Waiting time to access medical care in Canada is 20% more than the international average. Delay in instituting care in trauma patients has been shown to correlate with higher complication rates and an increase in mortality. About 11% of all fractures occur in the femur and are usually treated operatively. Delay to operative treatment is a source of distress to patients and a major factor for poor outcome. Knowledge gaps exist for statistics on operative delay to fixation of femur fractures and the influence on complications and cost of treatment. This study describes (1) the effect of delay to fixation of femur fractures on complications and on the overall cost of care in hospitals in Quebec Province of Canada; and (2) proposes a time frame within which femur fractures should be operated on to minimize the risk of complications and reduce treatment cost. 6,520 adult patients operated for closed femoral fractures between July 1993 and December 2002 were reviewed. Data was accessed from (a) the Quebec Trauma Registry, (b) the hospitalised patients’ database, Maintenance et exploitation des données pour l’étude de la clientèle hospitalière (MED-ECHO) and (c) the medical insurance claims databases, Régie de l’assurance maladie Québec (RAMQ). Excluded were poly-trauma, open fractures, pathological fractures and delayed diagnoses beyond a week. Data was analysed using the SPSS software version 17.0. Cost analysis was carried out using parametric techniques (Student’s t-test and the generalized longitudinal model). Mean operative delay for femoral fractures was 26.3 hours. Delay was associated with increased complications, ICU stay, length of stay (LOS), hospitalization costs and out-patient follow-up treatment costs. There was a progressive increase in these adverse events which was quite significant after the first 48 hours. ISS >15 predisposed to prolonged ICU stay, LOS and increased cost of treatment. All femur fractures appeared to have a predilection for over-65-year-olds and women. The major cost drivers of operative femur fracture treatment were ISS>15, operative delay ≥48 hours, occurrence of complications, and re-operations. Minimizing operative delay in femur fractures will not only mitigate patient suffering, but also reduce treatment and follow-up costs

With an ageing population and an increasing number of primary arthroplasties performed, the revision burden is predicted to increase. The aims of this study were to 1. Determine the revision burden in an academic hospital over a 11-year period; 2. identify the direct hospital cost associated with the delivery of revision service and 3. ascertain factors associated with increased cost. This is an IRB-approved, retrospective, single tertiary referral center, consecutive case series. Using the hospital data warehouse, all patients that underwent revision hip or knee arthroplasty surgery between 2008-2018 were identified. 1632 revisions were identified (1304 patients), consisting of 1061 hip and 571 knee revisions. The majority of revisions were performed for mechanical-related problems and aseptic loosening (n=903; 55.3%); followed by periprosthetic joint infection (n=553; 33.9%) and periprosthetic fractures (176; 10.8%). Cost and length of stay was determined for all patient. The direct in-hospital costs were converted to 2020 inflation-adjusted Canadian dollars. Several patients- (age; gender; HOMR- and ASA-scores; Hemoglobin level) and surgical- (indication for surgery; surgical site) factors were tested for possible associations. The number of revisions increased by 210% in the study period (2008 vs. 2018: 83 vs. 174). Revision indications changed over study period; with prevalence of fracture increasing by 460% (5 in 2008 vs. 23 in 2018) with an accompanying reduction in mechanical-related reasons, whilst revisions for infection remained constant. The mean annual cost over the entire study period was 3.9 MMCAD (range:2.4–5.1 MMCAD). The cost raised 150% over the study period from 2.4 MMCAD in 2008 to 3.6 MMCAD. Revisions for fractured had the greatest length of stay, the highest mean age, HOMR-score, ASA and cost associated with treatment compared to other revision indications (p < 0 .001). Patient factors associated with cost and length of stay included ASA- and HOMR-scores, Charlson-Comorbidity score and age. The revision burden increased 1.5-fold over the years and so has the direct cost of care delivery. The increased cost is primarily related to the prolonged hospital stay and increased surgical cost. For tertiary care units, these findings indicate a need to identify strategies on improving efficiencies whilst improving the quality of patient care (e.g. efficient ways of reducing acute hospital stay) and reducing the raise of the economic burden on a publicly funded health system

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 cost savings over a 90-day episode of care when compared to both the anterior and posterior exposure techniques. It reduced overall costs by approximately $2,000 and $7,000 per case versus the other groups respectively. The superior approach also demonstrated savings in inpatient and skilled nursing facility cost when compared to the other groups. Conclusions. Surgical technique can have a profound influence on the total cost of care for hip arthroplasty patients. The current study demonstrates that the posterior exposure resulted in the largest consumption of resources post-operatively as measured by total cost of care and that the superior exposure resulted in the least consumption of resources among the three surgical exposures assessed. The study suggests that while we focus on many aspects of improvement in the overall episode of care for our patients, that focus on surgical technique may be worthwhile

Total knee and hip arthroplasty (TKA and THA) are two of the highest volume and resource intensive surgical procedures. Key drivers of the cost of surgical care are duration of surgery (DOS) and postoperative inpatient length of stay (LOS). The ability to predict TKA and THA DOS and LOS has substantial implications for hospital finances, scheduling and resource allocation. The goal of this study was to predict DOS and LOS for elective unilateral TKAs and THAs using machine learning models (MLMs) constructed on preoperative patient factors using a large North American database. The American College of Surgeons (ACS) National Surgical and Quality Improvement (NSQIP) database was queried for elective unilateral TKA and THA procedures from 2014-2019. The dataset was split into training, validation and testing based on year. Multiple conventional and deep MLMs such as linear, tree-based and multilayer perceptrons (MLPs) were constructed. The models with best performance on the validation set were evaluated on the testing set. Models were evaluated according to 1) mean squared error (MSE), 2) buffer accuracy (the number of times the predicted target was within a predesignated buffer of the actual target), and 3) classification accuracy (the number of times the correct class was predicted by the models). To ensure useful predictions, the results of the models were compared to a mean regressor. A total of 499,432 patients (TKA 302,490; THA 196,942) were included. The MLP models had the best MSEs and accuracy across both TKA and THA patients. During testing, the TKA MSEs for DOS and LOS were 0.893 and 0.688 while the THA MSEs for DOS and LOS were 0.895 and 0.691. The TKA DOS 30-minute buffer accuracy and ≤120 min, >120 min classification accuracy were 78.8% and 88.3%, while the TKA LOS 1-day buffer accuracy and ≤2 days, >2 days classification accuracy were 75.2% and 76.1%. The THA DOS 30-minute buffer accuracy and ≤120 min, >120 min classification accuracy were 81.6% and 91.4%, while the THA LOS 1-day buffer accuracy and ≤2 days, >2 days classification accuracy were 78.3% and 80.4%. All models across both TKA and THA patients were more accurate than the mean regressors for both DOS and LOS predictions across both buffer and classification accuracies. Conventional and deep MLMs have been effectively implemented to predict the DOS and LOS of elective unilateral TKA and THA patients based on preoperative patient factors using a large North American database with a high level of accuracy. Future work should include using operational factors to further refine these models and improve predictive accuracy. Results of this work will allow institutions to optimize their resource allocation, reduce costs and improve surgical scheduling. Acknowledgements:. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors

Background. Cementless femoral fixation in total hip arthroplasty (THA) continues to rise worldwide, accompanied by the increasing abandonment of cemented femoral fixation. Cementless fixation is known to contribute to higher rates of post-operative complications and reoperations. New data is available from the Centers for Medicare and Medicaid Services (CMS) regarding total costs of care from the Bundled Payment for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) initiatives. Questions/purposes. How does femoral fixation affect (1) 90-day costs; (2) readmission rates; (3) re-operation rates; (4) length of stay (LOS); and (5) discharge disposition for Medicare patients undergoing elective or non-elective THA?. Methods. We performed a retrospective review of 1671 primary THA cases in Medicare patients across nine hospitals in an academic healthcare network. CMS data was used to evaluate lump costs including the surgical admission and 30-day or 90-day post-operative episodes. Costs were then correlated with clinical outcome measures from review of our electronic medical record. Demographic differences were present between the cemented and cementless cohorts. Statistical analyses were performed including multiple regression models adjusted for the baseline cohort differences. Results. After controlling for confounding variables, cemented patients were significantly more likely to be discharged home compared to cementless patients. Cemented femoral fixation also demonstrated a trend towards lower costs, fewer readmissions and shorter LOS. All of the reoperations within the early postoperative period occurred in cementless patients. Conclusion. In a large Medicare population, cemented femoral fixation outperformed cementless fixation with respect to discharge disposition and also trended toward superiority with regards to LOS, readmission, cost of care, and reoperations. Cemented femoral fixation remains relevant and useful despite the rising popularity of cementless fixation. Orthopaedic surgeons in training should become competent with femoral cementation technique

To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation. We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators. Our primary outcome measure was net income/loss for each in-patient episode. The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy. In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss. In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss. The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer. Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term

The high and ever increasing cost of medical care worldwide has driven a trend toward new payment models. Event based models (such as bundled payment for surgical events) have shown a greater potential for care and cost improvement than population-based models (such as accountable care organizations). Since joint replacement is among the most frequent and costly surgical events in medicine, bundled payments for joint replacement episodes have been at the forefront of evolution from fee-for-service to value-based care models and episode-based healthcare reform in general. Our education as surgeons in medical school, residency, fellowship, and in continuing education has been almost entirely non-economic in focus. Yet, we surgeons are now evolving from being primarily responsive for our patients' medical care to being also responsible for all expenditures associated with our patients' care. Similarly, while the cost of our patients' care was not even available to us, every dollar of expenditure for a patient's episode of care is now available to us in some circumstances. For example, a typical primary joint replacement episode may cost $30,000 for a patient insured by Medicare in the US. A surgeon performing 400 joint replacements per year is therefore authorizing upwards of $12M a year in health care spending by making the decisions to perform reconstructive procedures on those patients. The risk for value-based surgical episodes of care can be born by various entities including hospital systems or the surgeons themselves. Recent evidence demonstrates that quality improves and cost decreases more rapidly when surgeons take primary responsibility and risk for episodes of care as compared to when a hospital system or third party takes primary responsibility and risk. Yet, as surgeons, our education in the field of medical economics, value-based episodes of care, and payment reform is only just beginning. The more we understand about the cost and value of the services that we order for our patients, the more leadership can provide as healthcare evolves. The current presentation will describe the specific cost of care for the primary joint replacement patient preliminary experience with accepting risk and responsibility for these patients. It is likely that our patients will be best served if we surgeons provide as much leadership as possible in their care, both medically and economically

BACKGROUND. Telerehabilitation has been shown to both promote effective recovery after shoulder arthroplasty and may improve adherence to treatment. Such systems require demonstration of feasibility, ease of use, efficacy, patient and clinician satisfaction, and overall cost of care, and much of this data has yet to be provided. Few augmented reality rehabilitation approaches have been developed to date. Evidence suggests augmented reality rehabilitation may be equivalent to conventional methods for adherence, improvement of function, and relief of pain seen in these musculoskeletal conditions. We proposed that the development of an augmented reality rehabilitation platform during the pre and postoperative period (including post-shoulder arthroplasty) could be used to track patient activity and range of motion as well as promote recovery. METHODS. A prototype augmented reality platform equipped with a motion sensor system optimised for the upper arm was developed to be used to validate 4 arcs of shoulder motion and complete directed upper arm exercises designed for post-shoulder arthroplasty rehabilitation was built and tested. This system combined augmented reality instructions and motion tracking to follow patients over the course of their therapy, along with a telehealth patient-clinician interface. FINDINGS. The augmented reality platform was tested to validate shoulder range of motion examination similar to that of standard goniometer measurements. Healthy test subjects without shoulder pain or prior shoulder surgery performed the arcs of motion for 5 repetitions as part of a home therapy program. Each motion was measured with angular measurements as a proof of concept with high degree precision (less than 5 degrees). Remote patient-clinician interface testing was also conducted along with a clinician established therapy plan. DISCUSSION. Augmented reality systems that track patients' complex movements, including clinical shoulder range of motion, suggest the promising future of telerehabilitation in arthroplasty, particularly in telemonitoring before and after surgery. As this technology continues to gain acceptance, further studies that evaluate the outcomes of augmented reality rehabilitation for long-term follow-up are needed

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 cost savings was $725 per case. Conclusions. Appropriately balancing TKA patients intra-operatively might help mitigate costs associated with TKA procedures within the 90-day bundle. In this study, it was found that using new joint balancing technology generated a substantial cost-savings post-discharge, primarily due to patients requiring less outpatient physical therapy

Background. Total knee arthroplasty (TKA) is a routine, cost-effective treatment for end-stage arthritis. While the evidence for good-to-excellent patient-reported outcomes and objective clinical data is present, approximately 20% of patients continue to be dissatisfied with results of their surgery. Dissatisfaction is strongly correlated with unmet patient expectations, and these patients may experience a higher cost of care due to recurring office and emergency visits. Therefore, this survey asked a large group of United States (U.S) and international surgeons to prioritize areas of opportunity in primary TKA. Specifically, we compared surgeon responses regarding: 1) the top 5 areas needing improvement; which were stratified by: 2) surgeons' years of experience; and 3) surgical case volume. Methods. A total of 418 orthopaedic surgeons were surveyed. Two hundred U.S. surgeons and 218 international surgeons participated from 7 different countries including: The United Kingdom (40), France (40), Germany (43), Italy (40), Spain (38), and Australia (17). To participate, surgeons had to be board certified, in practice for 2 years, spend 60% of their time in clinical practice, and perform a minimum of 25 joint arthroplasties per year. Surgeons were asked to choose the top 5 areas of improvement for TKA from a list of 17 attributes including clinical and functional outcomes, procedural workflow and economic variables. Surgeons were able to specify additional options if needed. Results were stratified by annual case volume (25 to 50; 51 to 100; greater than 100 cases) and years of experience (1 to 10; 11 to 20; greater than 20). Single-tail proportion tests were used to compare results between cohorts, where an alpha of 0.05 was set as significant. Results. The most frequently identified opportunity in both groups was functional outcomes, selected by 63% of U.S. surgeons (p=0.001) compared to 71% of international surgeons (p=0.002). In the U.S. cohort, this was followed by cost (47%), which was not identified in the top 5 choices for international surgeons. Cost was followed by implant survivorship (45%), patient satisfaction (42%), and accuracy/precision (39%). In the international cohort, implant survivorship (57%), dynamic joint balancing (40%), accuracy/precision (39%), and patient satisfaction rates (35%) were noted. When stratified by years of experience and case volume, the top area for improvement remained functional outcomes for U.S. and International groups. Conclusion. The responses in the international survey demonstrate that functional outcomes, implant survivorship and costs had greater perceived potential for improvement, compared to the specific targeting of post-operative patient satisfaction. Functional outcomes remained a top area for improvement, regardless of years of experience or case volume. As a result, enhancing functional outcomes and implant survivorship may ultimately address patient satisfaction, by more consistently meeting patient expectations. These results serve as baseline data to help guide future improvements in knee arthroplasty

INTRODUCTION. Evolving payment models create new opportunities for assessment of patient care based on total cost over a defined period of time. These models allow for analyses of economic data that was previously unavailable and well beyond our familiar studies which typically include length of stay, surgical complications, and post-operative clinical and radiographic assessments. In the United States, the new Federal program entitled TheBundled Payment for Care Initiative created new opportunities for the assessment of surgical interventions. The purpose of the reported study was to assess the total reimbursement for care as a function of surgical technique in primary total hip arthroplasty (THA). METHODS. The total reimbursement for services performed following primary THA for patients insured by Medicare was analyzed for a group of patients at a single institution during the fiscal years of 2013 and 2014. The population included data on 356 patients who had surgery performed by seven surgeons who used the same pre-operative education, OR, PACU, PT, nursing, and case management. A total of 38 “pre-selected” patients underwent THA by an anterior exposure, 219 had surgery performed by a posterior exposure, and 99 had surgery performed by the superior exposure utilizing mechanical surgical navigation (HipXpert System, Surgical Planning Associates, Boston, MA). Reimbursement for all in-patient and out-patient services performed over the initial 90-day period from sugeical admission was compared across surgical techniques. Reimbursement includes the sum of all payments including the hospital, physicians, skilled nursing facilities, home care, out-patient care, and readmission. RESULTS. The authors previously reported that primary THA cases performed using the superior approach have shorter average length of stay, a lower complication rate, higher percentage of acetabular components within the “safe zone” when compared to the other approaches and higer rate of patients discharged directly to home. An average reimbursement of $24,848 for THA performed using posterior exposure, $21,446 for the selected anterior exposure, and $20,268 for the superior exposure with navigation. The cost of care for treatment by the superior exposure with navigation was statistically significantly less than the posterior exposure (p<0.001) but not significantly less than the selected anterior exposure patients (p=0.287). Medicare in-patient reimbursements for patients treated by the superior exposure with mechanical surgical navigation was significantly less than the selected anterior exposure group (p<0.002) and the posterior exposure group (p<0.001). Overall, 84% of patients with the superior exposure were discharged directly to home versus 69% in the selected anterior group and 60% in the posterior group thus minimizing the out-patient Medicare cost burden in THA performed using the superior exposure over the other techniques. CONCLUSION. The current study demonstrates the influence of surgical technique on the direct reimbursement for the continuum of care, indicative of incurred costs, across the first 90-day post-operative period. The superior exposure combined with surgical navigation demonstrates the potential for significantly reduced total cost burden in Medicare patients when compared to two of the most common surgical approaches used for primary THA

Significance. Increasing health care costs are bankrupting the United States and other industrialized countries. To control and/or reduce costs in health care, hospitals, payers, and patients are turning to evidence-based meta-analyses and health economic analyses to identify medical treatments that provide value (value=outcome/cost). Objective: To determine if clinical outcome (patient reported outcomes) analyses or value/economic analyses are more likely to provide the evidence needed for adoption of new technologies in arthroplasty. Methods. A proprietary joint arthroplasty database of patient reported outcomes (PROs) was analyzed to determine the minimum clinically important differences (MCIDs) for PROs used for total knee replacement surgery. The PROs analyzed were: (1) European quality of life (EQ-5D); Oxford Knee Score (OKS); (3) Lower Extremity Activity Scale (LEAS); and (4) Likert Pain Scale (LPS). The MCID was calculated using a distribution method where the MCID equals one half the standard deviation of the score change, MCID = σΔ/2. For clinical meta-analyses, new technologies must demonstrate statistically significant better PROs and the difference must be greater than the MCID. For economic analyses, quality adjusted life years (QALYs) are used. For example, if a total knee replacement (TKR) improved a patient's health-related quality of life by 10% (0.10) and the assumed implant life is 15 years, the patient received 1.5 QALYs (0.10 × 15 years). If the total cost of care for the knee replacement surgery is $30,000, the cost per QALY is $20,000 ($30,000/1.5 QALYs). Results. The MCIDs for EQ-5D, OKS, LEAS, and LPS are 0.086%, 4.6 points, 1.6 points, and 1.3 points, respectively. The mean change (one-year post-operative EQ-5D minus pre-operative EQ-5D) for health-related quality of life is 15% (0.15). The average patient received 2.25 QALYs (0.15 × 15 years) from the surgery. The average cost per QALY is $13,333. However, if a new technology improves the mean health-related quality of life by 1% and the assumed implant life is 15 years, the patient receives 0.15 QALYs of improvement. With an average cost per QALY of $13,333, the new technology will be cost effective if the new technology cost is less than or equal to $2,000 (0.15 × $13,333) per patient. Conclusions. Achieving clinical superiority with new arthroplasty technology will be difficult because the minimum clinically important differences that need to be achieved are significant (EQ-5D 8.6%, OKS 4.6 points, LEAS 1.3 points, and LPS 1.3 points). However, small mean improvements in health-related quality of life (1%) can make the new technology cost effective. New technologies for arthroplasty surgery will increasingly need economic analyses to demonstrate cost effectiveness. Orthopaedic surgeons and manufacturers must collaborate to routinely collect health-related quality of life (EQ-5D) patient reported outcomes to provide a pathway for adoption of new innovative arthroplasty technologies

Daycase surgery has advantages for patients, clinicians and trusts. The Best Practice Tariff uplift is £200/case for Minor Foot Procedures performed as daycases. Before discharge, Foot & Ankle daycase procedures in Cheltenham General Hospital require physiotherapy assessment and frequently an orthotic aid. This audit analysed length of stay of daycase patients on a Foot and Ankle list. The standard was 100% of daycase patients to be discharged the same day. Length of stay for a consecutive series of patients was calculated for all daycase procedures from October to December 2010. An intervention was made comprising a weekly multidisciplinary bulletin from the Orthopaedic Consultant. This highlighted post-operative weight-bearing instructions and orthotic requirements for forthcoming daycase patients to physiotherapists, nursing staff and junior doctors. The data was compared with a second consecutive series of patients from October to December 2011. The first series included 38 listed daycases of which 61% (23 patients) were daycase discharges. The second series comprised 41 listed daycases who received pre-operative physiotherapy assessment and provision of required orthotic aids; 85% (35 patients) of this group were discharged the same day. Data analysis using Fisher's exact test reveals this intervention had a statistically significant impact on the number of patients discharged the same day (p < 0.0207). The financial implications are increased Best Practice Tariff with an £1800 uplift and reduction in the estimated cost of unnecessary overnight stays of £4640 over the 3 months. Improved multidisciplinary communication can significantly improve the patient experience, bed occupancy and cost of care

Introduction. Management of a patient with a neck of femur (NOF) fracture is a key aspect of orthopaedic trauma care, with around 75 000 new cases in the United Kingdom annually costing the health care over £ 2 billion. Delaying time to theatre for operative intervention of hip fractures negatively impacts on patient outcome and is one of the key aspects of the hip fracture best practice tariff (BPT). One aspect of the peri-operative management of patients with hip fractures implicated in delayed surgery is the use of long term warfarin for anticoagulation. Anticoagulation reversal is a common cause of operative delay. Aim. The aim was to establish the impact this cohort of population had on achieving the BPT and how we could improve it. Material and Methods. Retrospective data was collected over a period of 12 months using the national hip fracture data base (NHFD). The delay to theatre specifically those who were on warfarin was identified. 10 % of the identified cohort was delayed to theatre due to high international normalised ratio (>1.5) and failed to achieve BPT. This cost the trust a loss of around £ 43,200. We have now introduced a simple hand-held warfarin testing device in accident and emergency. All patients on warfarin from history will have a pin prick and instantaneous INR estimated while the routine bloods are dispatched to the laboratory. If INR > 1.5 a stat 2mg intra venous Vit K (IVK) is initiated and INR rechecked at 6 hrs and if indicated further IVK is administered. The device costs £ 800 which is one off investment. Each patient will cost £ 6 for the strips and controls. This will avoid potential huge revenue loss and aid better medical practice. Conclusion. By the use of this simple device and its introduction in the A and E department, we can avoid the time lost for the anticoagulation reversal. This will mean improved patient care and compliance with BPT can be achieved in this cohort of NOF fracture patients

Introduction:. With the growing emphasis on the cost of medical care, there is renewed interest in the productivity and efficiency of surgical procedures. We have developed a method to systematically examine the efficiency of the surgical team during primary total knee replacement (TKR). In this report, we present data derived from a series of procedures performed by different joint surgeons. This data demonstrates a variation between the duration and efficiency of each step in this procedure and its relationship to the experience and coordination of the surgeon working with the scrub team. Methods:. After consent was achieved, videotaped recordings were prepared of ten primary TKR procedures performed by five highly experienced joint surgeons. For quantitative analysis, each procedure was divided into 7 principal tasks from initial incision to wound closure. In order to quantify efficiency, we recorded the occurrence of events leading to delays in each step of the procedure (Table 1). Starting with a total score of 100 points, deductions were made, based on the number of delaying events and its impact on the efficiency of the procedure. A final score for the surgery was then determined using the individual scores from each principal task. The experience of each member of the surgical team in participating in TKR, and in working with the surgeon, were recorded and correlated with the total efficiency score for the entire procedure. Results:. The average duration of the 10 procedures examined was 55 minutes (range: 38 to 81 mins). The longest steps during the procedure were closing the incision (13 mins; 24%) and performing the osteotomies of the distal femur (12 mins; 22%). A total of 570 delaying events were recorded from 10 surgeries, an average of 57 per surgery; least frequently the surgeon was handed the wrong instrument (0.4 /case), and most commonly, the surgeon diverting his attention from the surgical field, (35.2 times/ case). Using our scoring system, the mean efficiency of the surgeries was 81.2%. The least efficient step was performing osteotomies of the distal femur (71.5%), whereas the opening incision is the most efficient step (96%). The median experience of the surgical assistant working with each operating surgeon was 5 years. Surgical team experience correlated positively with efficiency. The mean score of surgeries of teams with 5 years' experience was 81.2%, vs. only 71.9% when the surgical tech had never operated with the surgeon previously. Conclusions:. The results of this study suggest that team experience has an important impact on operating efficiency, which has a direct impact on operation times. This suggests that a training exercise, which promotes operation knowledge and teamwork, will have a beneficial effect on efficiency

Introduction. With the growing emphasis on the cost of medical care, there is renewed interest in the productivity and efficiency of surgical procedures. We have developed a method to systematically examine the efficiency of the surgical team during primary total knee replacement (TKR). In this report, we present data derived from a series of procedures performed by different joint surgeons. This data demonstrates a variation between the duration and efficiency of each step in this procedure and its relationship to the experience and coordination of the surgeon working with the scrub team. Methods. After consent was achieved, videotaped recordings were prepared of ten primary TKR procedures performed by five highly experienced joint surgeons. For quantitative analysis, each procedure was divided into 7 principal tasks from initial incision to wound closure. In order to quantify efficiency, we recorded the occurrence of events leading to delays in each step of the procedure. Starting with a total score of 100 points, deductions were made, based on the number of delaying events and its impact on the efficiency of the procedure. A final score for the surgery was then determined using the individual scores from each principal task. The experience of each member of the surgical team in participating in TKR, and in working with the surgeon, were recorded and correlated with the total efficiency score for the entire procedure. Results. The average duration of the 10 procedures examined was 55 minutes (range: 38 to 81 mins). The longest steps during the procedure were closing the incision (13 mins; 24%) and performing the osteotomies of the distal femur (12 mins; 22%). A total of 570 delaying events were recorded from 10 surgeries, an average of 57 per surgery; least frequently the surgeon was handed the wrong instrument (0.4 /case), and most commonly, the surgeon diverting his attention from the surgical field, (35.2 times/ case). Using our scoring system, the mean efficiency of the surgeries was 81.2%. The least efficient step was performing osteotomies of the distal femur (71.5%), whereas the opening incision is the most efficient step (96%). The median experience of the surgical assistant working with each operating surgeon was 5 years. Surgical team experience correlated positively with efficiency. The mean score of surgeries of teams with 5 years experience was 81.2%, vs. only 71.9% when the surgical tech had never operated with the surgeon previously. Conclusions. The results of this study confirm that team experience has an important impact on the efficiency of operative procedures, and hence the duration of the operations that they perform. This suggests that training exercises that promote teamwork and the operative knowledge of each team member will have a beneficial effect on the efficiency of surgical facilities

New technology in joint replacement design and materials adds cost which must be documented by improved outcomes. This is not always the case as the recent metal/metal data has shown. The current economics of arthroplasty surgery have put increasing financial pressure on hospitals and will progress under new health care legislation. New technology must be cost effective and this will be increasingly difficult in an era of outstanding long term results with current designs. Cost may necessitate less expensive alternatives, e.g. generic implants, in arthroplasty patients. Joint replacement surgery has evolved over the past four decades into a highly successful surgical procedure. Earlier designs and materials which demonstrated inferior functional and long term results have disappeared in a Darwinian fashion. Through this evolutionary process many of the current designs have proven efficacy and durability. Current outcome data indicates that hip and knee designs demonstrate 90–95% success rates at 15 year follow-up. Technologic advances are necessary to improve implant design and materials, however, in an environment of reduced reimbursement to hospitals can the increase cost be justified. The rationale that technology in medicine would be expensive at the outset yet be cost effective eventually has in many areas not been the case. Currently about one half of the rapid increase in health care costs in relation to GNP may be attributed to technology. Uwe Reinhardt, an economist at Princeton University, in referring to new technology has stated that the health care system provides misaligned incentives that create over-utilisation or misutilisation of everything that is new. It is now common knowledge among health care economists that if the cost of health care is to be controlled the growth of technology must be constrained. Increasingly as new technology emerges the question will be: what is the cost-benefit analysis. A new era of comparative effectiveness research is being launched and will become predominant in medicine and arthroplasty surgery in the future. What is the newest may not always be the best. According to Reinhardt there is a need for comparative effectiveness studies of emerging and existing technology so that the new can be priced in a way that reflects its incremental value. New technology must demonstrate its benefit to justify its cost, often in arthroplasty there is little data available to document these better outcomes. In a recent study by Bozic the cost effectiveness of new technologies were evaluated. Based on the authors' findings for an alternative bearing with an incremental cost of $2000 to be cost saving for a 50 year old there would have to be a 19% reduction in 20 year failure rates. The likelihood of cost savings for these alternate bearings in patients 63 or older is highly unlikely at current costs. Newer biomaterials (metal/metal, ceramic/ceramic, highly cross linked polyethylene) also have limited outcome analysis in patients beyond short to mid-term follow-up evaluation and all of these technologies add significant cost to the implant. With diminishing reimbursement careful analysis of utilisation of these newer technologies must be weighed if hospitals are to maintain economic viability. The pharmaceutical, airline, and food industries have all moved toward generic products which are less costly and this will be the trend in the future in prosthetic implants as well. Newer technologies must demonstrate their efficacy in long term follow-up and be clearly superior to conventional implants. This is not always the case as new data on metal-metal implants is demonstrating. Change is not always progress

In May 2012, in airports across the globe, seven orthopaedic surgeons bravely said goodbye to their loved ones, and slowly turned towards their respective aircraft. Filled with expectation and mild trepidation they stepped into the unknown… the ABC fellowship of 2012.

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme in order to standardise the collection of information about infections acquired in hospital in the United Kingdom and provide national data with which hospitals could measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by the Center for Disease Control (CDC), should meet at least one of the defined criteria which would confirm the diagnosis and determine the need for specific treatment.

We have assessed the interobserver reliability of the criteria for superficial incisional infection set by the CDC in our current practice. The incisional site of 50 patients who had an elective primary arthroplasty of the hip or knee was evaluated independently by two orthopaedic clinical research fellows and two orthopaedic ward sisters for the presence or absence of surgical-site infection. Interobserver reliability was assessed by comparison of the criteria for wound infection used by the four observers using kappa reliability coefficients. Our study demonstrated that some of the components of the current CDC criteria were unreliable and we recommend their revision.

We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5594 admissions were cross-referenced with 22 810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative.

In 2004, we screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1122 of 1447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p < 0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p < 0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p < 0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1084) to 0.69% in 2004 (10 of 1447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1257) to 0.17% in 2004 (3 of 1806), p = 0.06). The cost of preventing one MRSA infection was £3200.

Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to £13 972 per patient.

From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and elective orthopaedic wards.