between satisfaction and pre-operative BMI, EQ5D and Oxford 12 scores, as well as changes in these scores from pre to post-TKA. Discriminant scores representing knee joint function during gait significantly improved on average after surgery (P =0.05). While overall knee joint function improved after primary TKA surgery, the amount of improvement in function was not reflected in post-operative patient satisfaction. However, the pre-operative function of the patient was negatively associated with satisfaction, indicating that patients with higher pre-operative function are overall less satisfied with their TKA surgery, regardless of any functional improvement due to the surgery. Interestingly, the only significant association with post-operative satisfaction was knee joint function, and the relationship between function and patient satisfaction following TKA appears to relate only to the baseline functional state of the patient, and not with functional improvement. This suggests that dissatisfaction post-surgery is more likely reflecting the unmet expectations of a higher functioning patient, and has implications for the need for improved understanding of pre-operative patient functional variability in TKA triage and expectation management.
Lateral epicondylitis, also known as “tennis elbow,” is a degenerative disorder of the common extensor origin of the lateral humeral epicondyle. The mainstay of treatment is non-operative and includes physiotherapy, activity modification, bracing, nonsteroidal anti-inflammatory drugs, and injections. There is a subgroup of patients however who do not respond to non-operative measures and require operative intervention. We conducted a retrospective review of prospectively collected data to assess whether the introduction of PRP injections for lateral epicondylitis led to a reduction in patients subsequently undergoing surgical release.Introduction
Methods
Total knee arthroplasty (TKA) has been shown to improve knee joint function during gait post-operatively. However, there is considerable patient to patient variability, with most gait mechanics metrics not reaching asymptomatic levels. To understand how to target functional improvements with TKA, it is important to identify an optimal set of functional metrics that remain deficient post-TKA. The purpose of this study was to identify which combination of knee joint kinematics and kinetics during gait best discriminate pre-operative gait from postoperative gait, as well as post-operative from asymptomatic. Seventy-three patients scheduled to receive a TKA for severe knee osteoarthritis underwent 3D gait analysis 1 week before and 1 year after surgery. Sixty asymptomatic individuals also underwent analysis. Eleven discrete gait parameters were extracted from the gait kinematic and kinetic waveforms, as previously defined (Astephen et al., J Orthop Res., 2008). Stepwise linear discriminant analyses were used to determine the sets of parameters that optimally separated pre-operative from post-operative gait, and post-operative from asymptomatic gait. Cross-validation was used to quantify group classification error. Knee flexion angle range, knee adduction moment first peak, and gait velocity were included in the optimal discriminant function between the pre- and post-operative groups (P<0.05), with relatively equal standardised canonical coefficients (0.567, −0.501, 0.565 respectively), and a total classification rate of 74%. A number of metrics were included in the discriminant function to optimally separate post-operative and asymptomatic gait function, including the knee flexion angle range, peak stance knee flexion angle, minimum late stance knee extension moment, minimum mid-stance knee adduction moment, and peak knee internal rotation moment (P<0.05). The mid-stance knee adduction moment had the largest standardised canonical coefficients in the function, and 89.5% of cases were correctly classified. Separation of pre and post-operative gait patterns included only three parameters, suggesting that current standard of care TKA significantly improves only walking velocity, knee flexion angle range, and the peak value of the knee adduction moment. A number of gait metrics, which were included in the discriminant function between post-operative and asymptomatic gait, could benefit from further improvement either through rehabilitation or design. With almost 90% classification, separation of post-operative gait function from asymptomatic levels is significant. The consolidation of knee joint function during gait into single, discrete discriminant scores allows for an efficient summary representation of patient-specific (or implant-specific) improvement in gait function from TKA surgery.
Controversy persists regarding preference between Herbert and Acutrak screw for internal fixation of scaphoid non-union. Acutrak screw has been shown to have better biomechanical compression properties than Herbert screw in the laboratory setting. The aim of this study was to assess the clinical, radiological and functional outcome of patients treated with the two different screw systems. A retrospective review of the results of patients with scaphoid non-union treated by a single surgeon. Group 1 comprised of 61 patients treated with Herbert screw between July1996 and June2000 and Group 2 comprised of 71 patients treated with Acutrak screw between July 2000 and December 2005. Union rates were assessed radiologically and clinically. Functional outcome was measured by using modified Mayo wrist score.Background
Methods
The indication for rotator cuff repair in elderly patients is controversial. Consecutive patients over the age of 70 years, under the care of a single surgeon, receiving an arthroscopic rotator cuff repair were reviewed. Predominantly, a single row repair was performed using one (34 cases) or two (30) 5mm Fastin, double-loaded anchors. Double-row repair was performed in four cases. Subacromial decompression and treatment of biceps pathology were performed as necessary. Data were collected from medical records, digital radiology archives and during clinic appointments. Pain, motion, strength and function were quantified with the Constant-Murley Shoulder Outcome Score, administered pre operatively and at 1-year post operatively. Ultrasound scans were performed at one year to document integrity of the repair. Sixty-nine arthroscopic cuff repairs were identified in 68 patients. The mean age was 77 years (70–86). The median ASA grade was 2 (79%). The dominant side was operated on in 68% of cases. A range of tear sizes were operated on (5 small, 17 moderate, 29 large and 18 massive). The tendons involved in the tear also varied (supraspinatus 12, supra and infraspinatus 53, supraspinatus and subscapularis 2, supraspinatus infraspinatus and subscapularis 2). Re-rupture occurred in 20 cases (29%). The mean Constant score increased from 23 (95% CI 19–26) to 59 (54–64) (P< 0.001). Where the repair remained sound, Constant score improved 42 points (95%CI 36–48). If the cuff re-ruptured, constant score also increased on average 12 points (95% CI 2–21). Re-rupture rate was highest for massive cuff repairs: ten out of eighteen (56%).Methods
Results
It is well established that non-union of the scaphoid requires operative intervention to achieve stable union, restore scaphoid anatomy and prevent further degenerative change. Acutrak screw has been shown to have better biomechanical compression properties than the Herbert screw in the laboratory setting. The aims of the study were to assess the rate of union, the functional outcome and post- operative complications of patients with the two different screw systems. A retrospective review of the patients who had undergone surgery for non-union of scaphoid treated by a single surgeon. The first group consisted of 61 patients who were treated with Herbert screw and iliac crest bone graft between July 1996 and June 2000. The rate and time to union were assessed clinically and radiologicaly. Their post-operative functional outcome was assessed with modified Mayo wrist score. Results were compared to second group of 71 patients treated with Acutrak screw plus iliac crest bone graft between July 2000 and December 2005.Introduction
Methods
To determine extent of correction in spinal osteotomy for fixed sagittal plane deformity Radiographic retrospective cohort analysis using standardised standing whole spine radiographs. Level III evidence 24 patients (14 females/10 males, av. 53.6 yrs) with sagittal plane deformity due to either ankylosing spondylitis (4), idiopathic (12), congenital (1), tumour (2), infectious (1), or posttraumatic (4) aetiologies. Max. 4 yrs follow up Sagittal balance, lumbar lordosis correction, osteotomy angle, pelvic indices Chevron (3), pedicle subtraction (17), and vertebral column resection (4) osteotomies were performed with the majority at L3 (9) and L2 (8). The C7-S1 sagittal vertical axis demonstrated a preoperative decompensation averaging 12.0 cm (range -7 to 37) with 55% of patients achieving normal sagittal balance postoperatively. Lumbar lordosis increased from 28.9° (range -28 to 63) to 48.9° (range 12 to 69) (22.3° av. correction). L3 osteotomy angle was largest, average 31° (range, 16 to 47). There were 11 complications comprising; major (1) and minor (1) neurological, junctional kyphosis (3), metalwork problems (2), dural tear (2) and infection (2). Four patients required additional surgery at latest follow-up. Technical outcome was good 11(50%), fair 8(36%), poor 3(14%). Spinal osteotomy is a very effective technique to correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio before undertaking what is a major reconstructive procedure. Most patients are satisfied, particularly when sagittal balance is achieved.
To compare the effect of intraoperative red cell salvage on blood transfusion and cost in patients undergoing idiopathic scoliosis surgery. Retrospective 37 patients (36 females, 1 male) underwent scoliosis surgery from February 2007 to October 2008. Intraoperative red cell salvage (Group 1) was used. They were compared with 28 patients (23 females, 5 males) operated from January 2005 to December 2006 without the use of cell salvage (Group 2). 36 patients in group 1 had posterior surgery and 1 had anterior surgery. In Group 2, 20 patients had posterior surgery, 7 anterior and 1 patient had anterior and posterior surgery. Both groups were comparable for age, number of levels fused, preoperative haemoglobin and haematocrit values. Amount of perioperative blood transfusion, costs 14 patients (50%) in group 2 had blood transfusion whereas only 6 (16%) were transfused blood in group 1. Average blood loss in group 1 was 1076 mls (range 315-3000) and 1626mls (419-4275) in group 2. An average of 2 units of packed red blood cells per patient was processed by the cell salvage system. Postoperative haemoglobin, haematocrit and hospital stay were comparable in both groups. Cost analysis shows the use of cell salvage is cost beneficial by £116.60 per case. The use of red blood cell salvage reduces the amount of blood transfusion and is cost beneficial.
A literature review of bone graft substitutes for spinal fusion was undertaken from peer reviewed journals to form a basis for guidelines on their clinical use. A PubMed search of peer reviewed journals between Jan 1960 and Dec 2009 for clinical trials of bone graft substitutes in spinal fusion was performed. Emphasis was placed on RCTs. Small and duplicated RCTs were excluded. If no RCTs were available the next best clinical evidence was assessed. Data were extracted for fusion rates and complications. Of 929 potential spinal fusion studies, 7 RCTs met the inclusion criteria for BMP-2, 3 for BMP-7, 2 for Tricalcium Phosphate and 1 for Tricalcium Phosphate/Hydroxyapatite (TCP/HA). No clinical RCTs were found for Demineralised Bone Matrix (DBM), Calcium Sulphate or Calcium Silicate. There is strong evidence that BMP-2 with TCP/HA achieves similar or higher spinal fusion rates than autograft alone. BMP-7 achieved similar results to autograft. 3 RCTs support the use of TCP or TCP/HA and autograft as a graft extender with similar results to autograft alone. The best clinical evidence to support the use of DBMs are case control studies. The osteoinductive potential of DBM appears to be very low however. There are no clinical studies to support the use of Calcium Silicate. The current literature supports the use of BMP-2 with HA/TCP as a graft substitute. TCP or HA/TCP with Autograft is supported as a graft extender. There is not enough clinical evidence to support other bone graft substitutes. This study did not require ethics approval and no financial support was received.
To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation. Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008). Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group. Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows
The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel. MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder. Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory.
Orthopaedic
60
Accident and Emergency
32
Other
25
We report our ten year experience of primary haematogenous non-tuberculous spinal infection. Retrospective case note review of 42 patients presented to our institution with primary spinal infection during 1995-2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated.Aim
Method
Twenty-two patients with piriformis syndrome underwent surgery between October 1995 and February 2002. The mean age was 56 years (range 28-90). Only 2 patients (9%) gave a history of trauma to the ipsilateral buttock. All the patients complained of deep buttock pain, which radiated to the ankle in 14 (63%), the calf in 4 (18%) and the thigh in 3 patients (13.6%). The symptoms were chronic, with a mean of 70 months (range 12-192) and patients had been previously seen by a mean of 2.6 specialists (range 1-6). There was associated neurosensory loss in 11 patients (50%). The symptoms were exacerbated by passive stretching and active contraction of the piriformis muscle. MRI of the lumbar spine (every case) and gluteal region (8 cases) were negative, while NCV tests (20 cases) were positive in 11 patients (55%). Previous conservative measures such as physiotherapy (59%) and epidural (40%) had failed. Every patient had surgical division of the piriformis tendon at the greater trochanter by the senior author. Abnormal anatomy was identified in 6 cases (29%). At 6 weeks (n=22), the symptoms had resolved in 6 patients (27%), were better in 8 (36%), no different in 7 (32%) and worse in 1 (4.5%). After a mean follow-up of 52 months (range 11-86), seven (35%) of patients were cured, 3 (15%) were better, 8 (40%) were no different, 2 (10%) were worse than pre-operatively and 2 had died of unrelated causes. Seventy-five percent of patients said that with hindsight they would undergo surgery again. One patient suffered a post-operative below knee DVT requiring no treatment. Surgery for piriformis syndrome in this selected group of patients led to an improvement or resolution of chronic symptoms in 64% of patients at 6 weeks, and 50% of patients after a mean follow-up of 52 months with minimal associated morbidity.
Performance evaluation in specialist orthopaedic hospitals was reviewed in comparison to district general hospitals (DGHs) using a variety of outcome measures, including surgical activity, length of stay and infection rates. Data regarding admission rates, operations performed or cancelled, outpatient activity and waiting times were obtained from the Hospital Episode Statistics department of the Department of Health. Surgical site infection (SSI) and MRSA infection rates from the Royal National Orthopaedic Hospital (RNOH) are compared to national data supplied by the Health Protection Agency. In comparison with DGHs, specialist orthopaedic hospitals admit fewer patients, with fewer emergencies; have a higher ratio of waiting list patients to number of patients admitted; have longer waiting list times on average; perform more primary joint arthroplasty surgery; undertake more revision procedures; discharge patients home following joint arthroplasty surgery on average one day earlier; have a lower total hip arthroplasty SSI rate (0.8%) compared with 2.3% in 146 DGHs and from RNOH data, provide a service with a lower surgical site infection and MRSA rate. Specialist orthopaedic hospitals in England provide a unique, efficient and effective service compared to DGHs. However, short-term performance measures, though simpler to collate, may not be as valuable as longer-term outcome measures, thus making direct comparisons between DGHs, specialist orthopaedic hospitals and independent treatment centres difficult.
We aimed to collate guidelines for preoperative marking in orthopaedic surgery, identify areas of convergence and difference and relate them to previous work on guideline effectiveness. We performed a systematic search of Medline and Google using ‘correct site’, ‘wrong site’, ‘marking’, ‘surgery’, ‘orthopaedics’ and ‘guidelines’. Orthopaedic societies and bodies, personal knowledge and unindexed conference abstracts were also used. We found nine guidelines from ten institutions in seven different countries; UK National Patient Safety Agency/Royal College of Surgeons of England, Australian College of Surgeons, JCAHO (USA), Canadian Orthopaedic Association, Veterans Health Association (USA), Copenhagen Hospital Corporation, German Coalition for Patient Safety, American Academy of Orthopaedic Surgeons and the New Zealand Orthopaedic Association. We identified four ‘core-steps’ common to the majority of guidelines. Firstly, using indelible pen. Secondly, the operating surgeon should mark the patient. Thirdly, the patient should be involved in confirming side/site. Finally, a ‘time-out’ before starting the procedure. Only one of the ‘core steps’ is carried out in theatre. The others are carried out before theatre emphasising the importance of accurately identifying and marking early in the patient’s journey. Common sense suggests guidelines should be simple, user friendly and quick to complete. Making guidelines compatible with existing values and not deviating from existing routines are recognised to increase their use. Guidelines issued by practitioners’ own professional bodies are likely to have more impact than those from outside the profession. However increasing the number of items a guideline contains does not necessarily make it better or safer. The four core steps we identified are the basis for any marking guideline. It is reasonable to assume that incorporating the guidance into clinical orthopaedic practice will further improve safety. Future work should focus on establishing the relative impact of each guideline aspect.
Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9). Overall it was calculated that HIAS had saved a total of 940 in-patient days.
Mean duration of symptoms was 25 days (range 1–202). Mean time from presentation to diagnosis was 19 days (range 0–172). Staphylococcus Aureus was the most common organism. Mean duration of Intravenous antibiotics was 60 days (range 13–240) followed by oral antibiotics for mean duration of 65 days (range 0–161). CRP was more reliable in monitoring the disease over time. At mean follow up of 5.4 years (0.6–10.5) there has been no mortality directly related to the infection. With our management there has been 14% recurrence rate. All re- presenting within the first year after initial presentation (Mean 5.5 Months, range 1–11). HIAS saved a total of 940 in-patient days with a total cost saving of approximately £350,000.00.
