Introduction. Pressure to control health care costs may limit the ability of new implants to enter the market. Customized individually made (CIM) knee implants are produced from CT scans of each patient and may result in improved clinical outcomes based on early data showing less blood loss, reduced bone resection, and better implant function and alignment. Limited economic evidence suggests that the use of CIM technology may result in
Background. Routine closed suction drainage and postoperative laboratory studies have long been tenets of most TJA protocols. However, recent literature has called into question whether either is necessary with modern outpatient TJA clinical pathways. Methods. Demographic, cost, and readmission data for 2,605 primary unilateral TJA cases was collected retrospectively and analyzed prior to and after a protocol change where routine closed suction drains and postoperative laboratory tests were eliminated. This protocol change was designed to treat all primary TJA like outpatients regardless of their admission status. Drain usage changed from routine to selective based on hemostasis. Lab studies changed from routine to selective for patients on warfarin for VTE prophylaxis (INR), with ASA 4 or 5 status (BMP), and with a hematocrit < 27% in the recovery room after THA (CBC). Results. Drain utilization decreased by 50% and postoperative labs decreased by 70%. Drain and lab test cost per patient decreased from $74.62 before to $19.91 after the change, while charges per patient decreased from $625.23 before to $77.15 after. The 30 and 90-day readmission rates decreased with no readmissions occurring before or after the change that could have been prevented by using a drain or obtaining labs. Conclusion. Selective elimination of routine closed suction drainage and postoperative laboratory studies as part of an outpatient TJA protocol is safe and provides
In 2000 our emergency department implemented a new management for the treatment of isolated, apex volar distal radial fractures involving immobilisation with a wrist splint, written information for carers and no planned follow up. Next day x-ray review acted as a safety net for misdiagnosed or less stable fractures. This has now been validated with a retrospective review of treatment for distal radial # within the ED. Patients were identified through the Emergency department’s electronic discharge record. Over a 9 month period 260 patients were identified with metaphyseal distal radial and/or ulna injuries to which a non orthopaedic junior doctor might be expected to apply the Buckle Fracture Algorithm. Of these 161 had isolated distal radial fractures suitable for treatment with a wrist splint. 118 were correctly identified and treated in the ED. 43 patients were sent to # clinic, of these 11 patients were discharged at the 1st visit, however 3 had 3 or more visits and 2 children had additional x-rays. Over this period 9 children were given splints inappropriately according to the protocol, most of these had stable injuries on reviewing the x-rays, 3 were identified and recalled for a cast. None of the children with injuries outside the protocol who were not recalled had an unplanned return with complications. Taking into account only those children who were correctly managed from the ED the estimated annual
The Dawn Hip - An Effective Strategy to Improve the Management of Traumatic Hip Fractures. Introduction. Traumatic hip fractures are managed with nationwide standards, and are regularly audited and published. A previous audit last year at the William Harvey revealed 66% of hip fractures were operated within 48 hours, compared to the national average of 75%. We implemented a strategy to improve this target by introducing the ‘Dawn Hip’ - a hip fracture operation which is prepared for surgery at 8am on the Emergency (CEPOD) list. Methods. Over a two month period after the introduction of the ‘Dawn hip’, the number of hip operations and start time on the CEPOD list were audited. Performance data were extrapolated from the National Hip Fracture Database (NHFD) and compared nationally. Results. Three months prior to the ‘Dawn hip’ the mean start time of surgery on the CEPOD list was 9.50am. Two months since the introduction of the dawn hip, 67% of all trauma hip operations were done on the CEPOD list. The mean start time of the CEPOD list improved to 8.38am. Data from the NHFD revealed 81% of traumatic hip fractures were operated on within 48 hours, with the national average being 80%. Conclusion. This is an effective strategy which increases efficiency of existing resources and improves hospital services and patient care. It requires a multidisciplinary approach and participation from both managerial and clinical departments. This strategy not only optimises the care we provide for hip fractures, but also increases trauma list space for other pending trauma operations. By meeting nationwide targets, the trust is rewarded with cash incentives, which is used to further improve services. In the current economic climate, this represents a method of optimising healthcare, increasing
The debate whether to use cemented or uncemented
components in primary total hip replacement (THR) has not yet been
considered with reference to the cost implications to the National
Health Service. We obtained the number of cemented and uncemented components
implanted in 2009 from the National Joint Registry for England and
Wales. The cost of each component was established. The initial financial
saving if all were cemented was then calculated. Subsequently the
five-year rates of revision for each type of component were reviewed
and the predicted number of revisions at five years for the actual
components used was compared with the predicted number of revisions
for a cemented THR. This was then multiplied by the mean cost of
revision surgery to provide an indication of the savings over the
first five years if all primary THRs were cemented. The saving at primary THR was calculated to be £10 million with
an additional saving during the first five years of between £5 million
and £8.5 million. The use of cemented components in routine primary
THR in the NHS as a whole can be justified on a financial level
but we recognise individual patient factors must be considered when deciding
which components to use.
Implant waste during total hip arthroplasty (THA) represents a significant cost to the USA healthcare system. While studies have explored methods to improve THA cost-effectiveness, the literature comparing the proportions of implant waste by intraoperative technology used during THA is limited. The aims of this study were to: 1) examine whether the use of enabling technologies during THA results in a smaller proportion of wasted implants compared to navigation-guided and conventional manual THA; 2) determine the proportion of wasted implants by implant type; and 3) examine the effects of surgeon experience on rates of implant waste by technology used. We identified 104,420 implants either implanted or wasted during 18,329 primary THAs performed on 16,724 patients between January 2018 and June 2022 at our institution. THAs were separated by technology used: robotic-assisted (n = 4,171), imageless navigation (n = 6,887), and manual (n = 7,721). The primary outcome of interest was the rate of implant waste during primary THA.Aims
Methods
In the current healthcare environment, cost containment has become more important than ever. Perioperative services are often scrutinized as they consume more than 30% of North American hospitals’ budgets. The procurement, processing, and use of sterile surgical inventory is a major component of the perioperative care budget and has been recognized as an area of operational inefficiency. Although a recent systematic review supported the optimization of surgical inventory reprocessing as a means to increase efficiency and eliminate waste, there is a paucity of data on how to actually implement this change. A well-studied and established approach to implementing organizational change is Kotter's Change Model (KCM). The KCM process posits that organizational change can be facilitated by a dynamic 8-step approach and has been increasingly applied to the healthcare setting to facilitate the implementation of quality improvement (QI) interventions. We performed an inventory optimization (IO) to improve inventory and instrument reprocessing efficiency for the purpose of cost containment using the KCM framework. The purpose of this quality improvement (QI) project was to implement the IO using KCM, overcome organizational barriers to change, and measure key outcome metrics related to surgical inventory and corresponding clinician satisfaction. We hypothesized that the KCM would be an effective method of implementing the IO. This study was conducted at a tertiary academic hospital across the four highest-volume surgical services - Orthopedics, Otolaryngology, General Surgery, and Gynecology. The IO was implemented using the steps outlined by KCM (Figure 1): 1) create coalition, 2) create vision for change, 3) establish urgency, 4) communicate the vision, 5) empower broad based action, 6) generate general short term wins, 7) consolidate gains, and 8) anchor change. This process was evaluated using inventory metrics - total inventory reduction and depreciation
Introduction. Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a
Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility. IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm. We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates
Aims. Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. Methods. TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. Results. Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. Conclusion. This study demonstrated significant
Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget. In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and
Abstract. Objectives. To analyse the costs and benefits of sending femoral head specimens for histopathological analysis and whether our practice had changed since the original study five years ago. Methods. The cohort definition was patients who had both undergone hip hemiarthroplasties (HHAs) and had femoral head specimens sent for histopathological analysis at our tertiary care institution from 2013 to 2016. Retrospective review of clinical and electronic notes was performed on these patients for history of malignancy, histopathological diagnosis of femoral head, indication for histopathological examination and radiological studies. The total number of HHAs performed at the centre and the costs involved in analysing each femoral head specimen were identified. Results. A total of 805 HHAs were performed at the centre. We identified 56 femoral head specimens from 56 patients (6.96%) that were sent for histopathological analysis after HHA. 29 patients (51.79%) had a known history of malignancy. Three femoral head specimens (10.34%) were histologically positive for malignancy. Two patients had hip radiographs demonstrating metastasis to the femoral head. The third patient had a PET-CT scan two weeks prior to fracture that did not show signs of metastatic disease. 27 patients (48.21%) had no history of malignancy. None of their femoral head specimens were found to be histologically positive for malignancy. 10 patients had no appropriate indication for histopathological analysis. The
Introduction. Total knee arthroplasty is a highly effective procedure to improve the quality of life in patients with advanced osteoarthritis. The number of these procedures are expected to grow 174% by 2030. This growth rate is expected to economically strain the health care system. A potential solution to alleviate this problem is the utilization of single use instruments (SUI). Potential advantages of SUI include: improved operating room efficiencies, decreased costs associated with traditional instrument management (sterile processing, shipping), and decreased infection risk. The present study examines the clinical results of SUI compared to standard instrumentation. Furthermore, economic modeling is performed to examine the
Closed ankle fractures have been reported to account for 10% off all fractures presenting to the Emergency Department. Many of these injuries require acute surgical management either via direct admission or through defined outpatient surgical pathways. While both methods have been shown to be safe, few studies have examined the cost effectiveness of each clinical scenario. The purpose of this study is to compare cost and resource utilization associated with inpatient and outpatient ankle fracture surgery at a Canadian academic institution. This is a retrospective chart review of patients who underwent acute ankle fracture surgery at London Health Sciences Centre between 2016 and 2018. Thirty patients who underwent inpatient ankle surgery for closed, isolated ankle fractures at University Hospital were compared to 30 consecutive patients who underwent outpatient ankle surgery for similar fractures at Victoria hospital. Data pertaining to age at time of surgery, sex, BMI, fracture type, operating/recovery room time, and length of hospital stay were collected. All emergency room visits, readmissions and complications within 30 days of surgery were also recorded. Inpatient and outpatient cohorts were similar with respect to average age (48 vs. 44, P=0.326) and body mass index (29.8 vs. 29.1, P=0.741). There was a greater proportion of patients with an American Society of Anesthesia (ASA) Classification of 3 or greater in the inpatient surgery group (48% vs. 23%). The inpatient group spent an average of 1.2 days in hospital while waiting for surgery and a average of 72 hours in hospital for their entire surgical encounter. The outpatient group spent an average of eight days (at home) waiting for surgery while spending an average of 7.4 hours in hospital during their entire surgical encounter. Outpatient ankle fracture surgery was associated with a
Abstract. Introduction. Uni-compartmental knee replacement (UKR) has become popularised due to quicker recovery times, reduced postoperative pain, and blood loss. The desire to increase bed capacity and reduce costs, while preserving safety and patient satisfaction, has led to increased interest in day-case arthroplasty. This study observes the feasibility of UKR as a day-case procedure and whether this affects short and long-term postoperative outcomes. Methodology. Between 2018 and 2021, at a single institution and operated by a single orthopaedic surgeon, seventy-seven patients received a UKR on an elective basis. The patients were divided into two groups: ‘day-case’ for those discharged on the same day, and ‘non day-case’ group. Results. 31 patients were identified as day case procedures with the remaining 46 requiring between one to three days before discharge. Mean age, sex, modal ASA score, BMI, Charlson co-morbidity index, and pre-op oxford knee score showed no statistically significant difference between the two groups (p>0.05). No significant difference between the post-op oxford knee score at 1 year was found for patients treated and discharged as a day case procedure (37.8 +/− 6.88) and those who remained as an inpatient postoperatively (37.8 +/− 10.7); t(df) = −0.0007, p=0.994. No patients in either group suffered any complications beyond the peri-operative period. 30-day and 90-day readmission rates were equal. Conclusions. With no significant differences in post-op knee scores, complication, and readmission rates, we feel UKR can be performed as a viable day case procedure in a planned elective setting. This will result in significant
Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery. Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged <18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery. Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41). Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant
The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years. We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential
Percutaneous flexor tenotomy involves cutting the flexor digitorum tendons to correct claw toe deformity to treat apical pressure areas and prevent subsequent infection in patients with peripheral neuropathy. Performing this under ultrasound guidance provides reassurance of complete release of the tendon and increases procedural safety. This study is a retrospective case series evaluating the effectiveness, safety, and patient satisfaction of performing percutaneous ultrasound-guided flexor tenotomy in an outpatient setting. People with loss of protective sensation, a digital flexion deformity, and an apical toe ulcer or pre-ulcerative lesion who presented to our institution between December 2019 and June 2022 were included in this study. Participants were followed-up at a minimum of 3 months. Time to ulcer healing, re-ulceration rate, patient satisfaction, and complications were recorded. An Australian cost analysis was performed comparing this procedure performed in rooms versus theatres. There were 28 ulcers and 41 pre-ulcerative lesions. A total of 69 tenotomy procedures were performed on 38 patients across 52 episodes of care. The mean time to ulcer healing was 22.5 +/- 6.4 days. There were 2 cases of re-ulceration. 1 patient sustained a transfer lesion. There were four toes that went onto require amputation, all in the setting of pre-existing osteomyelitis. 94% of patients strongly agreed that they were satisfied with the outcome of the procedure. Costs saved were estimated to be $1426. Flexor tenotomy is a minimally invasive procedure that can be performed in the outpatient setting, and therefore without delay to treatment, reducing risk of ulcer progression and need for subsequent amputation. This is the first study to report on flexor tenotomy under ultrasound-guidance. Ultrasound-guided percutaneous flexor tenotomy is safe and effective, with high patient satisfaction and low recurrence rates. This performance in the outpatient setting ensures significant time and
We report the impact of implementing a new short-stay hip and knee arthroplasty pathway in a National Health Service (NHS) hospital. This was enacted due to existing concerns with a long length of stay (LOS) and reduced elective operating capacity each winter due to emergency bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimise readmission rates and generate financial savings, all combining to facilitate full elective activity during the winter. We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It includes rigorous preoperative optimisation, specific anaesthetic protocols and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, including the initial six months post implementation of the short-stay pathway. LOS data was collected for the full period and data was compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected. There was an immediate and significant decrease in median LOS from 4 days pre-implementation to 1 day post-implementation. Patient satisfaction was high, and the 30-day readmission rate was unchanged (5.95%), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial
Abstract. Background. Daycase pathways which aim to discharge patients the same day following Unicompartmental Knee Replacement have been introduced in some centres, though most continue with Standard pathways. While Daycase pathways have
Aims. We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. Methods. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted. Results. Overall 71/101 patients completed the telephone consultation; no patients required surgery, and the mean and median PRWE scores were 23.9/100 (SD 24.9) and 17.0/100 (interquartile range (IQR) 0 to 40), respectively. Mean patient satisfaction with treatment was 34.3/40 (SD 9.2), and 65 patients (92%) were satisfied or highly satisfied. In total there were 16 contact calls, 12 requests for a consultant review, no formal complaints, and 15 minor adjustment suggestions to improve patient experience. A relationship was found between intra-articular injuries and lower patient satisfaction scores (p = 0.025), however no relationship was found between PRWE scores and the nature of the fracture. Also, no relationship was found between the type of immobilization and the functional outcome or patient satisfaction. Cost analysis of the self-care pathway V traditional pathway showed a
Introduction: Ranked as the second most common cause of long-term disability amongst American adults, osteoarthritis (OA) affects well over 60 million Americans per year. OA is one of the major contributors to health care-related economic cost in the US, which is generally considered unacceptably high when compared other Western industrialized nations. Methods: Three hundred and thirty-five patients undergoing primary unilateral or bilateral total hip arthroplasty (THA), metal-on-metal hip resurfacing (MOMHR), total knee arthroplasty (TKA), or unicondylar knee arthroplasty (UKA) were offered voluntary participation in an one-on-one preoperative education session with a pre-operative educator. Length of stay (LOS) and in-patient costs was collected for patients who received individual pre-operative education. This was then compared to patients who chose not to participate in the education sessions using linear regression models. Results: Patients who chose to participate enjoyed a significantly shorter LOS than those who did not receive education, controlling for age, sex, type of procedure, and number of co-morbid conditions (3.1 ± 1.1 vs. 4.5 ± 4.7; p<
0.01). THA patients participating in the preoperative education program exhibited a calculated
Anatomically specific fixation devices have become mainstream, yet there are anatomical regions and clinical conditions where no pre-contoured plates are available, such as for glenohumeral arthrodesis. In a case series of 4 glenohumeral arthrodesis patients, a consultant orthopaedic surgeon at GCUH implemented 3D printing technology to create reconstructions of each patient's shoulder girdle to pre-contour arthrodesis plates. Our aim was to quantify the cost-benefit & intra-operative time savings of this technique in glenohumeral arthrodesis. We hypothesized that the use of 3D printing for creating patient specific implants through pre-operative contouring of plates will lead to intra-operative time and
Tranexamic Acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomised control trial aimed to assess if an additional 24 hours of TXA post – operatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date this trial included high risk patients. This paper presents the results of a cost analysis undertaken alongside this RTC. TRAC-24 was a prospective randomised controlled trial on patients undergoing TKA and THA. Three groups were included, Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour post-operative oral regime, group 2 received only the perioperative dose and group 3 did not receive TXA. Cost analysis was performed out to day 90. Group 1 was associated with the lowest mean total costs, followed by group 2 and then group 3. The difference between groups 1 and 3 −£797.77 (95% CI −1478.22, −117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in groups 1 and 2 resulted from reduced length of stay, readmission rates, Accident and Emergency (A&E) attendances and blood transfusions. This study demonstrated significant
Aims. The aim of this study was to compare ten-year longitudinal healthcare costs and revision rates for patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). Methods. The Humana database was used to compare 2,383 patients undergoing UKA between 2007 and 2009, who were matched 1:1 from a cohort of 63,036 patients undergoing primary TKA based on age, sex, and Elixhauser Comorbidity Index. Medical and surgical complications were tracked longitudinally for one year following surgery. Rates of revision surgery and cumulative mean healthcare costs were recorded for this period of time and compared between the cohorts. Results. Patients undergoing TKA had significantly higher rates of manipulation under anaesthesia (3.9% vs 0.9%; p < 0.001), deep vein thrombosis (5.0% vs 3.1%; p < 0.001), pulmonary embolism (1.5% vs 0.8%; p = 0.001), and renal failure (4.2% vs 2.2%; p < 0.001). Revision rates, however, were significantly higher for UKA at five years (6.0% vs 4.2%; p = 0.007) and ten years postoperatively (6.5% vs 4.4%; p = 0.002). Longitudinal-related healthcare costs for patients undergoing TKA were greater than for those undergoing UKA at one year ($24,771 vs $22,071; p < 0.001) and five years following surgery ($26,549 vs $25,730; p < 0.001); however, the mean costs of TKA were comparable to UKA at ten years ($26,877 vs $26,891; p = 0.425). Conclusion. Despite higher revision rates, patients undergoing UKA had lower mean healthcare costs than those undergoing TKA up to ten years following the procedure, at which time costs were comparable. In the era of value-based care, surgeons and policymakers should be aware of the costs involved with these procedures. UKA was associated with fewer complications at one year postoperatively but higher revision rates at five and ten years. While UKA was significantly less costly than TKA at one and five years, costs at ten years were comparable with a mean difference of only $14. Lowering the risk of revision surgery should be targeted as a source of
The purpose of this prospective pilot study is to examine the feasibility of a physiotherapist led rapid access shoulder screening clinic (RASC). The goal of this study is to assess for improvements in patient access to care, patient reported outcome measures, patient reported experience measures, and cost outcomes using time driven activity based costing methods. Patient recruitment began in January 2021. Consultation requests from general practitioners and emergency rooms are analyzed and triaged through a central system. One half of patients awaiting consultation were triaged to the traditional route used at our center while the other half were triaged to be assessed at the RASC. Outcome measures consisting of the Simple Shoulder Test and SF-12 were recorded at the initial consultation and at follow up appointments. Cost benefit analysis was conducted using time driven activity based costing methods (TD-ABC). From January to August of 2021, 123 new patients were triaged for RASC assessment. On average, the RASC gets 10 new referrals per month. As of September 2021, there are 65 patients still on waitlist for RASC assessment with 58 having been assessed. Of the 58, 11% were discharged through the RASC, 48% pursued private physiotherapy, 14% had injections, 19% proceeded on for surgical consultation, and 8% did not show. Over time same time period, approximately 15 new patients were seen in consultation by the surgeon's office. Thirty-five responses were obtained from RASC patients during their initial intake assessment. The average age of respondents was 54.7 with 21 females and 14 males. Median SF-12 scores in the physical dimension (PCS-12) for RASC patients were 36.82 and mental (MCS-12) 49.38927. Median Simple Shoulder Test scores measured 6. Of the patients who responded to the follow up questionnaires after completing physiotherapy at the RASC, both the SF-12 and Simple Shoulder Test scoring improved. Median PCS-12 measured 47.08, MCS-12 of 55.87, and Simple Shoulder Test measured 8. RASC assessments by PT saved $172.91 per hour for consultation and $157.97 per hour for patient follow ups. Utilization of a physiotherapy led rapid access shoulder clinic resulted in improvements in patient outcomes as measured by the SF-12 and Simple Shoulder Test as well as significant direct
It has been established that a dedicated orthopaedic trauma room (DOTR) provides significant clinical and organizational benefits to the management of trauma patients. After-hours care is associated with surgeon fatigue, a high risk of patient complications, and increased costs related to staffing. However, hesitation due to concerns of the associated opportunity cost at the hospital leadership level is a major barrier to wide-spread adoption. The primary aim of this study is to determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency. Secondly, we sought to evaluate the associated financial impact of the DOTR, with respect to both after-hours care costs as well as the opportunity cost of displaced elective cases. This was a retrospective cost-analysis study performed at a single academic-affiliated community hospital in Toronto, Canada. All patients that underwent the most frequently performed orthopedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a four-year period from 2016-2019 were included. Patient data acquired for two-years prior and two-years after the implementation of a DOTR were compared, adjusting for the number of cases performed. Surgical duration and number of day-time and after-hours cases was recorded pre- and post-implementation.
Introduction:. Historically the incidence of Achilles re-ruptures has been described as around 5% after surgical repair and up to 21% after conservative management. In 2008 we commenced a dedicated Achilles tendon rupture clinic for both conservative and surgically managed patients using new standardised operating procedures (SOP). We have evaluated the impact of this new service, particularly with regard to re-rupture rate. Materials and methods:. The SOP was stage dependent and included an initial ultrasound examination, functional orthotics with early weight bearing, accelerated exercise and guidelines for the return to work and sport. Evaluation included re-rupture rate, complication rate, and outcome measured by the Achilles Tendon Total Rupture Score (ATRS) and Achilles Tendon Repair Score (AS). A basic cost evaluation was performed to assess any potential savings. Results:. A total of 213 patients (151 treated conservatively and 62 surgically) were included. Re-rupture occurred in two patients (1 conservative and 1 surgically managed). There were 16 major complications e.g. DVT, wound infection. The mean ATRS was 54.79, 67.66 and 71.05 at 4, 6 and 9 months respectively and the mean AS was 64.67, 73.96 and 71.05 at 4, 6 and 9 months respectively. The reduction in re-rupture compared to the literature was 4.1% and 19.1% for surgical and conservatively treated patients respectively.
Abstract. Objectives. Knee alignment affects both the development and surgical treatment of knee osteoarthritis. Automating femorotibial angle (FTA) and hip-knee-ankle angle (HKA) measurement from radiographs could improve reliability and save time. Further, if the gold-standard HKA from full-limb radiographs could be accurately predicted from knee-only radiographs then the need for more expensive equipment and radiation exposure could be reduced. The aim of this research is to assess if deep learning methods can predict FTA and HKA angle from posteroanterior (PA) knee radiographs. Methods. Convolutional neural networks with densely connected final layers were trained to analyse PA knee radiographs from the Osteoarthritis Initiative (OAI) database with corresponding angle measurements. The FTA dataset with 6149 radiographs and HKA dataset with 2351 radiographs were split into training, validation and test datasets in a 70:15:15 ratio. Separate models were learnt for the prediction of FTA and HKA, which were trained using mean squared error as a loss function. Heat maps were used to identify the anatomical features within each image that most contributed to the predicted angles. Results. FTA could be predicted with errors less than 3° for 99.8% of images, and less than 1° for 89.5%. HKA prediction was less accurate than FTA but still high: 95.7% within 3°, and 68.0 % within 1°. Heat maps for both models were generally concentrated on the knee anatomy and could prove a valuable tool for assessing prediction reliability in clinical application. Conclusions. Deep learning techniques could enable fast, reliable and accurate predictions of both FTA and HKA from plain knee radiographs. This could lead to
Introduction: The addition of recombinant human bone morphogenetic protein-2 (rhBMP-2) showed significant reduction of secondary intervention, fracture healing time and infection rates compared with intramedullary nailing alone in open tibia fractures. However, the upfront price of approx. 3000 € is a barrier to its regular use. The goal of the study was to determine potential
Total hip arthroplasty (THA) is a common and extremely beneficial procedure that is being performed more often as the population ages. Current THA follow-up guidelines require large amounts of resources and may not justify their cost with increased patient outcomes. Most problems that would require THA revision will cause symptoms. Late-presenting asymptomatic THAs that are found to require revision are complicated and expensive to address and often lead to poor patient outcomes. Follow-up visits for THA patients are essentially a screening tool to identify asymptomatic THAs that require revision. The rate of asymptomatic THA revision and the subsequent cost of screening for them is not well reported in the literature. Given the relative shortage of orthopaedic resources, efficient use of clinic time should be a priority and inefficient practices should be identified and changed. We calculated the rate of asymptomatic hip revisions over the first twenty years of THA ownership. We further calculated the cost of a single visit to the orthopaedic clinic for follow up of a THA. Finally, we calculated the
Aims. The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. Patients and Methods. Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants’ self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors. Results. The mean cost up to three months post-recruitment per participant was £542.40 (. sd. £855.20, n = 65) for the control group and £368.40 (. sd. £338.60, n = 67) for the intervention group, leading to an estimated cost difference of £174 (95% confidence interval (CI) -£30 to £378; p = 0.094). The cost difference per participant increased to £266 (95% CI £3.30 to £528; p = 0.047) at six months. Overall, 6.2% of participants (4/65, control group) and 10.4% of participants (7/67, intervention group) had sustained a fracture of the scaphoid (p = 0.37). In addition, 7.7% of participants (5/65, control group) and 22.4% of participants (15/67, intervention group) had other fractures diagnosed (p = 0.019). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of a fracture of the scaphoid (100.0% vs 93.8%) and of any other fracture (98.5% vs 84.6%). Conclusion. The use of immediate MRI in the management of participants with a suspected fracture of the scaphoid and negative radiographs led to
Aims. The ongoing COVID-19 pandemic has disrupted and delayed medical and surgical examinations where attendance is required in person. Our article aims to outline the validity of online assessment, the range of benefits to both candidate and assessor, and the challenges to its implementation. In addition, we propose pragmatic suggestions for its introduction into medical assessment. Methods. We reviewed the literature concerning the present status of online medical and surgical assessment to establish the perceived benefits, limitations, and potential problems with this method of assessment. Results. Global experience with online, remote virtual examination has been largely successful with many benefits conferred to the trainee, and both an economic and logistical advantage conferred to the assessor or organization. Advances in online examination software and remote proctoring are overcoming practical caveats including candidate authentication, cheating prevention, cybersecurity, and IT failure. Conclusion. Virtual assessment provides benefits to both trainee and assessor in medical and surgical examinations and may also result in
Introduction. Hip and knee device sales representatives (reps) can provide intra-operative guidance through their knowledge of the products, especially in complicated cases such as revision hip and knee arthroplasty. However, for an experienced arthroplasty surgeon in the majority of straightforward primary cases, the rep's presence may not be required for clinical decision-makings. With recent challenges in
Purpose. Traditionally, an inpatient hospital stay has been required for joint replacement surgery. The three primary drivers of cost for joint replacement have been implant cost, other hospital charges and postoperative rehabilitation costs. The three primary reasons that have made hospitalization necessary are pain control, blood loss / transfusion, and monitoring patients with comorbidities. Advances in surgical technique, implants, comprehensive blood management, and multimodal pain management have allowed a marked reduction in the hospital stay required and have eliminated the need for extensive formal rehabilitation. The purpose of this study is to evaluate if hip resurfacing can be performed safely and cost-effectively as an outpatient procedure. Methods. We present the short-term outcome of our first 125 hip resurfacings done as an outpatient procedure performed by two experienced surgeons. Young patients without major medical co-morbidities were selected. The average age was 53±7 years old (range: 38 to 66), there were 98 men and 27 women. The mean ASA score was 1.7±0.5 (range 1 to 3). The diagnosis was OA in 92, dysplasia in 22, and osteonecrosis in 9, and trauma in 2. There were no major complications noted in the first 6 weeks postoperative. There was one ER visit, and there were no hospitalizations required. Results. The average and highest pain score for each day was shown in Figure 1 for the first 5 days postoperative. Three patients required a morphine injection after discharge from the surgery center. No patients required a transfusion. The satisfaction survey showed: The cost comparison is obtained from the Blue Cross website which indicates that the “120 day episode of care” for total hip arthroplasty is $35,000, $ 45,000, and $65,000 at the three local hospitals, while cost at our surgery center was $26,000. This represents a
Purpose and background. To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within patient risk subgroups (low, medium and high risk of persistent disabling pain determined by the STarT Back tool). Methods. Adopting a cost-utility framework alongside a prospective, sequential comparison of separate patient cohorts (922 patients in total) with six-month follow-up, the base case analysis estimated the incremental LBP-related healthcare cost per additional quality-adjusted life year (QALY) by risk subgroup. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative approaches (a complete case analysis, the incorporation of non-LBP-related healthcare use and estimation of societal costs relating to work absence). Results. Stratified care was a dominant treatment strategy compared with usual care for patients at high risk, with mean healthcare
INTRODUCTION. Preoperative optimization and protocols for joint replacement care pathways have led to decreased length of stay (LOS), decreased narcotic use and are increasingly important in delivering quality,
Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The
Objectives. “Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. Methods. National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. Results. The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. Conclusions. The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant
Introduction. Traditionally an inpatient hospital stay has been required for all joint replacement surgery. The three primary drivers of cost for joint replacement have been implant cost, other hospital charges and postoperative rehabilitation costs. The three primary reasons that have made hospitalization necessary are pain control, therapy and possible transfusion. Advances in surgical technique, implants, comprehensive blood management, and multimodal pain management have allowed a marked reduction in the hospital stay required, eliminated the need for extensive formal rehabilitation. The purpose of this study is to evaluate if hip resurfacing can be performed safely and cost-effectively as an outpatient procedure. Methods. We present the short-term outcome of our first 77 hip resurfacings done as an outpatient procedure performed by two experienced surgeons. Young patients without major medical co-morbidities were selected. The average age was 53±6 years old (range: 38 to 66), there were 57 men and 20 women. The mean ASA score was 1.6±0.5 (range 1 to 2). The diagnosis was OA in 56, dysplasia in 17, avascular necrosis in 2, and others in 2. Results. All patients were successfully discharged on the day of surgery from our physician-owned outpatient surgery center. There were no major complications noted in the first 6 weeks postoperative. There was one ER visit, and there were no hospitalizations required. The average and highest pain score for each day was shown in Figure 1 for the first 5 days postoperative. Three patients required a morphine injection after discharge from the surgery center. No patients required a transfusion. The cost comparison is obtained from the Blue Cross website which indicates that the “120 day episode of care” cost for hip replacement was $35,000 at Providence, $ 45,000 at Palmetto, $65,000 at Lexington hospital, while cost at our surgery center was $26,000. This represents a
Aims. Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement. Methods. We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score. Results. A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold. Conclusion. Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial
Background. The Comprehensive Care for Joint Replacement (CJR) model was implemented in April-2016 to standardize cost and improve quality of care for two of the most commonly billed inpatient procedures for Medicare patients, total knee and total hip arthroplasty. The purpose of this study is to compare one institution's predicted savings and losses under the CJR model with actual savings and losses after two years of implementation and discuss new methods to maintain savings. Methods. Using our institution's data, we calculated the mean cost per episode of care. We calculated the percent reduction in target price and percent savings or losses per case for the CJR and Bundle Payment Care Initiative (BPCI) for each Medicare Severity Diagnosis Related Group (MS-DRG) using mean cost per episode and CJR and BPCI target prices. We compared the target prices, annual savings, and losses per episode of care for both CJR and BPCI. All CJR savings, projected and actual, were computed by comparing CJR savings to that of 2018 BPCI savings. Results. We found an average savings of 2.32% under CJR compared to the projected loss of −11.6% for MS-DRG 469 with fracture. There was a 7.97% savings for MS-DRG 470 without fracture compared to the projected 1.9%, a 20.94% savings for MS-DRG 470 with fracture compared to the projected 23.7%, and a loss of −3.98% for MS-DRG 469 without fracture compared to the projected 2.5% savings. Conclusions. The CJR target prices are lower than that of BPCI and this makes maintaining an episode of care at or below the target price increasingly difficult. Discharge disposition and readmission are well established factors that increase hospital cost [7]. However, reduction of these does not seem enough to maintain savings under the CJR model. New
Introduction. Robotic-arm assisted knee arthroplasty (rKA) has been associated with improved clinical, radiographic, and patient-reported outcomes. There is a paucity of literature, however, addressing its cost effectiveness. In the context of an integrated health system with an insurance plan and single source comprehensive data warehouse for electronic health records and claims data, we present an evaluation of healthcare costs and utilization associated with manual knee arthroplasty (mKA) versus rKA. We also examine the influence of rKA technology on surgeons’ practice patterns. Methods. Practice patterns of KA were assessed 18 months before and after introduction of robotic technology in April 2018. For patients also insured through the system's health plan, inpatient costs (actual costs recorded by health system), 90-day postoperative costs (allowed amounts paid by insurance plan), and 90-day postoperative utilization (length of stay, home health care visits, rehabilitation visits) were compared between mKA and rKA patients, stratified by total (TKA) or unicompartmental (UKA) surgery. Linear regression modeling was used to compare outcomes between the two pairs of groups (mKA vs. rKA, for both UKA and TKA). Log-link function and gamma error distribution was used for costs. All analyses were done using SAS statistical software, with p<0.05 considered statistically significant. Results. Overall KA volume increased 21%, from 532 cases in the pre-rKA period to 644 post-rKA introduction, with UKA surgeries increasing from 38 to 97 (155%). Of these KAs, 218 patients were insured through our system's health plan (38 rUKAs, 9 mUKAs, 91 rTKAs, and 80 mTKAs), allowing precise insurance claims analysis for postoperative utilization and cost. Patients with rKA had significantly lower mean home health costs (-90% difference for UKA, −79% difference for TKA, p<0.02) and home rehab costs (-64% difference for UKA, −73% difference for TKA, p≤0.007) than mKA patients. No significant differences were observed in outpatient rehab (visits or costs), total rehab costs, or length of stay. Mean total postoperative costs were significantly lower for rUKA than mUKA (-47% difference, p=0.02) but similar for TKA (p>0.05). There were no significant differences in total inpatient costs between MAKO and non-MAKO patients. Conclusion. Robotic-arm assisted KA can allow for increased UKA volume and potential for substantial
The discussion of outpatient unicompartmental knee arthroplasty (UKA) requires proof that it can be done safely and effectively, and also begs the question of whether it can be performed in an ambulatory surgery center (ASC) rather than a general hospital (which raises costs and is typically less efficient). Successful outpatient UKA requires carefully crafted algorithms/protocols, home support, preoperative planning and preparation, expectation management, risk stratification (not everyone is a candidate), perioperative pain management and buy-in from patients, support networks and the health care team. Relatively little data is available on the feasibility, safety and potential
Introduction. Proposed advantages of patient-specific instrumentation in total knee arthroplasty (TKA) include enhanced accuracy for component positioning, reduced operative time, and increased OR efficiency leading to potential
The Swansea Morriston Achilles Rupture Treatment
(SMART) programme was introduced in 2008. This paper summarises
the outcome of this programme. Patients with a rupture of the Achilles
tendon treated in our unit follow a comprehensive management protocol
that includes a dedicated Achilles clinic, ultrasound examination,
the use of functional orthoses, early weight-bearing, an accelerated
exercise regime and guidelines for return to work and sport. The
choice of conservative or surgical treatment was based on ultrasound
findings. . The rate of re-rupture, the outcome using the Achilles Tendon
Total Rupture Score (ATRS) and the Achilles Tendon Repair Score,
(AS), and the complications were recorded. An elementary cost analysis
was also performed. . Between 2008 and 2014 a total of 273 patients presented with
an acute rupture 211 of whom were managed conservatively and 62
had surgical repair. There were three
re-ruptures (1.1%). There were 215 men and 58 women with a mean
age of 46.5 years (20 to 86). Functional outcome was satisfactory.
Mean ATRS and AS at four months was 53.0
(. sd . 14), 64.9 (. sd. 15) (n = 135), six months 67.8
(. sd. 16), 73.8 (. sd. 15) (n = 103) and nine months
(72.4; . sd. 14) 72.3 (. sd. 13) (n = 43). The programme
realised estimated
Venous thromboembolism (VTE) is a serious complication after total hip and knee arthroplasty. There is still no consensus regarding the best mode of thromboprophylaxis after lower limb arthroplasty. The aim of this study was to ascertain the efficacy, safety profile and rate of adverse thromboembolic events of aspirin as extended out of hospital pharmacological anticoagulation for elective primary total hip and knee arthroplasty patients and whether these rates were comparable with published data for low molecular weight heparin (LMWH). Data was extracted from a prospective hospital acquired thromboembolism (HAT) database. The period of study was from 1st Jan 2013-31st Dec 2016 and a total of 6078 patients were treated with aspirin as extended thromboprophylaxis after primary total hip and knee arthroplasty. The primary outcome measure of deep vein thrombosis and pulmonary embolism within 90 days postoperatively was 1.11%. The secondary outcome rates of wound infection, bleeding complications, readmission rate and mortality were comparable to published results after LMWH use. The results of this study clearly show that Aspirin, as part of a multimodal thromboprophylactic regime, is an effective and safe regime in preventing VTE with respect to risk of DVT or PE when compared to LMWH. It is a cheaper alternative to LMWH and has associated potential
Aims. The purpose of this study is to determine if higher volume hospitals
have lower costs in revision hip and knee arthroplasty. Materials and Methods. We questioned the Centres for Medicare and Medicaid Services
(CMS) Inpatient Charge Data and identified 789 hospitals performing
a total of 29 580 revision arthroplasties in 2014. Centres were
dichotomised into high-volume (performing over 50 revision cases
per year) and low-volume. Mean total hospital-specific charges and
inpatient payments were obtained from the database and stratified
based on Diagnosis Related Group (DRG) codes. Patient satisfaction
scores were obtained from the multiyear CMS Hospital Compare database. Results. High-volume hospitals comprised 178 (30%) of the total but performed
15 068 (51%) of all revision cases, including 509 of 522 (98%) of
the most complex DRG 466 cases. While high-volume hospitals had
higher Medicare inpatient payments for DRG 467 ($21 458 versus $20 632,
p = 0.038) and DRG 468 ($17 003 versus $16 120,
p = 0.011), there was no difference in hospital specific charges
between the groups. Higher-volume facilities had a better CMS hospital
star rating (3.63 versus 3.35, p <
0.001). When
controlling for hospital geographic and demographic factors, high-volume
revision hospitals are less likely to be in the upper quartile of
inpatient Medicare costs for DRG 467 (odds ratio (OR) 0.593, 95%
confidence intervals (CI) 0.374 to 0.941, p = 0.026) and DRG 468
(OR 0.451, 95% CI 0.297 to 0.687, p <
0.001). Conclusion. While a high-volume hospital is less likely to be a high cost
outlier, the higher mean Medicare reimbursements at these facilities
may be due to increased case complexity. Further study should focus
on measures for
Introduction: Common pathologies seen in hand clinics include Dupuytren’s contracture, ganglia and trigger digits. Some patients can be treated in the out patient department by percutaneous fasciotomy, aspiration, or percutaneous A1 pulley release. The effectiveness and safety of these procedures has been documented in the literature. There are no studies investigating the cost effectiveness these of treatments. Aim: Our aim was to compare the cost of treatment of Dupuytren’s contracture, ganglia and trigger digits in the out-patient department with the operating theatre. Methods: All patients seen in a new patient hand clinic with a diagnosis of Dupuytren’s contracture, trigger digit or ganglion of the wrist or hand were prospectively identified over a 6 month period.. The number undergoing a procedure in the out-patient clinic or theatre was recorded. Costings of theatre time and out-patient time were obtained from the hospital management. Results: 80, 26, and 52 patients were treated with regard to Dupuytrens contracture, ganglia, and trigger digits respectively over the 6-month period. Of these, 37, 23, and 44 were treated by an out patient procedure, and 43, 3 and 8 underwent a formal operation. Based on a cost of £216 per out-patient clinic session, the cost of the out-patient procedures was calculated at £1872 over 6 months, or £3744 per annum. Based on a theatre cost of £1785 per session, to perform all the clinic procedures as formal operations would have cost £60,690 over 6 months, or £121380 per annum. The
A longer stay in the hospital after primary total hip replacement is consistent with an increased morbidity and slower recovery for patients. In addition, it is among the more costly aspects of a total joint replacement. A process, which reduces the length of stay following this procedure and synchronically maintains the high standards of safe care would certainly improve the clinical practice and provide financial benefits. Our objective was to evaluate the efficiency of a holistic perioperative, accelerated recovery programme following this procedure and in particular to assess its impact in the shot term patient’s recovery, morbidity, complications, readmission rate and
Patient specific instrumentation (PSI) uses advanced
imaging of the knee (CT or MRI) to generate individualised cutting
blocks aimed to make the procedure of total knee arthroplasty (TKA)
more accurate and efficient. However, in this era of healthcare
cost consciousness, the value of new technologies needs to be critically
evaluated. There have been several comparative studies looking at
PSI versus standard instrumentation. Most compare
PSI with conventional instrumentation in terms of alignment in the
coronal plane, operative time and surgical efficiency, cost effectiveness
and short-term outcomes. Several systematic reviews and meta-analyses
have also been published. PSI has not been shown to be superior
compared with conventional instrumentation in its ability to restore traditional
mechanical alignment in primary TKA. Most studies show comparative
efficacy and no decrease in the number of outliers in either group.
In terms of operative time and efficiency, PSI tended towards decreasing
operative time, saving a mean of five minutes per patient (0 to
20). Furthermore, while some
Slipped capital femoral epiphysis (SCFE) is the most common pediatric hip disorder. The most devastating complication is development of avascular necrosis of the femoral head. In order to reduce the potential for this complication occurring following delayed contralateral SCFE, there has been consideration in the literature of prophylactic pinning of the contralateral hip. The objective of this study was to determine the cost-effectiveness of this treatment strategy. The outcome probabilities and utilities utilised in a decision analysis of prophylactic pinning of the contralateral hip in SCFE, reported by Kocher et al, were used in this study. Costing data, reported in 2005 Canadian dollars, was obtained from our institution. Using this data, an economic evaluation was performed. The time horizon was four years, so as to follow the adolescents to skeletal maturity. Discounting was performed at 3% per year. Sensitivity analyses were conducted to determine the effect of variation of the outcome probabilities and utilities. In all analyses, prophylactic pinning resulted in
Surgical site infections constitute the cause of 13% to 18% of readmissions within 90 days of a total hip arthroplasty and are a leading cause of failure of revision total knee arthroplasty. The goals of wound closure are to enhance healing potential, prevent infection, and provide a cosmetic appearance. Traditionally, this has been achieved with the use of interrupted sutures. However, recently “barbed” sutures have been introduced which consist of a solid core with peripheral etched barbs in a helical array. These sutures have been used for both the deep and superficial layers of wound closure in a running fashion with the barbs intended to be self-retaining in the event that the suture is cut or pulls out of the tissue. Proposed advantages include the avoidance of knots, less needles required, improved efficiency, and creation of a “watertight” seal. Numerous studies have shown decreased times for wound closure with the use of barbed vs. interrupted sutures with no difference in infection or complication rates. With less needles and improved efficiency, there is the potential for
Introduction. Alternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services (CMS) to decrease overall healthcare cost by optimizing healthcare delivery. The associated shift of financial risk to participating institutions has been criticized to introduce patient selection in order to avoid potentially high cost of care. This study aimed to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery and hospital costs at a single care center. Methods. This is a retrospective review of THA patient from July 2015-December 2017 was performed. Patient were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before or after implementation of the CJR bundle. Patient age, gender, and BMI, as well as Elixhauser comorbidities and ASA scores were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared before and after CJR implementation. Results. 751 THA patients (273 Medicare and 478 Commercial Insurance) were evaluated before (29%) and after (71%) CJR bundle implementation. There was no difference in patient demographics (age, gender, or BMI); however, commercially insured patients had less Elxihauser comorbidies pre-bundle (p=0.033). After CJR implementation length of stay (p=0.010) for Medicare patients was reduced with a trend toward discharge to home (p=0.019). However, surgical time and OR service time as well as direct hospital costs were similar before and after the CJR bundle initiation. Conclusions. There was no differential patient selection after CJR bundle implementation, and value-based metrics (surgical time, OR service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any
Purpose. Arthritis is the most common chronic illness in the United States. TKR provides reliable pain relief and improved function for patients with advanced knee arthritis. Total joint replacement now represents the greatest expense in the national healthcare budget. Surgical costs are driven by two key components: fixed and variable costs. Patient Specific Instruments™ (PSI, Zimmer, Warsaw, IN, USA) has the potential to reduce both fixed and variable costs by shortening operative time and reducing surgical instrumentation. However, PSI requires the added costs of pre-operative MRI scanning and fabrication of custom pin guides. Previous studies have shown reduction in operating room times and required instrumentation, but question the cost-effectiveness of the technology. Also, these studies failed to show improvement in coronal alignment, but call for additional studies to determine any improvement in clinical function and patient satisfaction. Our pilot study aims to compare the incremental PSI costs to fixed and variable OR
Venous thromboembolism (VTE) is a potentially fatal complication after total hip replacement (THR) and may be associated with a considerable economic burden. In many centres, thromboprophylaxis using a subcutaneous (sc) anticoagulant in patients undergoing THR is restricted to 14 days or less. Rivaroxaban is a once-daily, oral, direct Factor Xa inhibitor in advanced clinical development for thromboprophylaxis after major orthopaedic surgery; it does not require monitoring or dose adjustment. In a phase III study, RECORD2, oral rivaroxaban 10 mg, given once daily for 35±4 days, significantly reduced the incidence of the primary endpoint (deep vein thrombosis, pulmonary embolism and all-cause mortality), compared with 40 mg sc enoxaparin, given for 14 days (2.0% vs 9.3%, respectively; relative risk reduction 79%; p<
0.001). The incidence of bleeding was low and similar in both groups, despite extended thromboprophylaxis with rivaroxaban. This analysis demonstrates the economic impact of extended thromboprophylaxis with oral rivaroxaban. The effect of rivaroxaban on healthcare costs was based on the primary efficacy results, and the associated reduced administration and monitoring costs, and includes non-drug costs only. The cost of symptomatic VTE was taken from published sources in the US and the UK 2007 NICE Guidelines. It was assumed that nurses spent 3 mins/day administering enoxaparin and training patients to self-inject for outpatient use. Hospital duration was 5 days. In the UK, full blood counts should be taken every 3 days when receiving enoxaparin. The total US health-care resource cost was $192/patient for enoxaparin and $39 for rivaroxaban (excluding drug costs). This saving of $153 was driven by reduced hospital costs associated with fewer VTEs when using rivaroxaban. In the UK, the total healthcare cost/patient was £44 with enoxaparin and £2 with rivaroxaban – savings driven equally by reduced hospitalization and monitoring costs with rivaroxaban prophylaxis. The different
There is no consensus on the management of TA rupture. For operative management, TA have been repaired under general/spinal anaesthetic (GA) or LA. LA repair may be at least as effective and can reduce anaesthetic complications. LA can be performed as a day case and could have significant
Introduction. There have been significant advancements in postoperative care following total hip arthroplasty (THA) over the past decade and it is essential to quantify the impact of efforts made to better optimize patients and improve postoperative care. The purpose of this study was to assess trends in discharge destination, length of stay (LOS), and readmissions following primary THA. Methods. Patients undergoing primary THA during 2011–2017 were identified in the American College of Surgeons National Quality Improvement Program using CPT code 27130. Non-elective surgery and simultaneous bilateral THA procedures were excluded. Patients were classified as having discharged home or to not home locations. Trends in discharge destination, LOS, 30-day readmission, 30-day reoperation, and American Society of Anesthesiologists (ASA) classification were assessed using the Cochran-Armitage test. Results. Of the 155,638 primary THA patients analyzed, 81% discharged home and 19% did not discharge home. From 2011–2017 there was a 21% increase in percentage of patients discharging home (72% in 2011, 87% in 2017, p<0.001) despite a significantly increasing number of patients with ASA score ≥ 3 (34% to 40%, p<0.001, Figure 1). Over this time period, hospital LOS decreased from 3.1 to 2.0 days for those discharging home (p<0.001) and from 3.8 to 3.6 days those not discharging home (p=0.003). There were no significant changes in 30-day reoperation rates for patients discharging home and readmission rates significantly decreased over time (3.2% in 2011 to 2.6% in 2017, p=0.02). Conclusion. From 2011–2017, patients undergoing THA were more likely to discharge home, had shorter hospital LOS and significantly decreased readmission rates. These trends persisted despite an increasingly comorbid patient population. It is likely these trends have resulted in significant
Introduction Bilateral total knee replacement under one anaesthetic is a common procedure. Claimed benefits include: shorter hospital stays, fewer complications of some kinds, lower over all cost and more efficient use of staff time. In general the literature supports these concepts though some writers caution against the procedure. Most studies come from large university hospitals but most joint replacements are done in smaller hospitals. At Calvary Hospital we instituted a quality assessment review of our experience to determine patient safety and
Widespread use of XLPE has reduced the incidence of both revision surgery and dislocations. This paper aims to create gross estimates of the magnitude of the resulting
Introduction. The purpose of bundled payment programs is to reduce cost via risk sharing, while still maintaining quality. If savings are achieved under a historic target price, the orthopedic surgeon will receive a monetary bonus. If costs are higher, a portion is deducted from payment to the orthopedic surgeon. The purpose of this study was to evaluate our experience with the Bundled Payments for Care Improvement Program (BPCI) when run by an orthopedic surgeon group to determine patient safety and who benefited the most financially. Methods. This program ran from January 2015 through September 2018. 3,186 Medicare total hip and knee replacements, elective (DRG 470) and for fracture (DRG 469), performed by our group were included. 90 day hospital and all postoperative expenditures were reconciled against our historic cost. All patients were medically optimized with discharge plans established preoperatively. We developed preferred skilled nursing facilities and home health care agencies with synergistic medical providers so that discharges were recommended as soon as appropriate. We hired two full-time case managers to have direct contact with patients pre-and post-operatively. Waiver assistance such as house and pet sitters were used if necessary at our expense. 35% of savings went to the convener, who acted as a liaison between our group and CMS. Expenditures for the 90-day period for all patients were calculated to determine where savings occurred and which entity benefitted financially. Results. There was an average 9.2% reduction in hospital readmissions. An estimated total savings of $5,100,000 occurred. There was a 17% reduction in hospital costs, a 12.1% reduction in admissions to skilled nursing facilities with a 34% reduction in length of stay, and a 5% reduction in admissions to inpatient rehabilitation facilities. There was a 35% reduction in home health visits, but no change in outpatient physical therapy visits. After group expenses, final bonus to the orthopedic provider was on average $262 per patient. Conclusion. The physician managed program was very successful from Medicare's standpoint, achieving significant monetary savings without reducing quality of care. However, the bonus to the providing and managing physicians was nominal. It also does not take into consideration the 50 plus hours spent in meetings to develop this program. Participation could be considered a defensive posture so as not to lose more reimbursement. However, experience was gained which will be valuable for future gain sharing programs. Physicians and physician organizations need to sit at the head of the table to manage future payment bundles and perhaps also act as the convener. We deserve this, as a result of demonstrating high safety and
Background. In surgeon controlled bundled payment and service models, the goal is to reduce cost but preserve quality. The surgeon not only takes on risk for the surgery, but all costs during 90 days after the procedure. If savings are achieved over a previous target price, the surgeon can receive a monetary bonus. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with cardiology consultation at their discretion, and without dictating specific testing. Our participation in the Bundled Payments for Care Improvement (BPCI) program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having costly readmissions for cardiac events. Objective. To determine the medical effectiveness and
Introduction. Current CMS reimbursement policy for total joint replacement is aligned with more cost effective, higher quality care. Upon implementation of a standardized evidenced-based care pathway, we evaluated overall procedural costs and clinical outcomes over the 90-day episode of care period for patients undergoing TKA with either conventional (Conv.) or robotic-assisted (RAS) instrumentation. Methods. In a retrospective review of the first seven consecutive quarters of Bundled Payment for Care Improvement (BPCI) Model 2 participation beginning January 2014, we compared 90-day readmission rates, Length of Stay (LOS), discharge disposition, gains per episode in relation to target prices and overall episode costs for surgeons who performed either RAS-TKA (3 surgeons, 147 patients) or Conv. TKA (3 surgeons, 85 patients) at a single institution. All Medicare patients from all surgeons performing more than two TKA's within the study period were included. An evidence-based clinical care pathway was implemented prior to the start of the study that standardized pre-operative patient education, anesthesia, pain management, blood management, and physical/occupational therapy throughout the LOS for all patients. Physician specific target prices were established from institutional historical payment data over a prior three year period. Results. RAS and Conv-TKA procedures exhibited an average gain per episode of $7,600 and $5,579, respectively. The average total cost per 90-day episode was $2,085 lower for patients receiving RAS-TKA ($28,943 versus $31,028), with the majority of
We present a case series of patients who underwent 3 or 4 part proximal humerus fracture fixation using an intra-osseous suture technique. 18 patients are included in the study with follow up data obtained ranging from 1 to 4 years. Oxford Shoulder Scores (OSS) and range of movement measurements were taken for all patients. The mean OSS for the group was 50/60 with a mean forward flexion of 140°, abduction of 132°, external rotation of 48° and internal rotation to the level 10. th. thoracic vertebra. Three patients developed adhesive capsulitis, 2 requiring subsequent arthroscopic release. This data compares favourably to outcomes reported in the literature with hemiarthroplasty or locking plate fixation. An activity based costing analysis estimated that the treatment costs for proximal humerus fractures was approximately £2,055 when performing a soft tissue reconstruction, £3,114 when using a locking plate and £4,679 when performing a hemiarthroplasty. This demonstrates a significant financial saving when using intra-osseous fixation compared to other fixation techniques. We advocate the use of the intra-osseous suture fixation technique for certain 3 and 4 part fractures. It gives good functional outcomes, significant
Pre-operative knowledge. Knowledge-based total hip arthroplasty is becoming increasingly recognised for improved safety, efficiency, and accuracy. Pre-operative knowledge of native and planned femoral anteversion, the exact size of implants, neck length and offset, and head lengths can serve to safely accelerate surgery and reduce the need for intra-operative imaging. Pre-operative knowledge of the effect on change in leg length and offset effected by specific implant combinations can serve to minimise undesired changes. The use of a smart mechanical navigation tool superimposed on this knowledge, can serve to easily and swiftly achieve optimal component position.
Introduction. Close to 30% of the surgical causes of readmission within 90 days post-total knee arthroplasty (TKA) and nearly half of those occurring in the first 2 years are caused by instability, arthrofibrosis, and malalignment, all of which may be addressed by improving knee balance. Furthermore, the recently launched Comprehensive Care for Joint Replacement (CJR) initiative mandates that any increase in post-acute care costs through 90-days post-discharge will come directly from the bundle payment paid to providers. Post-discharge costs, including the cost of readmissions for complications are one of the largest drivers of the 90-day cost of care. It is hypothesized that balanced knees post-TKA will lower the true provider costs within the 90-day bundle. Methods. Cost, outcomes and resource utilization data were collected from three independent surgeons pre- and post- adoption of intraoperative technology developed to provide real-time, quantitative load data within the knee. In addition, data were collected from Medicare claims, hospital records, electronic medical records (EMR), clinical, and specialty databases. The cohorts consisted of 932 patients in the pre-adoption group and 709 patients in the post-adoption group. These 2 groups were compared to the CMS national average data from 291,201 cases. The groups were controlled for age, sex, state, and BMI with no major differences between cohorts. The cost factors considered were the length of hospital stay, physician visits and physical therapy visits in addition to post-operative complications (e.g., manipulation under anesthesia (MUA) and aseptic revision). Results. After adoption of technology to improve ligament balancing intra-operatively, all three surgeons decreased their patients’ hospital stay (3.0 days to 2.6 days), number of physician visits (2.3 to 2.1), number of outpatient physical therapy visits (14.9 to 10.6) and MUA rate (2.3% to 1.8%). These clinical benefits subsequently lowered the 90-day net cost of TKA an average of $443 per case. When compared to the national average, this
Background. Non-invasive hemoglobin measurement was introduced to potentially eliminate blood draws postoperatively. We compared the accuracy and effectiveness of a non-invasive hemoglobin measurement system with a traditional blood draw in patients undergoing total joint arthroplasty. Methods. After IRB approval, 100 consecutive patients undergoing primary total hip or knee arthroplasty had their hemoglobin level tested by both traditional blood draw and a non-invasive hemoglobin monitoring system. Results were analyzed for the entire group, further stratifying patients based on gender, race, surgery (THA versus TKA), and post-operative hemoglobin level. Finally, we compared financial implications and patient satisfaction with the device. Paired t-test with 0.05 conferring significance was used. Stratified analyses of the absolute difference between the two measures were assessed using Mann- Whitney test. To assess the level of agreement between the two measures, the concordance correlation coefficient (CCC) was calculated. Results. Mean blood-draw hemoglobin value on POD1 was 11.063 ± 1.39 g/dL and 11.192 ± 1.333 g/dL with the non-invasive device. For all patients, the mean absolute difference between the two methods was 0.13 g/dL (p = 0.30). The CCC between the two methods was 0.58, conferring a moderate to strongly positive linear relationship (Figure 1). Non-invasive measurement was preferred by 100% of patients with a mean VAS score of 0/10. Additionally, the
Introduction. Robotic assisted Total Knee Arthroplasty (rTKA), provides surgeons with preoperative planning and real-time data allowing for continuous assessment of ligamentous tension and range-of-motion. Using this technology, soft tissue protection, reduced early post-operative pain and improved patient satisfaction have been shown. These advances have the potential to enhance surgical outcomes and may also reduce episode-of-care (EOC) costs for patients, payers, and hospitals. The purpose of this study was to compare robotic assisted vs. manual total knee arthroplasty: 1) 90-day episode-of-care (EOC) costs; 2) index costs; 3) lengths-of-stay (LOS); 4) discharge disposition; and 5) readmission rates. Methods. TKA procedures were identified using the Medicare 100% Standard Analytic Files including; Inpatient, Outpatient, Skilled Nursing (SNF) and Home Health. Members included patients with rTKA or manual TKA (mTKA) between 1/1/2016-3/31/2017. To account for potential baseline differences, propensity score matching (PSM) was performed in a 1-to-5 ratio, robotic to manual based on age, sex, race, geographic division, and comorbidities. After PSM, 519 rTKA and 2,595 mTKA were identified and included for analysis. Ninety-day episode-of-care cost, index cost, LOS, discharge disposition and readmission rates were assessed. Results. Overall 90-day EOC costs were $2,391 less for rTKA patients ($18,568 vs. $20,960; p<.0001). Index facility cost and LOS were also less for rTKA patients by $640 ($12,384 vs. $13,024; p=.0001) and 0.7 days (p<.0001). Additionally, rTKA patients were discharged to SNF less frequently (12.52% vs. 21.70%; p<.0001) and home with health aid (56.65% vs. 46.67%; p<.0001) or self-care (27.55% vs. 23.62%; p=.0566) more frequently and had a 90-day readmission reduction of 33% (p=.0423). Conclusion. Robotic assisted TKA resulted in an overall lower 90-day episode-of-care cost when compared to manual TKA. The 90-day EOC
Background. We identified several opportunities to significantly reduce cost for hip and knee arthroplasty procedures:. Customized instruments: by identifying the essential instruments for arthroplasty cases, we managed to have one universal tray for each case, and 3 specific trays from the implant manufacturing company. Customized wrap-free, color-coded, stackable trays: by using a wrap-free trays, preparation time in central sterile, opening tray time in OR and turn-over time were reduced. Also, stackable trays were organized based on side and size, therefore only 2 trays needed to be used in each case. Discounted implants: negotiated through optional case coverage with revision system and reps available as backup. Optional rep coverage protocols: designed through process management of the operating room surgical staff and central sterile. Aim of the study was to measure the
Background. The Bundled Payments for Care Improvement (BPCI) was developed by the US Center for Medicare and Medicaid (CMS) to evaluate a payment and service delivery model to reduce cost but preserve quality. 90 day postoperative expenditures are reconciled against a target price, allowing for a monetary bonus to the provider if savings were achieved. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative cardiovascular readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with or without additional cardiology consultation, without dictating specific testing. Typical screening includes an EKG, occasionally an echocardiogram and nuclear stress test, and rarely a cardiac catheterization. Our participation in the BPCI program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having readmissions for cardiac events. Objective. To determine the medical effectiveness and
Adequate soft tissue balance at the time of total knee arthroplasty (TKA) prevents early failure. In cases of varus deformity, once the medial osteophytes have been resected, a progressive release of the medial soft tissue sleeve (MSS) from the proximal medial tibia is needed to achieve balance. The “classic” medial soft tissue release technique, popularised by John Insall et al., consists of a sharp subperiosteal dissection from the proximal medial tibia that includes superficial and deep medial collateral ligament (MCL), semimembranosus tendon, posteromedial capsule, along with the pes anserinus tendons, if needed. However, this technique allows for little control over releases that selectively affect the flexion and extension gaps. When severe deformity is present, an extensive MSS release can cause iatrogenic medial instability and the need to use a constrained implant. It has been suggested that the MSS can be elongated by performing selective releases. This algorithmic approach includes the resection of the posterior osteophytes as the initial balancing gesture. If additional MSS release is necessary in extension, a subperiosteal release of the posterior aspect of the MSS is performed with electrocautery, detaching the posterior aspect of the deep MCL, posteromedial capsule and semimembranosus tendon for the proximal and medial tibia. Dissection is rarely extended more than 1.5 cm distal to the joint line. If additional release is necessary in extension, the medial compartment is tensioned with a laminar spreader and multiple needle punctures (generally less than 8) are performed in the taut portion of the MSS using an 18G or 16G needle. If additional release is necessary to balance the flexion gap, multiple needle punctures in the anterior aspect of the MSS are performed. This stepwise approach to releasing the MSS in a patient with a varus deformity allows the surgeon to target areas that selectively affect the flexion and extension gaps. Its use has resulted in diminished use of constrained TKA constructs and subsequent
Background. Non-operative cases of mallet finger can be followed up by the hand therapists. Both trust and national policies encourage appropriate indication for follow-up in fracture clinic & cost-effective approach without affecting the patient care. Aims. To reduce unnecessary fracture clinic follow up for Mallet finger injuries. Methods. Management for uncomplicated mallet finger injuries is provided by hand therapy and does not need surgical input. Hand Surgeons in the department agreed to a management protocol for Mallet finger injuries, to streamline patient management and save costs. All Mallet finger injuries less than 6 weeks old not requiring surgery to be referred for hand therapy at the first appointment in fracture clinic and left with an open appointment. Retrospective audit of all patients referred to hand therapy in 2015 (Jan-Dec) done to identify extra appointments. Results. Inclusion criteria: All mallet fingers seen in fracture clinic. Exclusion criteria: > 6-week-old injury at presentation, Patients requiring surgery (joint subluxation). Retrospective first Audit (01/01/2015-31/12/2015):. 55 patients identified fulfilling inclusion criteria. 33 patients had delayed referral to hand therapists (12–107 days). 37 patients had extra fracture clinic appointments totalling 72 appointments. Prospective re-audit (01/10/2016 – 31/12/2016):. 16 patients met inclusion criteria. Number of patients referred in their first fracture clinic: 10 patients. Other 6 patients had mean delay 20 days. Potential cost saving in fracture clinic for the trust over a year of £4730. Extra-fracture clinic in 7 patients, but 3 were clinically indicated (review to check possible subluxation) i.e. only 4 wasted clinic appointments. Conclusions. By restructuring our management for Mallet fingers we have streamlined the service. There is early referral to hand therapy, reduced fracture clinic appointments, decreasing pressure on fracture clinics, enhanced patient experience and
Patients over 70 years old have subclinical or impending rotator cuff dysfunction, raising concern about TSA in this population. The purpose of this study is to examine whether reverse total shoulder arthroplasty (RTSA) should be considered for the treatment of glenohumeral osteoarthritis in the presence of an intact rotator cuff (GHOA+IRC in patients older than 70 years of age. Twenty-five elderly (>70 years) patients at least one year status-post RTSA for GHOA+IRC were matched via age, sex, body mass index, smoking status, and whether the procedure involved the dominant extremity with 25 GHOA+IRC patients who received anatomic total shoulder arthroplasty (TSA). Standardised outcome measures, range of motion, and treatment costs were compared between the two groups. Treatment cost was assessed using implant and physical therapy costs as well as reimbursement. Patients who received RTSA for GHO+IRC had significantly lower pre-operative active forward elevation (AFE, 69° vs. 98°, p <0.001) and experienced a greater change in AFE (p=0.01), but had equivalent AFE at final follow-up (140° vs. 142°, p=0.71). Outcomes were otherwise equivalent between groups with no differences. In both those patients who underwent TSA and those that underwent RTSA, significant improvements between pre-operative and final follow-up were seen in all standardised outcome measures and in AFE (p<0.001 in all cases). RTSA provided these outcomes at a
This study reviewed all patients who received an EXOGEN Express bone stimulating device (BSD) to treat delayed union / non-union following operative treatment for a long bone fracture & evaluate if our results are comparable with the NICE guideline expectations. A retrospective review of records between December 2004 & January 2013 revealed 113 patients treated with a BSD. A total of 59 patients were eligible for analysis, (operative treatment for a long bone fracture with adjuvant EXOGEN BSD for non-union or delayed union). Twenty-one were open fractures. The BSD was applied at a mean of 264 days post-operatively. Thirty-five patients went on to have a 2nd operation before union was achieved. Forty-two patients went on to union following application of the BSD. Mean time to union was 293 days. Seventeen patients failed to unite by the end of the study. There were no adverse reactions to the EXOGEN BSD in this cohort. This study has shown that the use of an EXOGEN BSD is a safe, non-invasive method to successfully treat long bone non-unions following initial operative surgery, with potential
Introduction. Robotic-arm total knee arthroplasty (RTKA) was developed to potentially improve accuracy of bone cuts, component alignment, soft tissue balance, and patient outcomes. There is a paucity of data demonstrating that RTKA is superior to conventional total knee arthroplasty (CTKA) in terms of any of these metrics. This prospective comparative multicenter study was designed with these purposes in mind. Methods. Patients were enrolled between June 1st, 2016 and March 31st, 2018 in a prospective, non-randomized, open-label, multicenter, consecutive comparative cohort study comparing RTKA and CTKA. Only patients who satisfied the following inclusion criteria were included: body mass index (BMI) ≤ 40kg/m2, primary unilateral TKA procedure, at least 18 years of age, and no joint infection. The following data were collected for analysis:. Preoperative data on component size prediction from CT scans. Intraoperative data on bone resection levels and joint line maintenance. Functional activity scores, patient-reported symptoms, satisfaction and expectation scores using The New Knee Society Scoring System. Radiographic results, specifically coronal alignment. Results. For femoral components implanted, 82% were the exact size as predicted by the robotic-software and the remaining 18% were within 1 size (100% within 1 size). For tibial implants, 69% were the exact size of what the robotic-software predicted and 29% were within 1 size (98% within 1 size). RTKAs had significantly less distal lateral femoral resection (5.55 vs. 7.11 mm), distal medial femoral resection (6.89 vs. 7.97 mm), lateral tibial resection (7.76 vs. 8.54 mm), and medial tibial resection (4.11 vs. 5.56 mm, p<0.05) compared to CTKA. Joint line restoration was comparable between RTKA and CTKA, but required less tibial bone removal when using robotic techniques. Pre-operatively, all demographic, functional, symptom, satisfaction, and expectation measures were similar between treatment groups (all p<0.05, Tables 1–5). Those who underwent RTKA had significantly higher mean functional activity walking and standing score improvements from baseline to 4–6 weeks (1.4 vs. −1.2 points; p=0.019) and to 6 months (9.6 vs. 6.9 points; p=0.017) after surgery compared to CTKA. The mean overall functional activity score improvement from baseline to 1-year post-surgery was also higher for RTKA compared to CTKA (36.8 vs. 15.0 points; p=0.020). For all other parameters (standard activities, advanced activities, pain with walking, pain with stairs, satisfaction and expectation scores), score changes from baseline were not significantly different between groups, though many trended slightly higher for RTKA. Radiographic evaluation of RTKA demonstrated that varus deformity was corrected to neutral in 96% of cases and valgus deformity was corrected in 100%. Conclusion. To the best of our knowledge, this is the first study to prospectively evaluate outcomes of RTKA patients compared to CTKA. A number of positive early effects were seen with RTKA. This patient cohort will continue to be followed, and these findings may translate into longer-term patient reported outcomes improvement, longer component survivorship and
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. Background. The Bundled Payments for Care Improvement (BPCI) initiative was introduced to reduce healthcare costs while maintaining quality. We examined data from a healthcare system comprised of five hospitals that elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2 initiative beginning July 1, 2015. We compared one hospital that did 507 BPCI knee cases to the four other hospitals that did 566 cases. Stratifying the data by hospital volume, we sought to determine if costs decreased during the BPCI period, how the savings were achieved, and if savings resulted in financial rewards for participation. Methods. The Medicare data included the target cost for each episode (based on historical data from 2009–2012 for each hospital that was adjusted quarterly) and actual Part A and Part B spending for 90 days. Using 1,836 primary knee replacements, we analyzed the costs associated with the anchor hospitalization, inpatient rehabilitation, skilled nursing facilities, home health, outpatient physical therapy and readmission to compare the 1,073 knees done during the 16-month BPCI initiative period with the 763 knees done during the 1-year period preceding BPCI participation. Owing to the nonparametric distribution of the cost data, a Mann-Whitney U test was used to compare the higher volume hospital with the four lower volume hospitals. Results. Compared to the preceding year, the mean episode of care cost during BPCI participation decreased by 8.5% (from $20,853 to $19,087, p=0.24) at the higher volume hospital while remaining virtually unchanged (going from $20,383 to $20,380, p=0.10) at the lower volume hospitals. During the BPCI period, the mean Medicare 90-day target cost was $18,307 at the higher volume hospital and $22,287 at the lower volume hospitals (p<0.001). At the higher volume hospital, the major components of the savings included $367,290 from reduced readmission rates (5.7% versus 8.7%, p=0.11), $207,608 primarily due to a reduction in the length of stay at skilled nursing facilities (mean 15 days versus 25 days, p=0.005), and $130,894 associated with a decreased percentage of patients using inpatient rehabilitation (3.2% versus 4.9%, p=0.22). Although offset by other cost increases, the largest component of the savings at the lower volume hospitals was $262,548 due to a decrease in the percentage of patients (2.3% versus 4.8%, p=0.04) using inpatient rehabilitation. Despite its savings, the mean reconciliation penalty was $851 per case at the higher volume hospital while the lower volume hospitals received a mean reward of $2,165 per case. Conclusion. Based on the reduction in costs and decreased readmission rates, the BPCI initiative is achieving its objectives. Despite an 8.5% decrease in costs, the $18,307 target based on historical data resulted in an $851 penalty per case at the higher volume hospital. In contrast, as a result of a $3,980 higher target, the lower volume hospitals were rewarded even though they did not achieve
Introduction. While total hip arthroplasty is considered to be one of the most cost-effective medical interventions, the total cost of care for a population patients treated by THR can present a significant burden on the payer, whether it be an employer, private insurer or government. Data on the true cost of care has rarely been made available to the treating physician. Such lack of information makes comprehensive management difficult. Bundled payment models of care require knowledge of all costs associated with the care of our patients and opens new opportunity for analysis to improve management and outcomes. The current study assess the influence of surgical technique on total cost of care for total hip arthroplasty. Methods. Payment data for 341 patients who underwent total hip arthroplasty at a single institution from June 1. st. , 2011 to October 31. st. , 2014 were analyzed. Each procedure was performed using either the superior, anterior, or posterior exposure. The superior exposure was performed with femoral head excision and without dislocation of the hip. The data were analyzed for total cost, inpatient cost, inpatient physician cost, readmission cost, skilled nursing facility cost, and home healthcare agency cost among the different approaches. Results. The superior hip approach for total hip arthroplasty results in a significant total
In a global environment of rising costs and limited funds, robotic and computer-assisted orthopaedic technologies could provide the means to drive a necessary revolution in arthroplasty productivity. Robots have been used to operate on humans for 20 years, but the adoption of the technology has lagged behind that of the manufacturing industry. The use of robots in surgery should enable
Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated this transformation to same day discharge for arthroplasty care, most notably Partial Knee Arthroplasty (PKA). The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on PKA and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed 1,230 knee arthroplasty procedures with no readmissions for pain control. Average age and age range is identical to our inpatient cohort for our partial knee cases. Patient selection is based on medical screening criteria and insurance access. PKA is the ideal procedure to begin your transition to the outpatient space. We currently perform medial PKA, lateral PKA, and patellofemoral arthroplasty as an outpatient. The program centers on the patient, their family, home recovery, preoperative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space. Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for
Introduction. Cementless total knees were historically associated with early failure. These failures, likely associated with implant design, made cemented total knee arthroplasty (TKA) the “gold standard”. Manufacturers have introduced newer uncemented technologies that provide good initial stability and utilize a highly-porous substrates for bony in-growth. Outcome data on these implants has been limited. In addition, these implants typically have a price premium which makes them difficult to use in the setting of cost containment and in at risk 90-day bundles. Our purpose was to compare 90-day outcomes of a new uncemented implant with those of a comparable cemented implant from the same manufacturer. We hypothesized that the implants would have equivalent 90-day clinical and economic outcomes. Methods. Ninety-day clinical and economic outcomes for 252 patients with prospectively collected data from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database were reviewed. Ninety-day outcomes were compared between uncemented knees and an age-matched group of cemented knees (Triathlon cemented vs uncemented Triathalon-tritanium, Stryker Orthopedics, Mahwah, NJ, USA). Both cruciate retaining and posterior stabilized designs were included. MARCQI data: demographics, co-morbidities, length of stay, complications, emergency department visits, discharge disposition, and readmissions were reviewed. Financial data provided by the hospital's finance department was used for economic comparisons. Fischer's test was done to assess categorical data and a student's t-test was used to compare numerical data. Results. Uncemented knees had shorter length of stay (1.58 vs. 1.87, p<0.0001), were more frequently discharged home (90.48% vs. 68.75%; p<0.0001) and used less home care or extended care facilities (6.35% vs. 19.14%, p<0.0001; 2.78% vs. 11.72%, p=0.0001). More uncemented knees had “no complications”. Moreover, there were no reoperations in uncemented knees, compared to 19 reoperations in cemented knees most being manipulations (14 vs. 0, p=0.0028). Uncemented knees scored better than age matched counterparts Knee Injury and Osteoarthritis Outcomes Score (63.69 vs. 47.10, n=85 and 43, p<0.0001), and Patient Reported Outcomes Measurement Information System T-physical and T-mental (44.12 vs. 39.45, n=95 and 59, p<0.0001; 51.84 vs 47.82, n=97 and 59, p=0.0018). Cemented cases were more expensive overall, the surgical costs were higher ($6806.43 vs. $5710.78 p<0.01) and the total hospital costs were higher ($8347.65 vs. $7016.11 p<0.01). The 90-day readmission and hospital outpatient costs were not significantly different between the designs. Conclusion. The use of a modern uncemented TKA implants has increased, but data on outcomes and the economic impact has been limited particularly in regard to 90-day at risk global periods. Our study suggests that patients receiving an new uncemented TKA have a shorter length of stay, higher rate of discharge to home, better patient reported outcome measures, fewer complications and fewer reoperations than an age-matched group of patients receiving a similar, cemented design during the 90-day global period. Importantly, the uncemented knees had $1,095 less surgical episode costs (p< 0.001) and a 90-day
Refinement of surgical techniques, anaesthesia protocols, and patient selection have facilitated this transformation to same day discharge for arthroplasty care, most notably Partial Knee Arthroplasty (PKR). The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on Partial Knee Arthroplasty (PKA) and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed 1,230 Knee Arthroplasty procedures with no readmissions for pain control. Average age and age range is identical to our inpatient cohort for our partial knee cases. Patient selection is based on medical screening criteria and insurance access. PKA is the ideal procedure to begin your transition to the outpatient space. We currently perform medial PKA, lateral PKA, and patellofemoral arthroplasty as outpatient cases. The program centers on the patient, their family, home recovery, pre-operative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anaesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space. Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for
Cementless stem fixation is a widely used method of stem revision in North America and elsewhere in the world. There is abundant literature in its support. Most of the reports from 1985 to 2005 related to proximally or extensively porocoated designs, the former falling into disfavor with time because of unpredictable outcomes. With few exceptions (e.g. S-ROM) the modularity of these designs was limited to the head/neck junction. But this generation of designs was associated with some issues such as insertional fractures, limited control of anteversion (and risk of dislocation), limited applicability in the setting of severe bone loss (Paprosky Type 4 osteolysis or Vancouver Type B3 periprosthetic fracture), as well as ongoing concern relating to severe proximal stress shielding. In the past decade we have seen the mounting use of a new design concept: tapered fluted titanium stems (TFTS), which incorporate the advantages of titanium (for less flexural rigidity), conical taper (for vertical taper-lock stability), longitudinal ribs or flutes (for rotational stability), and surface preparation which attracts bone ongrowth for long term fixation. Four consecutive reports from our center have documented the superiority of the TFTS in our hands, with encouraging outcomes even when dealing with severe bone loss or periprosthetic fractures. There is an increasing body of other literature which reports a similar experience. Furthermore, with increasing experience and confidence in this design concept, we now use a monoblock or non-modular design in the majority of cases in which a TFTS is indicated. This circumvents the potential drawbacks of stem modularity, including taper corrosion and taper junction fracture. Our recent report of this concept in 104 cases with a 2-year minimum follow-up supports the use of this concept in many if not most stem revisions. The question remains as to which should be favored? Because of equipoise in the outcomes of the two fundamental stem designs, at least in our hands, clearly the surgeon needs to ask other, more practical questions:. Am I familiar enough with the TFTS technique so as to bypass the potential versatility of the modular stem for the simplicity and potential
In the current health care climate, there is an increasing focus on
Background:. Developing a successful outpatient service for Ilizarov frame removal provides both patient and cost benefits. Misinformation and patient trepidation can be detrimental to recovery and influence choices. Education may play an important role in tailoring an efficacious service. Objective:. Review Belfast Regional Limb Reconstruction frame removal practice, introduce changes aimed at improving care and evaluate effects. Methods:. 1 year retrospective review of Ilizarov frame removal. Evaluation of service prior to and following provision of a new patient information leaflet, alongside a test wire removal technique. Subsequent service evaluation supplemented via patient reported feedback questionnaire. Results:. Retrospectively 85% Ilizarov frames removed in clinic, 54% required Entonox. Annual cost £19000. 46% patients unaware of process, gathering information from unprofessional sources. General anaesthetic and analgesic requirements related to psychosocial influences; no correlation between fracture configuration, elective reconstructive cases and operative techniques. Prospectively 96% patients found information leaflet educational and beneficial. 87% Ilizarov frames removed in clinic. 100% patients who had outpatient removal recommend this method. Entonox use reduced to 15% with average pain score 4.6/10 without analgesia. Patients felt happier. Projected annual
Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay and opened the opportunity for
Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for
Carpal tunnel decompression is one of the most commonly performed orthopaedic operations. Last year 160 patients attended our department for surgery. There have been reports in the literature of good results and improved patient satisfaction for wound closure with Vicryl Rapide following Dupuytren's surgery. We looked at 200 consecutive patients who underwent carpal tunnel decompression. Wounds were closed using either non-absorbable monofilament sutures (first 97 patients) or interrupted Vicryl Rapide (next 103 patients). We compared the incidence of wound problems in the early post operative period, scar sensitivity and the number of patients requiring a further outpatient appointment because of ongoing problems associated with these issues. There was a higher incidence of early wound problems (p=0.0359) in patients whose wounds were closed with nylon. There was no difference in the rates of scar tenderness (p=1) or in the number of patients requiring further clinic appointments (p=0.356). There are also potential
Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. ERAS allows for the incorporation of evidence based practices and incorporated a comprehensive assessment of the patient's journey through the surgical process from pre-operative screening through to post-operative care. The purpose of this study was to determine if optimisation of ERAS protocol with pre-operative screening and incorporating patient-specific factors into their post operative care would improve length of stay (LOS) and readmission rates following total joint arthroplasty (TJA) in a Canadian community hospital setting. The study collected clinical, demographic data and the physical status perioperative using the American Society of Anaesthesiologists (ASA) classification on 508 patients who underwent TJA between January and August 2015 and compared similar data from the same time frame in the previous calendar year prior to implementation of the pathway. Cohorts were analysed for length of stay (LOS), readmission rates, Pre-operative assessments (completed by anaesthesia, nursing and pharmacy), relevant labs, patient history (surgery, medical, social), and patient values were all considered when developing a specific patient plan for care post-operatively. A post-operative management tool was used to optimise pain control, post-operative nausea and vomiting, bowel management, diabetes blood glucose control, venous thromboembolism prophylaxis, as well as monitoring parameters specific to patient medical history (e.g. respiratory, cardiac). While in hospital, physiotherapy and nursing were consulted by the pharmacist to assess whether patient's post op management needed to be altered to optimise mobilisation and recovery in hospital. The average patient's LOS and readmission rates in 30 days was analysed to assess the change after implementation of the post-operative management tool based on patient specific factors. A total of 508 patients (mean age: 66 years), ASA classification was 3 or greater for 430 patients. The patients were assessed for LOS, readmission rates in 30 days. The mean LOS decreased from 3.6 to 3.3 days after optimisation of the ERAS protocol (student t test p=0.021). The 30-day readmission rate decreased from 2.9% to 1.4% post intervention (z test p=0.087) when compared to the same time period in the previous calendar year prior to protocol implementation. Overall, the
Introduction. Preoperative templating of femoral and tibial components can assist in choosing the appropriate implant size prior to TKA. While weight bearing long limb roentograms have been shown to provide benefit to the surgeon in assessing alignment, disease state, and previous pathology or trauma, their accuracy in size prediction is continually debated due to scaling factors and rotated views. Further, they represent a static time point, accounting for boney anatomy only. A perceived benefit of robotic-assisted surgery is the ability to pre-operatively select component sizes with greater accuracy based on 3D information, however, to allow for flexibility in refining based on additional data only available at the time of surgery. Methods. The purpose of this study was to determine the difference of pre-operative plans in size prediction of the tibia, femur, and polyethylene insert. Eighty four cases were enrolled at three centers as part of an Investigational Device Exemption to evaluate a robotic-assisted TKA. All patients had a CT scan as part of a pre-operative planning protocol. Scans were segmented and implant sizes predicted based on the patients boney morphology and an estimated 2mm cartilage presence. Additional information such as actual cartilage presence and soft tissue effects on balance and kinematics were recorded intra-operatively. Utilizing this additional information, surgical plans were fine tuned if necessary to achieve minimal insert thickness and balance. Data from the Preoperative CT plan sizing and final size were compared to determine the percentage of size and within one size accuracy. Results. The pre-operative plan was able to determine the femoral and tibial components within one size for 100% of cases. Intra-operatively, surgeon upsized femoral 15 out of 85 (18%), downsized femoral 1 out of 85 (1%), baseplate 13 out of 85 (15%), and downsized baseplate 4 out of 85 (5%). Polyethylene exact size could be planned 93% of the time. Discussion/Conclusion. Robotic-assisted pre-operative CT based planning was accurate over 70% of the time for the femur and tibial components, and over 90% with respect to the insert thickness Additionally, intraoperative information allowed for adjustments to provide patients with ideal coverage of articular surfaces and for joint balancing providing optimal individualized component placement. Further research is needed to determine the potential
We present a complete audit cycle of Emergency Department management of paediatric clavicle fractures at Derriford Hospital. Local guidelines divide the clavicle into three zones. Fractures with minimal displacement in the middle 3/5th heal in the majority of cases without complication and can be discharged without need for follow up, provided parents are adequately educated. An initial audit cycle of 63 cases identified short comings in adherence to the guidelines. These included: Unnecessary fracture clinic follow up of ‘Zone 2’ fractures in 85% and omission of written advice in 86%. The results were circulated, ‘aide memoir’ icons were added to the department's computer coding system, staff teaching sessions were organised and a patient advice sheet was produced. Following the implementation of changes, a 23 case re-audit showed fewer unnecessary referrals to fracture clinic (17% vs. 85%) and improvements in the number of parents being given written advice (43% vs. 14%). Staff training, provision of information leaflets and changes to the ED coding system dramatically improved the adherence to hospital guidance. This resulted in standardisation of care, fewer unnecessary appointments and
We present a complete audit cycle of Emergency Department (ED) management of paediatric buckle fractures of the distal radius at Derriford Hospital. Local hospital management guidelines state that the limb should be supported in a wrist splint for 3 weeks following injury and, provided parents are adequately educated, no formal follow-up is required. Auditable standards were obtained from the local guidance. An initial audit cycle of 54 cases identified shortcomings in compliance with guidelines. These included: Inappropriate immobilisation in 34 (63%) cases, omission of written advice in 35 (65%) cases and arrangement of unnecessary follow-up in 31 (57%) cases. Following circulation of the results, ‘aide-memoir’ icons were added to the emergency department computer coding system, teaching sessions for emergency department staff were organised and new paediatric specific wrist splints were introduced. A re-audit of 33 patients evaluated the effect of the changes. This demonstrated a 27% improvement in correct wrist support usage (27/33, 82%) and 25% fewer unnecessary referrals to fracture clinic (27/33, 82%). Staff training and provision of appropriate wrist splints were crucial to improving the adherence to guidance. This resulted in standardisation of care, fewer unnecessary appointments for patients and
Introduction. Postoperative dislocation remains a vexing problem for patients and surgeons following total hip arthroplasty (THA). It is the commonest reason for revision THA in the US. Dual mobility (DM) THA implants markedly decrease the risk of THA instability. However, DM implants are more expensive than those used for conventional THA. The purpose of this study was to perform a cost-effectiveness analysis of DM implants compared to conventional bearing couples for unilateral primary THA using a computer model-based evaluation. Methods. A state-transition Markov computer simulation model was developed to compare the cost-utility of dual mobility versus conventional THA for hip osteoarthritis from a societal perspective (Figure 1). The model was populated with health outcomes and probabilities from registry and published data. Health outcomes were expressed as quality-adjusted life years (QALYs). Direct costs were derived from the literature and from administrative claims data, and indirect costs reflected estimated lost wages. All costs were expressed in 2013 US dollars. Health and cost outcomes were discounted by 3% annually. The base case modeled a 65-year-old patient undergoing THA for unilateral hip osteoarthritis. A lifetime time horizon was analyzed. The primary outcome was the incremental cost-effectiveness ratio (ICER). The willingness-to-pay threshold was set at $100,000/QALY. Threshold, one-way, two-way, and probabilistic sensitivity analyses were performed to assess model uncertainty. Results. DM THA exhibited absolute dominance over conventional THA with lower accrued costs (US$45,960 versus $47,103) and higher accrued utility (12.08 QALY versus 11.84 QALY). The ICER was -$4,771/QALY, suggesting that DM THA is cost-saving compared to conventional THA. The cost threshold at which dual mobility implants were cost-ineffective was $25,000 (Figure 2), and the threshold at which DM implants ceased being cost-saving was $12,845. Sensitivity analyses demonstrated that the probability of intraprosthetic dislocation, primary THA utility, and age at index THA most influenced model results. In the probabilistic sensitivity analysis, 90% of model iterations resulted in
INTRODUCTION. Wasted implants represent both an increased risk and cost to our healthcare system. In our institution, a sterilely packaged implant that is opened and not implanted is wasted in one out of 20 primary total knee replacement procedures. The cost of these wasted implants exceeds $1 million per year. We propose the introduction of a novel, computer based, e.Label and compatibility system to reduce implant-related medical errors and waste in total knee arthroplasty. We hypothesize that the implementation of this system will help reduce medical errors and wasted implants by improving and standardizing the visual markers and by ensuring that parts are compatible so that implant mismatches and inappropriate laterality are prevented. METHODS. A software program was implemented which creates an e.Label for all components (Figure 1) and checks imbedded, manufacturer provided, compatibility charts to ensure that parts are of appropriate laterality, and are compatible with each other. Upon implementation, the program was studied prospectively for seven months and compared to a retrospective cohort in regards to number, type, and cost of wasted implants. Critical errors that were detected were also recorded. RESULTS. During the retrospective period there were 83 wasted implants in 1450 surgeries, or an incidence of 5.7%. After implementation of the computer based system, there were two wasted implant in 244 surgeries performed by the study physicians, or an incidence of 0.8% (Figure 2). One critical medical error was identified and prevented during the study period (Figure 3). The annualized
Introduction. The aim of the study was to compare and contrast the clinical outcome of conversion of practice of a shoulder surgeon from open to arthroscopic shoulder stabilisation for traumatic anterior shoulder instability. Patients and Methods. Comparison of a cohort consecutive series of 24 patients treated by open stabilisation and a prospective consecutive cohort series of 30 patients treated by arthroscopic stabilisation. Clinical outcomes were assessed with Oxford Shoulder Score Instability (OSS-I) and a Patient Satisfaction Survey at a minimum of 1 year follow up. The operation time as well as cost analysis were also evaluated. Results. The average OSS-I for open stabilisation was 39.6 (range 19-48) as compared to 39.8 (range 23-48) with the arthroscopic group and these scores did not show a statistically significant difference. Both cohorts were pleased with the clinical outcome and were happy to recommend the procedure to others. No complications in either group were seen. Operative time and costs were significantly more in the open group, even taking into account initial learning curve of the arthroscopic method. All arthroscopic procedures were performed as day-cases compared to over-night stays for the open group also providing better use of hospital resources and
We reviewed the current screening protocol for MRSA detection in patients admitted for elective lower limb arthroplasty as we thought it may not be cost effective and there is no evidence base for validity of MRSA screening swabs. The current institutional screening protocol includes MRSA swabs from nose and groin taken on 2 different occasions; the 1st swab taken at time patient was placed on the waiting list and the 2nd swab taken at the Orthopaedic pre-clerking clinic around 6–8 weeks later. We found that during the study period, of 1791 patients who underwent MRSA screening swabs, only 16 patients had positive results. Of these, 9 patients had known MRSA (2 in care home) and no data was available in 2 patients. However in 5 patients, there was an initial negative swab which later was found to be positive. The time interval in these ranged from 0.6 to 85 weeks (Conversion rate = 0.3%). The laboratory cost for these screening swabs was £9,027. Given the low prevalence rate of MRSA and low conversion rate at 6 weeks, there is a role for accepting a single-swab screening protocol. This would also result in significant
Percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and injection of local steroids for the treatment of the trigger digit. We treated 43 patients, average age 57 years (range12-78). All trigger digits were grade III-IV (Quinnell classification). A mean duration of pre-operative symptoms was 7.3 months (range 2-13 months). A percutaneous release was performed with a 19-gauge hypodermic needle under local anaesthesia in the outpatient setting. All patients were evaluated with respect to clinical resolution of symptoms and general satisfaction. We report a 97% successful release and only one case of incomplete release. A result in terms of abolishing triggering was immediate and patient acceptance was excellent. By two weeks, all the patients had no pain at the operative site. After a mean follow-up of 30.2 months (range12-50), there had been no recurrences. There were no digital nerve injuries, flexor tendon injuries, and infections. The percutaneous release is a safe and effective technique, which provides significant
Introduction. Measured outcomes from knee joint arthroplasty (TKA) have primarily focused on surgeon-directed criteria, such as alignment, range of motion measured in the clinic, and implant durability, rather than on functional outcomes. There is strong evidence that subjective reporting by patients fails to capture objective real-life function. 1,2. We believe that the recent emphasis on clinical outcomes desired by the patient, as well as the need to demonstrate value, requires a new approach to patient outcomes that directly monitors ambulatory activity after surgery. We have developed and tested a system that: 1) autonomously identifies patients who are not progressing well in their recovery from TKA surgery; 2) characterizes patient activity profiles; 3) automatically alerts health care providers of patients who should be seen for additional follow-up. We anticipate that such a system could decrease secondary procedures such as manipulation under anesthesia (MUA) and reduce hospital re-admission rates thereby resulting in significant
Introduction. Tranexamic acid (TXA) has been shown to decrease hemoglobin loss and reduce the need for transfusions in primary hip and knee arthroplasty. Recently, authors have proven similar results in revision total knee arthroplasty (TKA). No previous paper has focused on the safety and efficacy of TXA for revision TKA for periprosthetic joint infection (PJI). The purpose of our study was to evaluate the safety and efficacy of topical TXA in revision TKA for PJI. Methods. We performed a retrospective review of all patients who underwent two-stage revision total knee arthroplasty for infection at our institution between September 25, 2007 and July 12, 2013. We evaluated hemoglobin loss, need for transfusion, one-year reinfection rate, length of stay (LOS), complications and one-year mortality with and without the use of TXA in all patients who underwent Stage-1 removal of hardware with antibiotic spacer placement and/or revision (Stage-2) for PJI of the knee. All data sets were analyzed using a two-sample t-test. Results. During the study period, 45 patients underwent 49 Stage-1 procedures (20 knees with TXA, 29 without) and 44 patients underwent 47 Stage-2 revisions (28 with TXA, 19 without). Tranexamic acid use significantly decreased the hemoglobin loss in the Stage 1 group (19.8% vs 30.05%, p=0.0004) and the Stage-2 group (24.5% vs 32.01%, p=0.01). Furthermore, in both groups, the use of TXA was associated with a significant reduction in transfusion rates (Stage-1 25% vs 51.7%, p=0.04; Stage-2 25% vs 52.6%, p=0.05). There was a non-statistical decreased LOS of over a day in both groups (Stage-1 5.15 vs 6.72 days, p=0.055; Stage-2 5.21 vs 6.84 days, p=0.09). Finally, in both groups, there was no statistical difference in one-year re-infection rate (p=0.98) or one-year mortality (0 vs 0). There was a single upper extremity DVT around a PICC line, occurring in a patient who underwent a Stage 1 procedure augmented with topical TXA. There were no PEs. Conclusion. Topical tranexamic acid is both safe and effective for use in both stages of revision TKA for PJI. Despite the small number of patients, we show a significant reduction in the hemoglobin loss and transfusion requirement in both stages of TKA revision for PJI. Although it did not reach significance with our number of patients, we feel an average LOS over a day shorter in each group is a strong potential for
Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips. Materials/Methods: Of the 30585 births (over a 6 year period) in the population served by our hospital, 2742 babies (8.96percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive). Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans. Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and