Background/Purpose of study. The increasing aging of the population will see a growing number of patients presenting for spine surgery with appropriate indications but numerous medical comorbidities. This complicates decision-making, requiring that the likely benefit of surgery (outcome) be carefully weighed up against the potential risk (complications). We assessed the influence of comorbidity on the risks and benefits of spine surgery. Methods. 3′699 patients with degenerative lumbar disorders, undergoing surgery with the goal of pain relief, completed the multidimensional Core Outcome Measures Index (COMI; scored 0–10) before and 12 months after surgery. At 12mo they also rated the global treatment outcome and their satisfaction. Using the Eurospine Spine Tango Registry, surgeons documented surgical details, American Society of Anesthesiologists (ASA) scores and surgical/general complications. Results. 29.8% patients were rated ASA1 (normal healthy), 44.8% ASA2 (mild/moderate systemic disease), 25.0% ASA3 (severe) and 0.4% ASA4 (life-threatening). In going from ASA1 to ASA3 (ASA4 group too small), surgical complications increased significantly from 3.6% to 11.1% and general complications increased from 2.3% to 12.6%; 12-month outcomes showed a corresponding decline, with a good global outcome being reported by 78% ASA1 patients, 76% ASA2, and 68% ASA3. Satisfaction with treatment was 87%, 85%, and 79%, respectively and reduction in COMI, 4.2±2.9, 3.7±3.0, and 3.3±3.0 points, respectively. Conclusion. The negative impact of comorbidity on the outcome of spine surgery has not been well investigated/quantified to date. The ASA grade may be helpful in producing algorithms for decision-making and preoperative counselling regarding the corresponding risks and benefits of surgery. No Conflict of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Despite considerable legacy issues, Girdlestone's Resection Arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical comorbidities which preclude staged or significant surgical interventions, and / or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes. We reviewed all cases of GRA performed in our unit during an 8 year period, reviewing the demographics, indications, and information pertaining to previous surgeries, and post op outcome for each. Satisfaction was based on a binary summation (happy/unhappy) of the patients’ sentiments at the post-operative outpatient consultations. 13 cases were reviewed. They had a mean age of 75. The most common indication was PJI, with 10 cases having this indication. The other three cases were performed for avascular necrosis, pelvic osteonecrosis secondary to radiation therapy and end stage arthritis on a background of profound learning disability in a non-ambulatory patient. The average number of previous operations was 5 (1-10). All 13 patients were still alive post girdlestone. 7 (54%) were satisfied, 6 were not. 3 patients were diabetic. 5 patients developed a sinus tract following surgery. With sufficient pre-op patient education, early intensive physiotherapy, and timely orthotic input, we feel this procedure remains an important and underrated and even compassionate option in the context of massive lysis and / or the presence of pelvic discontinuity / refractory PJI. GRA should be considered not a marker of failure but as a definitive procedure that gives predictability to patients and surgeon in challenging situations

Mental disorders in particular depression and anxiety have been reported to be prevalent among patients with spinal pathologies. Goal of the current study was to analyze the relationship of Zung pre- and post-op score to other PROs and length of stay. Secondary outcomes included revision surgery and post-operative infections. Data from the international multicenter prospective spine degenerative surgery data repository, DegenPRO v1.1 (AO Spine Knowledge Forum Degenerative) were utilized. Patients undergoing cervical or lumbar procedure were included. Patient's demographics, Charlson Comorbidity Index, surgical information, Zung score, NDI, pain related PROs and EQ-5D, and complications at surgery and at various post-op time periods. Except for hospital duration, data were analyzed, using multivariable mixed linear models. A robust linear regression model was used to assess the association between Zung score and hospital duration. All models were adjusted for gender and age. 42 patients had Zung score administered. Among those patients 22 (52%) were within normal range, 18 (43%) were mildly and 2 (5%) severely depressed. 62% of the patients had a lumbar pathology with fusion procedures being the most common. Median EQ-5D (3L) score at surgery was significantly higher (0.7, IQR: 0.4-0.7) for patients within normal range than for those with mild (0.4, IGR: 0.3-0.7) or severe depression (0.3, IQR: 0.3-0.3, p-value: 0.05). Compared to patients within normal Zung range, mixed models, indicated lower EQ-5D (3L) score values and higher values for neck and arm pain at surgery with both PROs and EQ-5D (3L) improving in patients with depression over the follow-up time. No association was found between Zung score and hospital length of stay. The initial analysis showed that 43% of the patients were mildly depressed and mainly male patients. Zung score was correlated with post-operative improvements in EQ-5D and arm and neck pain PROs

Adverse events (AEs) are still a major problem in spinal surgery, despite advances in surgical techniques, innovative technologies available and the introduction of checklist and predictive score systems aimed at reducing surgical complications. We previously analysed the results of the introduction of the WHO Safety Surgical Checklist (SSC) in our Institution, comparing the incidence of complications between two periods: from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist effectiveness. The sample size was 917 patients with an average of 30 months of follow-up. Complications were observed in 107 patients (11.6%) among 917 spinal surgery procedures performed, with 159 (17.3%) complications in total. The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. We observed a reduction of the overall incidence of complications following the introduction of the WHO Surgical Checklist: in 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%) (p<0.0005). Thus, the SSC appeared to be an effective tool to reduce complications in spinal surgery and we proposed to extend the use of checklist system also to the pre-operative and post-operative phases in order to further reduce the incidence of complications. We also believe that a correct capture and classification of complications is fundamental to generate a clinical decision support system aimed at improving patients’ safety in spinal surgery. In the period between January 2017 and January 2018 we prospectively recorded the adverse events and complications of patients undergoing spinal surgery in our department, without using any collection system. Then we retrospectively recorded the intraoperative and postoperative adverse events of surgically treated patients during the same one-year period, using the SAVES v2 system introduced by Rampersaud and collaborators (Rampersaud YR et al. J Neurosurg Spine 2016 Aug; 25 (2): 256-63) to classify them. In the one-year period from January 2017 to January 2018 a total of 336 patients underwent spinal surgery: 223 for degenerative conditions and 113 for spinal tumors. Comorbidities were collected (Charlson Comorbidity Index [CCI]). Overall, a higher number of adverse events (AEs) was recorded using SAVES compared to the prospective recording without the use of any capture system and the increased number was statistically significant for early postoperative AEs (138/336 vs 44/336, p<0.001). 210 adverse events were retrospectively recorded using the SAVES system (30 intraoperative adverse events, 138 early postoperative and 42 late postoperative adverse events). 99 patients (29.5%) on the cohort had at least one complication. Furthermore, the correlation between some risk factors and the onset of complications or the prolonged length of stay was statistically analyzed. The risk factors taken into account were: age, presence of comorbidities (CCI), ASA score, previous surgery at the same level, type of intervention, location of the disease, duration of the surgery. In particular, the duration of the surgery (more than 3 hours) and the presence of previous surgeries resulted to be risk factors for complications in multivariate analyses

Abstract. Objective. To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Methods. This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59–82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2–4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results. The mean (range) duration of anaesthesia was 38.66 (20–60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130–210 and 75–145 mmHg, respectively (mean [range] drop, 74.13 [33–125] mmHg). Mean (range) propofol dose was 1.74 (1–3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20–50) min. The mean (range) postoperative recovery score (local scale, range 5–28 where lower values are superior) was 5.2 (5–8). The mean (range) length of stay was 8 (1–20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions. Our data demonstrate that rTSA under ISB-RA is safe, cost-effective and a potentially viable alternative for patients with multiple comorbidities. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours

Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The cost savings from reduced LOS amounts to £110 - £247 per patient when NPWT is used. We hypothesize that in primary TKA patients with high risk of wound related problems that may delay discharge from hospital, there may be an overall cost saving when using NWPT dressings. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Lack of ability in basic mobility skills is associated with increased mortality in patients with hip fractures. The aim of this study was to identify predictors for performing basic mobility skills at discharge. Methods. From June 2015 to May 2016, 235 consecutive patients (76% female, median age 85 (78–89 IQR)) with hip fractures admitted to the Department of Orthopedic Surgery at North Denmark Regional Hospital were included. Basic mobility was assessed at discharge using the Cumulated Ambulation Score (CAS), which consists of 1) getting in and out of bed, 2) rising from a chair and 3) walking. Possible scores for each task is: unable (CAS=0), supported (CAS=1) or independent (CAS=2). A total score of 6 indicates independence in basic mobility. Inclusion was restricted to first time hip fractures and age ≥65. Exclusion criteria were death during admission or unrecorded CAS at discharge. Results. Before surgery 90.6% were independent in basic mobility (CAS=6). Getting out of bed at discharge: independently 37.5%, supported 56.5% and unable 6.0%. Rising from a chair: independently 49.8%, supported 43% and unable 7.2%. Walking: independently 43.8%, supported 38.3% and unable 17.9%. A total of 79 (33.6%) patients achieved independence in all tasks (CAS=6) at discharge. Independence in: 1) getting in and out of bed, 2) rising from a chair, and 3) walking, respectively had significant association with advanced age, length of stay and Charlson Comorbidity Index >0. Medial fractures were associated with inability to rise from a chair. Advanced age was the only variable significantly associated with each task of CAS. Pre-fracture function was associated with the inability to rise from a chair and walking. Delay of surgery > 48 hours after admission was significantly associated with the inability to walk. Conclusion. Elderly patients with comorbidities and dependent pre-fracture function should receive extra attention in rehabilitation

Financial and human cost effectiveness is an increasing evident outcome measure of surgical innovation. Considering the human element, the aim is to restore the individual to their “normal” state by sparing anatomy without compromising implant performance. Gait lab studies have shown differences between different implants at top walking speed, but none to our knowledge have analysed differing total hip replacement patients through the entire range of gait speed and incline to show differences. The purpose of this gait study was to 1) determine if a new short stem femoral implant would return patients back to normal 2) compare its performance to established hip resurfacing and long stem total hip replacement (THR) implants. 110 subjects were tested on an instrumented treadmill (Kistler Gaitway, Amherst, NY), 4 groups (short-stem THR, long-stem THR, hip resurfacing and healthy controls) of 28, 29, 27, and 26 respectively. The new short femoral stem patients (Furlong Evolution, JRI) were taken from the ongoing Evolution Hip trial that have been tested on the treadmill with minimum 12months postop. The long stem total hip replacements and hip resurfacing groups were identified from out 800 patient gait database. They were only chosen if they were 12 months postop and had no other joint disease or medical comorbidities which would affect gait performance. All subjects were tested through their entire range of gait speeds and incline after having a 5 minute habituation period. Speed intervals were at 0.5kms increments until maximum walking speed achieved and inclines at 4kms for 5, 10, 15%. At all incremental intervals of speed, the vertical component of the ground reaction forces, center of pressure and temporal measurements were collected for both limbs with a sampling frequency of 100Hz. Body weight scaling was applied to correct for mass differences and a symmetry index to compare the implanted hip to the contralateral normal hip. All variables for each subject group were compared to each other using an analysis of variance (ANOVA) with Tukey post hoc test with significance set at α=0.05. The four experimental groups were reasonably matched for demographics and the implant groups for PROMs. Hip resurfacing had a clear top walking speed advantage, but when assessing the symmetry index on all speeds and incline, all groups were not significantly different. Push-off and step length was statistically less favourable for the short/long THR group (p=0.005–0.05) depending on speed/incline. The primary aim of this study was determine if implant design affected gait symmetry and performance. Interestingly, irrespective of implant design, symmetry with regards to weight acceptance, impulse, push-off and step length was returned to normal when comparing to healthy controls. However individual implant performance on the flat and incline, showed inferior (p<0.05) push-off force and step length in the short stem and long stem THR groups when compared to controls. Age and gender may have played a part for the short stem group. It appears that the early gait outcomes for the short stem device are promising. Assessment at the 3 year mark should be conclusive

Frail patients with neck of femur fracture, amongst other medical problems, are frequently fast-tracked to orthopaedic wards to meet government A&E waiting time targets. This is a second cycle of audit since 2008 examining the safety of fast-tracking following individual critical incidents. Data was collected prospectively between March and June 2011 by the first on-call orthopaedic doctor. 56 patients (12 male), average age 81.2y (50–97) were fast tracked. 52 were correctly referred as intra/extracapsular fracture, however 4 did not have a neck of femur fracture. 9 patients were transferred with no verbal referral to the receiving orthopaedic doctor. On arrival to the ward, 8 patients were found to have abnormal observations and acute medical problems requiring immediate review from the physicians. There were a total of 150 omissions from a total of 456 points from the fast track protocol. Vital observations of patients fast-tracked after 2100h were worse (MEWS range 0 to 11) when compared with those fast-tracked prior to 2100h (MEWS range 0 to 3). This occurs at a time when medical staff support is minimal. Fast-tracking is a common practice amongst many district-general and some teaching hospitals in Scotland. These data support concerns from orthopaedic surgeons highlighting a need for more complete initial assessment and management in A&E prior to transfer to the ward. Recent evidence suggests medical optimisation of the multiple acute and chronic medical comorbidities common amongst patients with neck of femur fracture is the main facilitator of early surgery which significantly reduces post-operative mortality

Summary Statement. This data may help explain the variability in physical function after primary TKR as compared to primary THR. Introduction. Total knee replacement (TKR) and total hip replacement (THR) reliably relieve pain, restore function, and ensure mobility in patients with advanced joint arthritis; however these results are not uniform across all patient populations. We compared baseline demographic and symptom profiles in patients from a US national cohort undergoing primary TKR and THR. Methods. Patients undergoing primary TKR and THR between 7/1/2011 and 3/30/2012 were identified from the national research consortium which collects comprehensive data on enrolled patients from 120 surgeons across 23 states. Gathered data includes patient demographics, comorbidity (Charlson Comorbidity Index), operative joint pain severity, physical function (SF-36; Physical Component Score (PCS)), emotional health (SF-36 Mental Component Score (MCS)), and musculoskeletal burden of illness (Hip and Knee Disability and Osteoarthritis Outcome Scores; Oswestry Disability Index). Descriptive statistics compared baseline demographic and symptom profiles. Results. Our analysis compared 1362 primary TKR patients and 1013 primary THR patients. US TKR patients were significantly older (66.5 vs. 64.3 years), more obese (BMI 31.7 vs. 29.3), and less educated (p<0.005). TKR patients had higher rates of comorbidities, specifically diabetes, gastrointestinal ulcers, and cerebrovascular disease (p≤0.006). THR patients had significantly worse physical function (PCS 31.6 vs. 33.3), lower back pain (35.6% vs. 30.5% moderate-severe), and operative joint pain, stiffness, and function (p<0.005). Conclusion. US patients undergoing primary TKR are older with more comorbidities, however THR patient baseline functional and musculoskeletal limitations are significantly greater than primary TKR patients

Objectives

Electronic forms of data collection have gained interest in recent years. In orthopaedics, little is known about patient preference regarding pen-and-paper or electronic questionnaires. We aimed to determine whether patients undergoing total hip (THR) or total knee replacement (TKR) prefer pen-and-paper or electronic questionnaires and to identify variables that predict preference for electronic questionnaires.