The presence of metastatic bone disease (MBD) often necessitates major orthopaedic surgery. Patients will enter surgical care either through emergent or electively scheduled care pathways. Patients in a pain crisis or with an acute fracture are generally admitted via emergent care pathways whereas patients with identified high-risk bone lesions are often booked for urgent yet scheduled elective procedures. The purpose of this study is to compare the post-operative outcomes of patients who present through emergent or electively scheduled care pathways in patients in a Canadian health care system. We have conducted a retrospective, multicenter cohort study of all patients presenting for surgery for MBD of the femur, humerus, tibia or pelvis in southern Alberta between 2006 and 2021. Patients were identified by a search query of all patients with a diagnosis of metastatic cancer who underwent surgery for an impending or actual pathologic fracture in the Calgary, South and Central Alberta Zones. Subsequent chart reviews were performed. Emergent surgeries were defined by patients admitted to hospital via urgent care mechanisms and managed via unscheduled surgical bookings (“on call list”). Elective surgeries were defined by patients seen by an orthopaedic surgeon at least once prior to surgery, and booked for a scheduled urgent, yet elective procedure. Outcomes include overall survival from the time of surgery, hospital length of stay, and 30-day hospital readmission rate. We have identified 402 patients to date for inclusion. 273 patients (67.9%) underwent surgery through emergent pathways and 129 patients (32.1%) were treated through urgent, electively scheduled pathways. Lung, prostate, renal cell, and breast cancer were the most common primary malignancies and there was no significant difference in these primaries amongst the groups (p=0.06). Not surprisingly, emergent patients were more likely to be treated for a pathologic fracture (p<0.001) whereas elective patients were more likely to be treated for an impending fracture (p<0.001). Overall survival was significantly shorter in the emergent group (5.0 months, 95%CI: 4.0-6.1) compared to the elective group (14.9 months 95%CI: 10.4-24.6) [p<0.001]. Hospital length of stay was significantly longer in the emergent group (13 days, 95%CI: 12-16 versus 5 days, 95%CI: 5-7 days). There was a significantly greater rate of 30-day hospital readmission in the emergent group (13.3% versus 7.8%) [p=0.01]. Electively managed MBD has multiple benefits including longer post-operative survival, shorter length of hospital stay, and a lower rate of 30-day hospital readmission. These findings from a Canadian healthcare system demonstrate clinical value in providing elective orthopaedic care when possible for patients with MBD. Furthermore, care delivery interventions capable of decreasing the footprint of emergent surgery through enhanced screening or follow-up of patients with MBD has the potential to significantly improve clinical outcomes in this population. This is an ongoing study that will justify refinements to the current surgical care pathways for MBD in order to identify patients prior to emergent presentation. Future directions will evaluate the costs associated with each care delivery method to provide opportunity for health economic efficiencies

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 cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears. In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model. Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits. The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects

Abstract. Introduction. The risk of Covid-19 community and hospital acquired infection (HAI) on patient outcomes in trauma is still relevant. Patient's should be routinely consented for this risk to ensure informed consent for perioperative contraction. Method. A prospective audit was completed from December-March 2022 examining a consecutive series of patient admissions with capacity to consent. The standards for compliance was RCOS Toolkit 5#3 stating the importance of enhanced consent for risk of contraction, in operating and changes to care pathways. The target was 95% compliance. 2/2 contingency tables were generated to determine odds ratio for compliance versus Covid+ rate. Results. This audit generated 80 consecutive patients from which 28 were excluded as non-operative or lacking capacity. It was found that 25% (13/52) had been specifically consented for risks of Covid-19. The rate of PCR-positive results was 15% (8/52) with a mortality of 25%. Approximately 2% of patients in this series were informed of the risk and had a positive Covid-PCR. An odds ratio of 0.38 indicates that being informed of the risk is not associated with rate of infection e.g by adopting enhanced personal protective measures. Conclusions. The pandemic recovery has not removed this substantial community and nosocomial risk. Our results demonstrate poor compliance with RCS guidance despite ongoing relevance to care. Consent includes the counselling of a patient to specific Covid-related risks including thrombosis & death. Dissemination of these results will be followed by completion of the audit cycle to look for improvements in compliance

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 cost savings in reduced SNF usage ($1,481) and readmissions ($944). Discharge to home versus Sub-acute Rehabilitation Facilities (SAR's) was 14% higher in the RAS group (62% vs 48%, p<0.05). Conclusions. Implementation of a standardized care pathway across all service departments and physicians resulted in a reduction in overall episode of care costs, with further reductions in cost and discharge to SARs observed with the use of RAS

Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures. We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs. This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated. Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07). HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments

Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS

Objectives. The goal of this study was to describe and evaluate the implementation of a tailored care pathway as an alternative to a standard joint care protocol in the postoperative in-hospital rehabilitation after total knee replacement (TKR) on clinically relevant outcome parameters. Methods. We monitored an orthopaedic department regarding postoperative rehabilitation after TKR on several outcome parameters throughout a period of 32 months, whilst introducing a new care pathway after 17 months. Outcome parameters were monitored and comprised: Time to get functionally recovered (in days), length of stay (in days) and destination of discharge. Key-differences between the joint care protocol and the new tailored pathway were: 1. determination of individual short term rehabilitation goals on the basis of a preoperative clinical prediction rule and postoperative monitoring of functional recovery, 2. Enhancement of expertise of and collaboration between health care professionals and 3. implementation of fast track rehabilitation. We compared the patients operated after implementation of the tailored care pathway with those who were treated according to the joint care protocol. Regression analysis was used to estimate differences between the two groups of patients while correcting for baseline differences in risk profile between the groups. Results. Introduction of the tailored care pathway decreased the length of stay on average from 5.2 days to 4.2 days, (p< 0.01). In addition, there was a 7% non-statistically significant reduction in the number of patients who required inpatient rehabilitation after hospital discharge. Conclusion. Introduction of the tailored care pathway reduced the mean length of stay by one day, whilst patient safety and satisfaction remained unaltered

Metastatic bone disease (MBD) is a significant contributor to diminished quality of life in cancer patients, often leading to pathologic fractures, hypercalcaemia, intractable bone pain, and reduced functional independence. Standard of care management for MBD patients undergoing orthopaedic surgery is multi-disciplinary, includes regular surgical follow-up, case by case assessment for use of bone protective medications, and post-operative radiation therapy to the operative site. The number of patients in southern Alberta receiving standard of care post-operative management is currently unclear. Our aim is to develop a database of all patients in southern Alberta undergoing orthopaedic surgery for MBD and to assess for deficiencies and opportunities to ensure standard of care for this complex patient population. Patients were identified for database inclusion by a search query of the Alberta Cancer Registry of all patients with a diagnosis of metastatic cancer who underwent surgery for an impending or pathologic fracture in the Calgary, South and Central Alberta Zones. Demographic information, primary cancer history, previous local and systemic treatments, anatomical location of MBD event(s), surgical fixation techniques, and post-operative care details were collected. The rate of standard of care post-operative treatment was evaluated. A comparison of outcomes between tertiary urban centres and rural centres was also completed. Survival was calculated from time of first operation to date of death. Univariate and multivariate analyses were performed to identify the impact of post-operative care variables on survival amongst patients surviving longer than one month. We identified 402 patients who have undergone surgical treatment for MBD in southern Alberta from 2006-2018. Median age at time of surgery was 66.3 years and 52.7% of patients were female. Breast, lung, prostate, renal cell and multiple myeloma were the most common primary malignancies (n=328, 81.6%). Median post-operative survival was 6.8 months (95%CI: 5.7-8.3). 203 patients (52.5%) were treated with post-operative radiotherapy and 159 patients (50.8%) had post-operative surgical follow-up. Only 39 patients (11.3%) received bone protective agents in the peri-operative period. On multivariate survival analysis, post-operative surgical follow-up was associated with improved survival (p<0.001). Patients were treated at nine hospitals across southern Alberta with most patients treated in an urban center (65.9%). Post-operative survival was significantly longer amongst patients treated in an urban center (9.0 months, 95%CI: 6.9-12.3 versus 4.3 months, 95%CI: 3.4-5.6, p<0.001). The burden of MBD is significant and increasing. With treatment occurring at multiple provincial sites, there is a need for standardized, primary disease-specific peri- and post-operative protocols to ensure quality and efficacious patient care. To provide evidence informed treatment recommendations, we have developed a database of all patients in southern Alberta undergoing orthopaedic surgery for MBD. Our results demonstrate that many patients were not treated according to post-operative standard of care recommendations. Notably, half of the included patients did not have documented surgical follow-up, post-operative radiation treatment was low and only 11% were actively treated with bone protective agents. This data justifies the need for established surgical MBD care pathways and provides reference data to benchmark prospective QA and QI outcomes in this patient population

Aims. COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department. Methods. We retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19. Results. A total of 214 patients had orthopaedic surgical procedures, with 166 included for analysis. Patients undergoing procedures under general or spinal anaesthesia had a higher risk of contracting perioperative COVID-19 compared to regional/local anaesthesia (p = 0.0058 and p = 0.0007, respectively). In all, 15 patients (9%) had a perioperative diagnosis of COVID-19, 14 of whom had fragility fractures; six died within 30 days of their procedure (40%, 30-day mortality). For proximal femoral fractures, our 30-day mortality was 18.2%, compared to 7% in 2019. Conclusion. Based on our findings, patients undergoing procedures under regional or local anaesthesia have minimal risk of developing COVID-19 perioperatively. Those with multiple comorbidities and fragility fractures have a higher morbidity and mortality if they contract COVID-19 perioperatively; therefore, protective care pathways could go some way to mitigate the risk. Our 30-day mortality of proximal femoral fractures was 18.2% during the COVID-19 pandemic in comparison to the annual national average of 6.1% in 2018 and the University Hospital Coventry average of 7% for the same period in 2019, as reported in the National Hip Fracture Database. Patients undergoing procedures under general or spinal anaesthesia at the peak of the pandemic had a higher risk of contracting perioperative COVID-19 compared to regional block or local anaesthesia. We question whether young patients undergoing day-case procedures under regional block or local anaesthesia with minimal comorbidities require fourteen days self-isolation; instead, we advocate that compliance with personal protective equipment, a negative COVID-19 swab three days prior to surgery, and screening questionnaire may be sufficient. Cite this article: Bone Joint Open 2020;1-9:520–529

Introduction. The correction of paediatric scoliosis is a surgical procedure in which substantial bleeding occurs, and which historically has been associated with high levels of blood transfusion. Transfusions are associated with risks of infection, allergic reactions, volume overload and immunosuppression. The purpose of our study was to evaluate the efficacy of a care pathway implemented at St Thomas' hospital over ten years with a focus on minimising the need for blood transfusions. A Spinal Surgery Care Pathway was developed including: nurse-led clinics facilitating pre-operative haemoglobin optimisation; intra operative cell-salvage, the use of tranexamic acid, and a transfusion criteria awareness programme. Methods. We reviewed the records of all patients 18 years of age or younger undergoing spinal corrective surgery between 2000 and 2010. Collating data from the surgical records and haematology laboratory, we identified the proportion of patients requiring transfusion and the respective volume of blood or blood products transfused. Results. 534 spinal procedures were undertaken on patients over the decade of interest. Over this time, the proportion of patients requiring transfusion reduced from 83.3% in 2000, to 6.4% in 2010 (p < 0.001); a consistent year on year reduction was witnessed between 2005 and 2010. In those requiring transfusion, the volume of packed red cells transfused fell from a mean of 7.7 units in 2000, to 1.5 units in 2010 (p < 0.001). These results were despite an increase in posterior fusions, associated with higher bleeding, from 50.0% to 79.4% over the same time period. Conclusion. Over ten years, we have demonstrated that the implementation of a multifaceted, multidisciplinary pathway together with challenging cultural attitudes to blood transfusion, can dramatically and sustainably reduce the need for blood transfusion and the risks associated therewith. These data lends weight to the adoption of such a care pathway in paediatric scoliosis surgery

We have a national UK database for hip fracture outcome. It has been developed synchronously with an agreed care pathway that is multi-disciplinary, including surgeons, anaesthetists, geriatricians, osteoporosis experts, healthcare managers and lay charities. Care has been improved and audit established for future evolution. The database started in 2007 and now includes 85 units. The synchronous care pathway deals with falls and osteoporosis prevention, perioperative multi-disciplinary care, rehabilitation and outcome results. Key issues are avoidance of delay and cancellation of surgery and how we deal with patients with medical co-morbidities. Outcome is analysed prospectively to take account of co-morbidities and variations in surgical techniques. The care pathway and data base are now universally accepted as a national priority with advice for all UK trauma units to participate. Of the 121 registered units, only 85 actively contribute data. The cost and staff needs for data input are now accepted. To date, 12,983 clinical cases have been entered. Variation of trauma theatre list operating time per head of population and other related resource has been highlighted. This has been accepted by politicians and health managers. The NHS Institute of Improvement has started a rapid improvement plan to support units with poor resource/audit outcome. It is early days in terms of validity of outcome data for technical variations in treatment eg. fixation/replacement/use of bone cement. We have a national increase in resouce for hip fractures. We now have some logic to interaction between surgeons and medics/managers. Objectively struggling units get active support. We accept the possible lack of validity of some outcome data. Some units who look bad on paper should not be disadvantaged

Integrated Regional Orthopaedic (MSK) Assessment clinics (ROAC) are now mandated in many provinces for the assessment and triage of patients referred for total joint arthroplasty (TJA). Their introduction underscores the lack of means for Primary Care Physicians (PCP) to appropriately refer patients for surgical consideration. Thus, problems arise when patients who are clear candidates for surgery are subject to a significant extra step in the care pathway by attending a ROAC while those who have insufficient problems are also seen, contributing to costs and crowding the access portal. We postulated that a patient reported outcome measure, decision aid combined with a validated grading of a weight bearing knee X-ray would provide an inexpensive yet effective tool to significantly improve the referral process for Knee OA (compared with the current mechanism). To date we have enrolled two hundred and forty-five consenting patients to the study, all referred by their PCP to the ROAC with a diagnosis of symptomatic Knee Osteoarthritis. All patients were evaluated as per the current ROAC protocol which included a medical history, physical examination and an X-ray (standing AP, lateral and patella-femoral skyline). Prior to the visit, subjects were sent a copy of a patient decision aid, Oxford Knee Score (OKS) and requested to answer whether their current clinical status described as Patient Acceptable Symptom State (PASS2) was acceptable. All radiographs were analyzed and scored for OA severity using the validated grading from 0 – 13. Of the 245 cases, 200 completed OKS and PASS2 uestionnaires and had standing X-rays for evaluation (only 120 completed the decision aid and these were left out of this report). Of the 200 included cases, 104 were referred from the ROAC to see a surgeon. In analysis, we found that a self-reported PASS 2 answer NO and an AP X-ray graded at 6 or above predicted over 75% of those patients that were referred. This represents a 3.4 greater likelihood of referral using this simple analysis. The OKS did not modify this prediction. Thus, use of a validated grading of a standing AP X-ray along with a response, ‘readiness for surgery’ indicated 75% of patients appropriate for surgical consideration. Patients with less severe gradings are likely being unnecessarily referred to ROAC leading to overuse of scarce resources, crowding the access and adding to costs, others, who score higher, are being needlessly delayed. The ability to discreetly screen for the best possible candidates should be a continued focus of ROAC and will lead to improved use of expensive resources, overall patient care and satisfaction and the provision of tools to the PCP for appropriate referral

Increasing pressure to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA) is evident in current health care systems for numerous reasons. Patient autonomy and health care economics has challenged the ability of THA implants to maintain functional integrity before achieving bony union. Although collared stems have been shown to provide improved axial stability, it is unclear if this stability correlates with activity levels or results in improved early function to patients compared to collarless stems. This study aims to examine the role of implant design on patient activity and implant fixation. The early follow-up period was examined as the majority of variation between implants is expected during this time-frame. Patients (n=100) with unilateral hip OA who were undergoing primary THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=50) or collarless (n=50) cementless femoral stem. Patients will be seen at nine appointments (pre-operative, < 2 4 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Patients also underwent supine radiostereometric analysis (RSA) imaging < 2 4 hours post-operation prior to leaving the hospital, and at all follow-up appointments. Nineteen collared stem patients and 20 collarless stem patients have been assessed. There were no demographic differences between groups. From < 2 4 hours to two weeks the collared implant subsided 0.90 ± 1.20 mm and the collarless implant subsided 3.32 ± 3.10 mm (p=0.014). From two weeks to three months the collared implant subsided 0.65 ± 1.54 mm and the collarless implant subsided 0.45 ± 0.52 mm (p=0.673). Subsidence following two weeks was lower than prior to two weeks in the collarless group (p=0.02) but not different in the collared group. Step count was reduced at two weeks compared to pre-operatively by 4078 ± 2959 steps for collared patients and 4282 ± 3187 steps for collarless patients (p=0.872). Step count increased from two weeks to three months by 6652 ± 4822 steps for collared patients and 4557 ± 2636 steps for collarless patients (p=0.289). TUG test time was increased at two weeks compared to pre-operatively by 4.71 ± 5.13 s for collared patients and 6.54 ± 10.18 s for collarless patients (p=0.551). TUG test time decreased from two weeks to three months by 7.21 ± 5.56 s for collared patients and 8.38 ± 7.20 s for collarless patients (p=0.685). There was no correlation between subsidence and step count or TUG test time. Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. The presence of a collar on the stem did not affect patient activity and function and these factors were not correlated to subsidence, suggesting that initial fixation is instead primarily related to implant design

Background. There is increasing impetus to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA). The direct anterior (DA) approach is a muscle sparing technique that is believed to support these new pathways. Implants designed for these approaches are available in both collared and collarless variations and understanding the impact each has is important for providing the best treatment to patients. Purpose/Aim of Study. This study aims to examine the role of implant design on implant fixation and patient recovery. Materials and Methods. Patients (n=50) with unilateral hip OA who were undergoing primary DA THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=25) or collarless (n=25) cementless, fully hydroxyapatite coated femoral stem. Patients were seen at nine appointments (pre-operative, <24 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients underwent supine radiostereometric analysis (RSA) imaging <24 hours post-operation prior to leaving the hospital, and at all follow-up appointments. Patients also completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Findings/Results. Twenty-two patients that received a collared stem and 27 patients that received a collarless stem have been assessed. There were no demographic differences between groups. From <24 hours to two weeks the collared implants subsided 0.90 ± 1.20 mm and the collarless implants subsided 3.80 ± 3.37 mm (p=0.001). From two weeks to three months the collared implants subsided 0.67 ± 1.61 mm and the collarless implants subsided 0.45 ± 0.46 mm (p=0.377). Step count was reduced at two weeks to 3108 ± 1388 steps for collared patients and 2340 ± 1685 steps for collarless patients (p=0.072). Step count was increased at three months to 8939 ± 3494 steps for collared patients and 6114 ± 2529 steps for collarless patients (p=0.034). TUG test time was increased at two weeks compared to pre-operatively by 3.45 ± 6.01 s for collared patients and 2.29 ± 4.92 s for collarless patients (p=0.754). TUG test time decreased from two weeks to three months by 6.30 ± 6.05 s for collared patients and 5.68 ± 4.68 s for collarless patients (p=0.922). Conclusions. Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. Presence of a collar on the stem impacted patient activity but not function. This suggests that both the implant design as well as the surgical technique may play a role in the patient's early post-operative experience

Clinical pathways are optimal patient care processes that have been developed to improve the quality of care for patients. Anecdotal evidence has suggested that patients presenting to the healthcare system with rotator cuff tears experience less than ideal quality care plagued by lengthy wait times, challenges in coordinating care, and inefficient use of healthcare resources. Therefore, diagnosis and treatment of patients with rotator cuff tears are in need of quality improvement through evidence-informed decision making. The purpose of this study is to develop a clinical pathway for patients presenting to the healthcare system with rotator cuff tears. The following steps were taken in developing the clinical pathway: 1) a multidisciplinary expert panel was formed; 2) goals of the clinical pathway were identified by the panel; 3) the literature and current clinical practices for best practice were reviewed; 4) recommendations for treatment algorithms were developed using consensus methods. The panel consisted of fourteen experts representing the two largest cities in Alberta, Canada (Edmonton and Calgary). The team consisted of at least one member from the clinical domains of sport medicine, orthopaedic surgery, athletic therapy, and physiotherapy. The first goal of the clinical pathway was to standardise screening, diagnosis, and physical examination of the patient. The second goal was to provide recommendations for appropriate investigations. The final goal was to map steps in the patients' care pathway including sequencing and timing recommendations for treatment and interventions. Best practices were reviewed by the panel and using a modified Delphi method, clinical pathways for three types of rotator cuff tears (acute, chronic, and acute-on-chronic) were developed. A clinical pathway that reflected best practices was developed from the literature and experts. The clinical pathway for diagnosis and treatment of patients with rotator cuff pathology will help to standardised patient care, improve patient flow, reduce unnecessary interventions, reduce healthcare utilisation and costs, and improve the quality of patient care

Significant advances in perioperative pain management, such as multimodal periarticular injection, and subtler advances in surgical technique have resulted in improved postoperative experiences for patients with less pain, earlier rehabilitation, and shorter stays in hospital. Concurrently, and by applying the learnings from above, significant advances have been made in unicompartmental knee arthroplasty care pathways leading to safe programs for outpatient surgery. A natural extension of this process has been the exploration of outpatient total joint arthroplasty (TJA). There are some papers written on the topic, but not many. The papers are generally report that outpatient TJA can be a safe and effective procedure, but the devil is in the detail. Firstly, most authors in this field carry a bias towards positive outcomes given they fact they are expert, academic, and innovative surgeons, often having controlling interest in the management of the complete perioperative pathway. Secondly, and largely as a result of the above, there is a major selection bias as to who receives outpatient TJA. In all cases, the patients are younger, fitter, and with less comorbidities. Patients reported in the published literature on outpatient TJA therefore do not represent the average patient that the average surgeon would operate on. Recall, TJA patients are becoming heavier and older patients (85+) are also receiving TJA at increasing rates. It is useful to remember that TJA is a stressful event from a physiological perspective for the patient. Serious complications, including death, can and do occur. Further, some significant events, like cardiac ischemia occur around the second to third day postoperatively. These patients often require medical intervention for stabilization and need readmission when sent home before these events occur. This obviously is not a trivial issue given the penalties applied to hospitals in the US for early readmissions after TJA. The fundamental questions at this early stage of outpatient TJA are 1) whether it is scalable to a larger audience, and 2) whether or not processes can be developed to make it a routine, standard of care. Given that the current literature is limited and written by expert surgeons on a highly select group of patients, and given that patients in general are getting older and less healthy, it is difficult to imagine a future of TJA as drive through surgery

Although most uncomplicated paediatric fractures do not require routine long-term follow-up with an orthopaedic surgeon, practitioners with limited experience dealing with paediatrics fractures will often defer to a strategy of unnecessary frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway may help reduce unnecessary radiation exposure to this patient population and reduce costs to patient families and the healthcare system. A retrospective analysis including patients who presented to SickKids hospital between October 2009 and October 2014 for management of clavicle fractures was performed. Patients with previous clavicle fractures, perinatal injury, multiple fractures, non-accidental injury, underlying bone disease, sternoclavicular dislocations, fractures of the medial clavicular physis and fractures that were managed at external hospitals were excluded from the analysis. Variables including age, gender, previous injury, fracture laterality, mechanism of injury, polytrauma, surgical intervention and complications and number of clinic visits were recorded for all patients. Radiographs were analysed to determine the fracture location (medial, middle or lateral), type (simple or comminuted), displacement and shortening. 339 patients (226 males, 113 females) with an average age of 8.1 (range 0.1–17.8) were reviewed. Diagnoses of open fractures, skin tenting or neurovascular injury were rare, 0.6%, 4.1%, and 0%, respectively. 6 (1.8%) patients underwent surgical management. All decisions for surgery were made on the first consultation with the orthopaedic surgeon. For patients managed non-operatively, the mean number of clinic visits including initial consultation in the emergency department was 2.0 (±1.2). The mean number of radiology department appointments was 4.1 (± 1.0) where patients received a mean number of 4.2 (±2.9) radiographs. Complications in the non-operative group were minimal; 2 refractures in our series and no known cases of non-union. All patients achieved clinical and radiographic union and returned to sport after fracture healing. Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary-care physician, then routine clinical or radiographic follow up is unnecessary. Development of a paediatric clavicle fracture pathway may reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients' families without jeopardising patient outcomes

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 cost savings to optimising the ERAS protocol for the hospital is substantial; with approximately $238 saved per patient. Pre-operative screening and incorporating patient-specific factors into an individualised care plan to optimise the ERAS protocol for TJA reduced mean length of stay without a concomitant increase in readmission rates with significant cost saving

To propose a national specification for hospitals which offer treatment of complex bone and joint infections to adults. Patients with bone and joint infections are treated in a wide variety of hospitals in the UK. A few have developed services with infection physicians, microbiology laboratory support and dedicated orthopaedic and plastic surgeons working together to deliver a multidisciplinary care pathway. However, many patients are treated in non-specialist units leading to multiple, often unsuccessful procedures with long hospital stays, high costs and additional pain and disability. Inappropriate antibiotic therapy without adequate surgery risks antibiotic resistance. A draft specification was written defining the types of patients who should be referred to a specialist unit for treatment. A description of the components which must be available to treat these cases (staffing, expertise, diagnostic support, outcome assessment and governance structure) was proposed. This draft was circulated to infection units in the UK for consideration and agreed with the Health Department in England. Complex bone and joint infections would be best served nationally by 3–6 networks, each with a single specialist centre. This is similar to national arrangements for bone sarcoma treatment. Patients to be referred will include those with:. Chronic osteomyelitis (long bone, pelvis, spine). Chronic destructive septic arthritis. Complex prosthetic joint infections (multiple co-morbidities, difficult/multi-resistant organisms, multiply operated or failed revision surgery). Infected fractures and non-unions. Specialist units should have:. Orthopaedic surgeons who specialise in infection (joint revision, Ilizarov techniques, etc). Infection physicians who can treat medically unwell patients with complex co-mordidities and multi-resistant infections. Plastic surgeons with experience in difficult microsurgical reconstruction techniques. Scheduled (at least weekly) meetings of all of the above, with a radiologist to discuss new referrals and complex cases. A home IV therapy service. Dedicated in-patient beds staffed by infection trained staff. Multi-disciplinary (one-stop) out-patient clinics. Quality measures assessed, including PROMS, clinical success rates, and functional outcome. Education and research programmes. This service specification is a tool for developing regional units. It facilitates the creation of designated centres in a national network (hub and spoke model). This service specification has been agreed and published by NHS England

Background. The Perioperative Surgical Home (PSH) is a multi-disciplinary rapid recovery pathway aimed at transforming surgical care by delivering value and improving outcomes and patient satisfaction. Our institution developed a PSH pathway for total hip arthroplasty (THA) patients in March 2014. The Orthopaedic and Anesthesia Services co-managed the patients throughout the entire surgical process. Weekly meetings were held to discuss medical and social requirements for upcoming patients including disposition planning. All patients received day of surgery physical therapy, and anesthesia post-surgical pain control and medical co-management. We hypothesized that the PSH would provide enhanced care for THA patients. To our knowledge this is the first report on the PSH in a total joint population. Methods. We prospectively followed 180 THA patients from the PSH group (SH) and compared them to a group matched for age, body mass index (BMI), American society of anesthesiologist score (ASA), and Charleson comorbidity index score (CCI) that were not involved in the PSH (NSH). We used Wilcoxon, Chi square, and multivariate analysis to compare the groups for length of stay (LOS), total direct cost (TDC), complications, readmissions at 30 days, and discharge disposition location. Results. No significant difference was found between the two cohorts with respect to age, BMI, ASA, or CCI. The average age, BMI, ASA and CCI were 64, 30, 2.5, and 3.6. The average LOS of the SH cohort was 2.1 days which was significantly lower than the NSH cohort at 3.6 days (P<0.001). Significantly more patients were discharged to home in the SH group, 83% versus 71% in the NSH group (P=0.006) regardless of age (P=0.003) and ASA (P=0.048). No significant difference was found between the two groups with regard to complications (P=0.346), TDC (P=0.883), or readmissions at 30 days (P=0.637). Discussion. The implementation of the PSH led to decreased length of stay and allowed more patients to be discharged to home, without an increase in complications or readmissions. We were able to accomplish this in patients with higher ASA and CCI scores which has not been the case in other rapid recovery programs. Effective care pathways require contribution and cooperation by multiple healthcare personnel throughout the phases of patient care. We feel that key factors contributing to the success of the PSH include post-surgical co-management by anesthesia, early physical therapy, and weekly meetings to discuss patients’ individual needs for disposition