Introduction. Recent literature has shown increasing interest in analysing return to theatre (RTT) as a quality indicator across different surgical specialities. The aim of this study is to express “RTT at 90 days” as a useful predictor in identifying complications following primary total knee replacement (TKR). Methods. Patients who had been to theatre within 90 days of primary TKR were identified and their clinical notes were reviewed. Patients’ co morbidities, surgeon's grade, details of revision procedures and their final outcome were analysed. Results. Between 2010 and 2012 a total of 1388 primary TKR were performed. Eleven patients, 11/1388 (0.79%) RTT within 90 days, mean age was 71 years (51 to 85), mean body mass index (BMI) was 30.7 (21 to 45). Out of these 11 patients, six had Manipulation Under Anaesthesia (MUA) for stiffness, two had wound exploration and primary closure and three patients underwent revision arthroplasty following failed salvage procedures. Conclusion. Using RTT as a quality marker, it is possible to assess performance of surgeons and institutions much quicker than with joint registry. Our results showed that RTT at 90 days for TKR in our institution is significantly lower than national average (0.79% versus 1.8%)

Aim of the study: to determine if WOMAC pain and function outcomes and patient satisfaction are maintained after the institution of a new standardised care pathway for people undergoing primary hip or knee replacement (TJA).

Twenty-three institutions partnered to design and implement a care pathway to provide a seamless transition from acute to rehabilitation sectors by pre-surgery streaming of patients to inpatient or home-LOS were tracked against bench marks of minimum 50% discharged home and an inpatient rehab stay of seven days. Subjects were recruited to the evaluation pre-surgery completing the WOMAC. Follow-up WOMAC and satisfaction questionnaires were completed three months later. The sample of five hundred ensured that the 99% confidence interval (CI) of the mean for each of WOMAC pain and function would be within two and five points respectively of the results of a randomised trial where TJA patients received home-based or inpatient rehabilitation.

On average greater than 50% of people were discharged home from acute care and over 50% of those individuals receiving inpatient rehab were discharged in seven days, with 80% discharged by day ten. 349 (73%) of those accrued (mean age 69 222 females) completed three month follow-up Those discharged home have mean pain and physical scores of 82.7 and 78.7% (where high scores are better pain relief and function) and those receiving inpatient rehab have pain and function scores of 78.6 and 72.4%. These values are within our a priori CI for outcome. 13% reported dissatisfaction with rehabilitation planning and care.

This model of care has achieved the goals of increasing the proportion of people discharged home following TJA and decreased rehabilitation LOS with increased system capacity for rehabilitation. The patient outcomes are maintained.

Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

Aims. Hip hemiarthroplasty is a standard treatment for intracapsular proximal femoral fractures in the frail elderly. In this study we have explored the implications of early return to theatre, within 30 days, on patient outcome following hip hemiarthroplasty. Patients and Methods. We retrospectively reviewed the hospital records of all hip hemiarthroplasties performed in our unit between January 2010 and January 2015. Demographic details, medical backround, details of the primary procedure, complications, subsequent procedures requiring return to theatre, re-admissions, discharge destination and death were collected. Results. A total of 705 procedures were included; 428 Austin Moore and 277 Exeter Trauma Stems were used. A total of 34 fractures (in 33 patients) required early return to theatre within 30 days. Age, gender, laterality, time from admission to primary procedure, American Society of Anesthesiologists grade, and implant type were similar for those requiring early return to theatre and those who did not. Early return to theatre was associated with a significantly higher length of stay (mean 33.6 days (7 to 107) versus 18.6 days (0 to 152), p < 0.001), re-admission rate (38.2% versus 8.6%, p < 0.001), and subsequent revision rate (17.6% versus 1.3%, p < 0.001). We found no difference in level of care required on discharge or mortality. Conclusion. Proximal femoral fractures are common in the elderly population, with far-reaching medical and economic implications. Factors such as infection or dislocation may require early return to theatre, and this is associated with outcomes which may be both medically and economically detrimental. This illustrates the importance of avoiding early complications to improve longer term outcome. Return to theatre within 30 days is associated with longer length of stay, higher re-admission rate, and higher subsequent revision rate. It may be a useful short-term quality indicator for longer term outcome measures following hip hemiarthroplasty for intracapsular fractures of the proximal femur. Cite this article: Bone Joint J 2017;99-B:958–63

Aim of the study: To calculate minimum-provider-volumes in total knee replacement by means of German routine data for the first time. Materials and methods: In patients with primary total knee replacement (TKR) the correlation between hospital volume per year and risk of “insufficient mobility” (primary quality indicator) and “wound infection” (secondary quality indicator) was calculated by means of logistic regression models based on the data of 110.349 primary total knee replacements operated in 1.016 German hospitals in 2004. Results: For both indicators a statistically significant relationship between hospital volume and outcome could be proven. Other risk factors such as age and ASA-status also had a significant influence, but did not appear as important confounders. The risk for the secondary quality indicator “infection” decreased constantly by increasing hospital volume, thus the curve was very flat. This supports the hypothesis that high volume hospitals show up to have a higher quality level than low-volume hospitals. A threshold value of 116 TKR per year (95% CI 90–141) could be calculated. However, the explanation value of the hospital volume was too low to derive a threshold level that clearly discriminates between good and bad quality of care. The relationship between the primary quality indicator “insufficient mobility” and the hospital volume unexpectedly showed a U-shaped distribution. This questions the concept of a minimum provider volume regulation for primary total knee replacement regarding the risk factor “insufficient mobility”. Therefore, in this case no quantitative threshold values were calculated. Conclusion: This analysis supports the hypothesis of a volume-outcome-relationship in primary total knee replacement. However, a minimum provider volume that clearly discriminates between good and bad quality of care could not be calculated on basis of German quality assurance data

Backgroud: Allogeneic transfusion rates after primary hip and knee arthroplasty are used as quality indicators for hospitals, but hospital comparisons may be hampered by low event rates. Extended hospital stay is often used and may be more suitable as an alternative. This study aims to assess whether transfusion rates and extended hospital stay can be used to reliably rank hospitals. Methods. We used the baseline data from the LISBOA implementation trial, where data on patient characteristics and outcomes were collected in a sample of approximately 100 patients undergoing elective primary total hip or knee arthroplasty for each of the 23 participating hospitals. We calculated the reliability of ranking (Rankability) of transfusion rates and extended hospital stay (> 4 postoperative days), using fixed and random effects logistic regression analysis, by dividing the between-hospital variation to the sum of within and between-hospital variation. Rankability thus shows which part of the hospital differences are true differences and not due to random variation. Results. 1163 total hip and 986 total knee procedures were assessed. After adjustment for patient characteristics the odds ratio (OR) of receiving a transfusion in a hospital after total hip ranged from 0.72 to 1.38 and from 0.30 to 3.30 in total knee. Rankability was 17% for hip and 36% for knee arthroplasty, meaning that only 17% and 36% are true hospital differences. Larger hospital variation was found for extended hospital stay (OR range [0.28–3.51] for hip and [0.10–9.95] for knee arthroplasty), and better rankability. Conclusion. Although allogeneic transfusion rates are useful for monitoring quality within hospitals, they should not be used for ranking hospitals. A large proportion of differences in transfusion rates between hospitals is due to random variation, suggesting that this outcome is not suitable for ranking hospitals contrary to extended hospital stay. Level of evidence. Level 2. Financial disclosure. This study was funded by a grant from The Netherlands Organisation for Health Research and Development and by a grant from Sanquin Blood Supply. Conflict of interest. The authors declare that there are no conflicts of interest. Approval. The Medical Ethical Committee of the Leiden University Medical Center decided that ethical approval was not required under Dutch National law for this type of study

The aim of this study was to define return to theatre (RTT) rates for elective hip and knee replacement (HR and KR), to describe the predictors and to show the variations in risk-adjusted rates by surgical team and hospital using national English hospital administrative data. . We examined information on 260 206 HRs and 315 249 KRs undertaken between April 2007 and March 2012. The 90-day RTT rates were 2.1% for HR and 1.8% for KR. Male gender, obesity, diabetes and several other comorbidities were associated with higher odds for both index procedures. For HR, hip resurfacing had half the odds of cement fixation (OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR, unicondylar KR had half the odds of total replacement (OR = 0.49, 95% CI 0.42 to 0.56), and younger ages had higher odds (OR = 2.23, 95% CI 1.65 to 3.01) for ages < 40 years compared with ages 60 to 69 years). There were more funnel plot outliers at three standard deviations than would be expected if variation occurred on a random basis. . Hierarchical modelling showed that three-quarters of the variation between surgeons for HR and over half the variation between surgeons for KR are not explained by the hospital they operated at or by available patient factors. We conclude that 90-day RTT rate may be a useful quality indicator for orthopaedics. Cite this article: Bone Joint J 2014; 96-B:1663–8

Patient reported outcomes and satisfaction as a measure of service quality is becoming an increasingly important tool in local service assessment as well as a quality indicator within commissioning frameworks. We analyse the introduction of SCP led MDT facilitated patient group meetings addressing the education and preparation of patients listed for ankle and hindfoot surgery at WSH HYPOTHESIS- To identify the outcome benefits to patients from this type of quality initiative. This has been previously demonstrated in other specialities in the trust such as hip and knee replacement resulting in mandatory attendance as part of the care pathway. Feedback was gathered via a patient questionnaire from 60 patients invited to meetings over an 18 month period. Two groups of patients who have undergone hindfoot/ankle surgery at WSH were compared. Group 1 attended a 1 hour MDT meeting preoperatively designed to educate the patient on all aspects of their surgery from pre assessment through to post operative management. Group 2 did not attend any such meeting whether invited or not. Results. Group 1 found the meetings beneficial in preparing them for surgery and improved their knowledge of disease, treatment options and recovery. Group 2 felt less prepared with less knowledge of post op limitations, and available support. No significant difference in length of stay was observed. Recommendations. Additional to their consultant examination, patients undergoing major foot surgery benefit from receiving additional information provided by a mixed group of professionals involved in their care. Physiotherapists and occupational therapists as well as volunteer post operative patients at these meetings provided valuable advice and instruction in preparing for and recovering from this type of surgery

Purposes. To develop disease-specific quality indicators for patients with low-back-pain presenting to Danish chiropractic clinics. Methods and results. A cross-disciplinary group of healthcare providers (the indicatorgroup) prioritized nine evidensbased indicators and standards in a systematic consensus process. A pilot test including 206 low-back-pain patients was carried out in eight chiropractic clinics. An audit meeting with the test-clinics was conducted after the test-period, and the indicatorgroup designed the final set of indicators. The indicator domains were: Anamnesis, test for discogenic back pain, neurology, radiology, classification, exercise therapy, outcome assessment (process and result) and re-evaluation. Two indicators: outcome assessment as a process-indicator (standard ≥ 95 %, standard reached (95% CI): 95.8 % (91.6 – 98.3)) and outcome assessment as a result-indicator (standard ≥ 50 %, standard reached: 67.7 % (59.9 – 74.8)) met the standards set by the indicatorgroup. After evaluating the test-results the indicatorgroup decided to maintain all nine indicators, however, lowering the standards on anamnesis, discogenic back pain and classification. Conclusion. It was possible to identify the patient population and collect data with regard to the nine indicators. At the time being primary care chiropractic clinics in Denmark do not meet the quality standards set by professionals. This may however be partly due to practical problems in the data collecting process. Both the indicatorgroup and the test-clinics, recommend future nationally widespread implementation of the developed indicators. This could be the first step in joining the Danish healthcare accreditation programme

Purpose: Musculoskeletal injuries affect up to 13% of adults annually. Despite this high incidence, quality of primary care, including analgesia, may be sub-optimal. The goal of this study is to describe the quality of primary care for ambulatory patients with isolated limb injury and to identify related factors. Method: A cross sectional study was undertaken on 166 consecutive ambulatory adult patients with isolated limb injury who presented to orthopedics service in a Level one Trauma Centre. Quality of care was assessed by evaluating analgesia, walking aids, immobilization, and quality of referral diagnosis according to actual expert recommendations. Patient satisfaction was assessed by Visit Satisfaction Questionnaire. Results: This study revealed low quality of primary care for more than 50% of injured patients. More than half the patients had pain level over 5/10 and more than a quarter had insufficient/absent analgesia prescriptions. A third had unacceptable immobilization and 36% of patients with a lower limb injury did not receive a walking aid prescription. A total of 37% had an absent or inadequate referral diagnosis. Factors associated with lower quality depended on the specific quality indicator and included: living further away from the hospital, younger age, initially consulting at another health care center, having a fracture, and being a smoker. Conclusion: The high frequency of low quality of care underlines the necessity for orthopedic surgeons to be involved in primary care education. Identifying factors associated with lower quality of care will orient efforts to improve medical care of patients with isolated traumatic injury

Introduction: Patient self-assessment plays a significant rule in the monitoring of patients within clinical studies as well as a separate quality indicator. The self-assessment of function, disease activity and quality of life is known to have a predictive value in the disease progression of rheumatoid arthritis (RA) and other orthopaedic diseases. However, all questionnaires challenge the clinical infrastructure. The questionnaire administration and their processing require still considerable manpower and is a potential source for errors. We analysed the in-house processes, identified the essential requirements and explored possible electronic solution with the aim to reduce necessary manpower and failure sources. Materials and methods: In a first step we defined a set of questionnaires we want to administer on a regular base. We then evaluated candidate systems with respect to data handling and to further statistic processing. Two years later we re-evaluated the system and possible alternatives. We then paid special attention to scanning features and data export options. Finally we performed reliability and handling tests and a first clinical trial. Results: The standardized set for shoulder patients comprises 144 items per patients. The set was designed as a four-color print for automatic processing with Qualicare. Four large studies with a total of more than 300 evaluations were performed using Qualicare. Our reevaluation of the system revealed major problems with the line scanner, the data processing in the system and the data export into statistics programs. After intensive search we installed a new scanning system based on an OMR reader that detects regions of interests on the questionnaire (Remark Office). This system allows simple form generation with the PC, the use of bar-code and faster processing. Reliability was more than 0.95 and handling revealed no major problems. Since first trials were successful the new system became the standard for all questionnaires in our department. Discussion: The high amount of variables in patient self-assessment requires automated processing to save manpower and to avoid failures during manual processing. During a three-year period we identified scanning and export options as the key factors for long-term success. The new system (Remark Office) accomplishes both requirements and might serve as the base for large studies or regular quality control

Aims

Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?

Aims

The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures.

Aims

This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH).

Aims

The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation.

Aims

In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip.

Objectives

Nasal carriers of Staphylococcus (S.) aureus (MRSA and MSSA) have an increased risk for healthcare-associated infections. There are currently limited national screening policies for the detection of S. aureus despite the World Health Organization’s recommendations. This study aimed to evaluate the diagnostic performance of molecular and culture techniques in S. aureus screening, determine the cause of any discrepancy between the diagnostic techniques, and model the potential effect of different diagnostic techniques on S. aureus detection in orthopaedic patients.

Aims

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.