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Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_1 | Pages 68 - 68
1 Jan 2016
Yang C Chang C Chen Y Chang C
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Introduction. Total knee arthroplasty [TKA] is a common procedure to relieve painful disability from advanced knee arthritis. However, related blood loss, ranging from 800 to 1200 ml, increase risk and disruption of recovery in anemic patients following TKA. Various methods for blood conservation had been proposed and examined. In the literature, the intra-articular administration of a solution mixing bupivacaine and epinephrine was commonly used after knee surgeries. Therefore, we conducted a retrospective, case controlled review of our primary TKAs to determine the hemostatic efficacy of this regimen following TKAs. Material and Methods. Over a period of 12 months, 135 eligible patients were divided two groups simply according to the intra-articular injection or not: a control group (N=63) and a treatment group (N=72). In the treatment group, a 40 ml vial of 0.5% bupivacaine with epinephrine 1: 200000 was given prior to the deflation of pneumatic tourniquet. No drainage was used in all TKAs. Without recordable drainage, a Gross formula, considering gender and body composition, was used for estimate blood loss following TKAs. In addition, serial changes in hemoglobin as well as the requirement of allogenic transfusion were also compared between groups. Results. The mean calculated blood loss in the treatment group was 650.4 +/− 257.1 ml, compared to 648.8+/− 222.1 ml in the control group (p=0.9). Similar decrease in hemoglobin as well as rates of allogenic transfusion needs were observed between groups.[2.5+/− 0.9 g/dl vs. 2.4+/− 0.8 g/dl; 13.9% vs. 12.7%, respectively]. Discussion and Conclusion. Although local analgesics mixing vasoconstrictive agents seem a logic solution to save blood loss and relieve pain simultaneously, the hypothesis that intra-articular injection of bupivacaine and epinephrine would save blood and even transfusion needs following TKAs is not supported by various bleeding parameters in this study. In addition to temporary benefit in pain relief, this regimen only has little effect on blood conservation. Therefore, new regimen as well as hemostatic means are still required and explored to reduce blood loss following TKAs


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_19 | Pages 18 - 18
22 Nov 2024
Gupta V Shahban S Petrie M Kimani P Kozdryk J Riemer B King R Westerman R Foguet P
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Aim

Predicting success of a Debridement, Antibiotics and Implant Retention (DAIR) procedure for Periprosthetic Joint Infection (PJI) remains a challenge. A failed DAIR might adversely affect the outcome of any future revision surgery for PJI. Hence, the ability to identify and optimise factors predictive of DAIR success would help target the procedure to the appropriate patient cohort and avoid unnecessary surgery for patients where a DAIR is unlikely to eradicate infection.

Method

A retrospective review of our prospective Bone Infection Group database was performed to identify all patients who underwent a DAIR of their hip or knee arthroplasty. Diagnosis of PJI was confirmed using the Musculoskeletal Infection Society (MSIS) 2013 and the European Bone and Joint Infection Society (EBJIS) 2021 classification systems. DAIR surgery was grouped into “successful” or “unsuccessful” outcomes as per the MSIS working group outcome-reporting tool.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_4 | Pages 115 - 115
1 Apr 2019
Verstraete M Conditt M Chow J Gordon A Geller J Wade B Ronning C
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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).


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 112 - 112
1 Dec 2015
Caetano A Nunes A Angelo A Sousa J Cardoso C
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Posttraumatic osteomyelitis (PTO) is a complex condition that results in considerable morbidity. Tibia is one of the most common sites of PTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Developments in surgery have greatly improved the ability to treat this condition. However, some authors defend that functional outcome is often poorer after successful limb reconstruction than after treatment with amputation below the knee, especially in patients with systemic factors that might significantly compromise reconstructive treatment. Limb salvage is associated with a longer convalescence time and a higher risk of complications, additional surgeries, and rehospitalisation. We present a case report of a patient with PTO requiring amputation of the leg despite aggressive surgical treatment.

The authors present a case of an 86-year-old woman with past medical history significant for diabetes, hypertension, severe peripheral artery disease and congestive heart failure. In March 2013 the patient sustained a tibia and fibula fracture (42-C1 AO Classification). Closed reduction and intramedullary nailing were performed. Osteomyelitis was diagnosed 1 month later. Implant removal, debridement, stabilization with external fixator and a vascularized skin graft were performed. Graft necrosis with bone exposure occurred after 1 month. Cultures were positive for multiple pathogens, including methicillin-sensitive Staphylococcus aureus. Several surgical debridement, vacuum-assisted closure therapy (VAC) and specific antibiotic therapy were performed for 8 weeks. Clinical deterioration with persistent bacteremia and infectious process led to the amputation below the knee in October 2014. Symptomatic relieve was achieved and C-reactive protein returned to her normal values.

Minimal stump necrosis was detected. Seven months postoperatively the patient is doing well with assisted gaitpilaa and few limitations in her daily life and there are no signs of systemic or local infection.

Management of posttraumatic osteomyelitis remains a challenge.

Amputation may prove to be the most appropriate way of restoring function and improving patient's quality of live, if there is failure to achieve bone healing and restore function. The decision to amputate should be considered carefully and individually, involving both patient and family.


Shoulder replacement surgery is a well-established orthopaedic procedure designed to significantly enhance patients’ quality of life. However, the prevailing preoperative admission practices within our tertiary shoulder surgery unit involve a two-stage group and save testing process, necessitating an admission on the evening before surgery. This protocol may unnecessarily prolong hospital stays without yielding substantial clinical benefits. The principal aim of our study is to assess the necessity of conducting two preoperative group and save blood tests and to evaluate the requirement for blood transfusions in shoulder arthroplasty surgeries. A secondary objective is to reduce hospital stay durations and the associated admission costs for patients undergoing shoulder arthroplasty. We conducted a retrospective observational study covering the period from 1st January 2023 to 31st August 2023, collecting data from shoulder arthroplasty procedures across three hospitals within the Aneurin Bevan University Health Board. Our analysis included 21 total shoulder replacement cases and 13 reverse shoulder replacement cases. Notably, none of the patients required postoperative blood transfusions. The mean haemoglobin drop observed was 14 g/L for total shoulder replacements and 15 g/L for reverse shoulder replacements. The mean elective admission duration was 2.4 nights for total shoulder replacements and 2 nights for reverse shoulder replacements. Our data indicated that hospital stays were extended by one night primarily due to the preoperative group and save blood tests. In light of these findings, we propose a more streamlined admission process for elective shoulder replacement surgery, eliminating the need for the evening-before-surgery group and save testing. Hospital admissions in these units incur a cost of approximately £500 per night, while the group and save blood tests cost around £30 each. This revised admission procedure is expected to optimise the use of healthcare resources and improve patient satisfaction without compromising clinical care


In patients with hand sepsis does bedside debridement compared to operating theatre debridement have similar clinical outcomes, hospital cost and time to discharge in a District Hospital setting in South Africa?. A case series of 130 adult patients presenting to a district level orthopaedic unit over 1 year with hand sepsis requiring debridement. All included patients were debrided at the bedside (i.e. the emergency room, ward, OPD) under wrist or digital block. Patients excluded from the study included patients with necrotising soft tissue infections that required debridement in theatre. A cost analysis was done based on operating theatre (OT) costs saved as defined by Samuel1 et al. If an average theatre time of 45 min is taken then the cost saved per patient is approximately R1500 and approximately R300000 for the patients included in the case series. This excludes ward and other hospital costs related to a longer hospital admission. The mean time to discharge for the included patients was 24 hours. This study suggests that bedside debridement can be a viable and cost effective option for selected cases of hand sepsis that can avoid the high cost and time associated with operating theatre debridement with similar outcomes. This has implications for the future treatment of hand sepsis in resource constrained settings were operating theatre time is not only very expensive but also very scarce


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_3 | Pages 4 - 4
23 Jan 2024
Clarke M Pinto D Ganapathi M
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Patient education programmes prior to hip and knee arthroplasty reduce anxiety and create realistic expectations. While traditionally delivered in-person, the Covid-19 pandemic has necessitated change to remote delivery. We describe a ‘Virtual Joint School’ (VJS) model introduced at Ysbyty Gwynedd, and present patient feedback to it. Eligible patients first viewed online educational videos created by our Multi-Disciplinary Team (MDT); and then attended an interactive virtual session where knowledge was reinforced. Each session was attended by 8–10 patients along with a relative/friend; and was hosted by the MDT consisting of nurses, physiotherapists, occupational therapists, and a former patient who provided personal insight. Feedback on the VJS was obtained prospectively using an electronic questionnaire. From July 2022 to February 2023, 267 patients attended the VJS; of which 117 (44%) responded to the questionnaire. Among them, 87% found the pre-learning videos helpful and comprehensible, 92% felt their concerns were adequately addressed, 96% felt they had sufficient opportunity to ask questions and 96% were happy with the level of confidentiality involved. While 83% felt they received sufficient support from the health board to access the virtual session, 63% also took support from family/friends to attend it. Only 15% felt that they would have preferred a face-to-face format. Finally, by having ‘virtual’ sessions, each patient saved, on average, 38 miles and 62 minutes travel (10,070 miles and 274 hours saved for 267 patients). Based on the overwhelmingly positive feedback, we recommend implementation of such ‘Virtual Joint Schools’ at other arthroplasty centres as well


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_11 | Pages 20 - 20
1 Nov 2022
Haque S Eldesoki A Lim J
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Abstract. Background. Different surgical sub specialities rely on fixed number of porters each morning to bring patients to operating theatre. In daily morning trauma meetings usual practice is to present the whole list of one theatre and then move on to next theatre list. Once all the theatres trauma list are presented, porters are sent to get patients to theatre. With different sub-specialities starting simultaneously and competing for fixed numbers of porters, this can cause significant delay in getting the patients to anaesthetic room. Methods. Retrospective pilot project in level 1 major trauma centre were more that two trauma list a day is a common norm. Pilot project:. First (Golden) patient for every trauma list would be presented at the start of the trauma meeting. Meeting would pause and consultant chairing the meeting would request the trauma theatre representative to send for these patients. Once this is done the meeting would recommence as usual. Results. (a). The porters were sent on an average more than 30 minutes earlier in the pilot week. (b). This was further reflected in the patients being brought into holding bay. (c). The patients were in the anaesthetic room on an average 40 minutes before in pilot group compared to usual practice. Conclusion/Findings. Presenting first patient of each trauma list and then asking theatre to send porter to get the patient to theatre can save appreciable time. Implications. To run an hour of theatre costs £1200. This initiative can save lot of money for NHS


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_2 | Pages 32 - 32
10 Feb 2023
Jadav B
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3D printing techniques have attracted a lot of curiosity in various surgical specialties and the applications of the 3D technology have been explored in many ways including fracture models for education, customized jigs, custom implants, prosthetics etc. Often the 3D printing technology remains underutilized in potential areas due to costs and technological expertise being the perceived barriers. We have applied 3D printing technology for acetabular fracture surgeries with in-house, surgeon made models of mirrored contralateral unaffected acetabulum based on the patients’ trauma CT Scans in 9 patients. The CT Scans are processed to the print with all free-ware modeling software and relatively inexpensive printer by the surgeon and the resulting model is used as a ‘reduced fracture template’ for pre-contouring the standard pelvic reconstruction plates. This allows use of the standard surgical implants, saves time on intra-operative plate contouring, and also aids in reduction to an extent. We share through this presentation the workflow of the freeware softwares to use in order to use this surgical planning and implant preparation that may remove the perceived barriers of cost and technology from surgeons that wish to explore using 3D printing technology for acetabular fracture management and may extend applications to other regions


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_3 | Pages 7 - 7
23 Jan 2024
Richards OJ Johansen A John M
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BACKGROUND. Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00. AIM. To investigate whether routine pretransfusion blood sampling for trauma admissions exceeds requirements. METHODS. Electronic records were used to collect pretransfusion sampling data for all adult non-elective trauma patients listed for theatre under a trauma and orthopaedics consultant between 1/1/2023-31/1/2023. Data were collected on unnecessary samples, rejected samples and total excess samples. RESULTS. 113 patients (mean age[±SD] 64.09[±19.96]) underwent 132 procedures. On average, unnecessary sampling occurred at a rate of 0.48 samples per operation, equating to a cost of £945.00/month. Samples were rejected by the laboratory at a rate of 0.25 samples per operation. Common reasons for rejection were ‘patient date of birth discrepancy’ (between sample and request form), ‘patient address discrepancy’ and ‘signature discrepancy’. Overall, total excessive sampling occurred at a rate of 0.60 samples per operation. CONCLUSION. Nearly half of trauma patients undergo unnecessary blood testing in anticipation of potential perioperative transfusion. This has implications for sustainability, financial cost and patient welfare. This signals poor understanding of WBS requirements and is an area that requires improvement


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_2 | Pages 17 - 17
10 Feb 2023
Weber A Dares M
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Percutaneous flexor tenotomy involves cutting the flexor digitorum tendons to correct claw toe deformity to treat apical pressure areas and prevent subsequent infection in patients with peripheral neuropathy. Performing this under ultrasound guidance provides reassurance of complete release of the tendon and increases procedural safety. This study is a retrospective case series evaluating the effectiveness, safety, and patient satisfaction of performing percutaneous ultrasound-guided flexor tenotomy in an outpatient setting. People with loss of protective sensation, a digital flexion deformity, and an apical toe ulcer or pre-ulcerative lesion who presented to our institution between December 2019 and June 2022 were included in this study. Participants were followed-up at a minimum of 3 months. Time to ulcer healing, re-ulceration rate, patient satisfaction, and complications were recorded. An Australian cost analysis was performed comparing this procedure performed in rooms versus theatres. There were 28 ulcers and 41 pre-ulcerative lesions. A total of 69 tenotomy procedures were performed on 38 patients across 52 episodes of care. The mean time to ulcer healing was 22.5 +/- 6.4 days. There were 2 cases of re-ulceration. 1 patient sustained a transfer lesion. There were four toes that went onto require amputation, all in the setting of pre-existing osteomyelitis. 94% of patients strongly agreed that they were satisfied with the outcome of the procedure. Costs saved were estimated to be $1426. Flexor tenotomy is a minimally invasive procedure that can be performed in the outpatient setting, and therefore without delay to treatment, reducing risk of ulcer progression and need for subsequent amputation. This is the first study to report on flexor tenotomy under ultrasound-guidance. Ultrasound-guided percutaneous flexor tenotomy is safe and effective, with high patient satisfaction and low recurrence rates. This performance in the outpatient setting ensures significant time and cost savings for both the practitioner and patient


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_14 | Pages 6 - 6
23 Jul 2024
Mohammed F Soler A
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Trauma, across the United Kingdom, is managed using several software, paper based lists on Microsoft Word/Excel or Teams. There is usually poor handover or no handover in a standard format- during the on call, in the trauma meetings or in the wards. The software in the market for trauma management are not cost friendly or adaptable to local demands. The alternatives like Microsoft WORD based lists are fraught with their own problems. We endeavoured to make our trauma management effective. A Quality Improvement Project was done. The goals to achieve at end of a year were:. Daily Trauma Handover in standardised format >90%. Ward Handover in standardised format >90%. Availability of outcomes of patients in clinic >80%. Reduction of paper usage >90% at the end of six months. Availability of updated “outliers” information >90% at the weekend ward round. Documentation from the Trauma Meeting > 90%. On-Call documentation in standardised format >90%. Doctor Satisfaction >75% in terms of: ease of us;, searchability of patient; ward round experience; morning trauma meeting experience; handover experience; inter-specialty communication; reliability; daily time saving; on-call time saving; patient care/safety; overall satisfaction. We used Microsoft Sharepoint List to manage our trauma workload and have named the tool as “The List”. The List has achieved all objectives as above in one year's time, except Outlier information which was at 67% in a recent PDSA (Plan-Do-Study-Act) cycle. The survey showed excellent doctor satisfaction and 90% respondents felt that The List saved an hour or more during the on-call and also during the ward rounds. We conclude that The List is a very powerful tool making trauma meetings efficient and handover effective. It is indigenous, adaptable, safe, sustainable, cost neutral and easy to use


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_2 | Pages 109 - 109
10 Feb 2023
Sun J Tan SE Sevao J
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Anatomically specific fixation devices have become mainstream, yet there are anatomical regions and clinical conditions where no pre-contoured plates are available, such as for glenohumeral arthrodesis. In a case series of 4 glenohumeral arthrodesis patients, a consultant orthopaedic surgeon at GCUH implemented 3D printing technology to create reconstructions of each patient's shoulder girdle to pre-contour arthrodesis plates. Our aim was to quantify the cost-benefit & intra-operative time savings of this technique in glenohumeral arthrodesis. We hypothesized that the use of 3D printing for creating patient specific implants through pre-operative contouring of plates will lead to intra-operative time and cost savings by minimising time spent bending plates during surgery. This study analysed 4 patients who underwent shoulder arthrodesis by a single consultant orthopaedic surgeon at GCUH between 2017-2021. A CT-based life-size model of each patient's shoulder girdle was 3D printed using freely available computer software programs: 3D Slicer, Blender, Mesh Mixer & Cura. Once the patient's 3D model was created, plate benders were used to contour the plate pre-op, which was then sterilised prior to surgery. Arthrodesis was performed according to AO principles of fixation. The time spent pre-bending the plate using the 3D model was calculated to analyse the intra-op time and cost-saving benefits. For the 4 cases, the plate pre-bending times were 45, 40, 45 & 20 minutes (average 38.8 mins). The intra-op correction time to make small adjustments to the plate was 2 min/ case. 3 plates needed minor (3 degree) adjustment to fine-tune scapula spine contouring. 1 plate needed a 5 degree correction to fine-tune hand position. On average, the pre-bending of the plate saved approximately 38.8 mins intra-op/ case. These shorter anaesthetic and operating times equate to approximately $2586 saving/ case, given an estimate of $4000/hour of theatre costs. We conclude that pre-bending plates around 3D-printed life-size models of an individual's shoulder girdle prior to surgery results in approximately 38.8 mins time saving intra-op when used in shoulder arthrodesis. This is a viable and effective technique that will ultimately result in significant operative time and financial savings


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_19 | Pages 78 - 78
22 Nov 2024
Lutro O Tjørhom MB Fenstad AM Leta TH Hallan G Bruun T Furnes O Gjertsen J Dale H
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Aim. The current recommendation in Norway is to use four doses of a first-generation cephalosporin (cefazolin or cephalotin) as systemic antibiotic prophylaxis (SAP) the day of surgery in primary joint arthroplasty. Due to shortage of supply, scientific development, changed courses of treatment and improved antibiotic stewardship, this recommendation has been disputed. We therefore wanted to assess if one dose of SAP was non-inferior to four doses in preventing periprosthetic joint infection (PJI) in primary joint arthroplasty. Method. We included patients with primary hip- and knee arthroplasties from the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register for the period 2005-2023. We included the most used SAPs (cephalotin, cefazolin, cefuroxime, cloxacillin and clindamycin), administered as the only SAP in 1-4 doses, starting preoperatively. Risk of revision (Hazard rate ratio; HRR) for PJI was estimated by Cox regression analyses with adjustment for sex, age, ASA class, duration of surgery, reason for- and type of arthroplasty, and year of primary arthroplasty. The outcome was 1-year reoperation or revision for PJI. Non-inferiority margins were calculated for 1, 2 and 3 doses versus reference of 4 doses of SAP at the day of surgery, against a predetermined limit of 15% increased risk of PJI. Results. In total 274,188 primary arthroplasties (total hip 133,985, hemi hip 51,442, and total knee 88,761) were included. Of these primary arthroplasties, 2,996 (1.1%) had subsequent revisions for PJI during the first postoperative year. One dose of SAP was given in 9,603 arthroplasties, two doses in 10,068, three doses in 18,351, and four doses in 236,166 arthroplasties. With the recommended four doses as reference, the HRR (95% CI) for 1-year revision for infection was 0.9 (0.7-1.1) for one dose, 1.0 (0.8-1.2) for two doses, and 0.9 (0.8-1.1) for three doses. The corresponding adjusted 1-year revision incidences for PJI was 0.9 (0.7-1.1), 1.0 (0.8-1.2), 0.9 (0. 8-1.1) and 1.0 (1.0-1.1) for one, two, three and four doses respectively, and less than four doses was found to be non-inferior. Conclusions. One preoperative dose of SAP in primary joint arthroplasty surgery seems to be non-inferior to the current recommendation of four doses of a first-generation cephalosporin as PJI-prophylaxis. This finding may simplify the course of treatment for arthroplasty patients, save costs, and improve antibiotic stewardship


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_13 | Pages 33 - 33
1 Dec 2022
Chen H Pike J Huang A
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The purpose of this prospective pilot study is to examine the feasibility of a physiotherapist led rapid access shoulder screening clinic (RASC). The goal of this study is to assess for improvements in patient access to care, patient reported outcome measures, patient reported experience measures, and cost outcomes using time driven activity based costing methods. Patient recruitment began in January 2021. Consultation requests from general practitioners and emergency rooms are analyzed and triaged through a central system. One half of patients awaiting consultation were triaged to the traditional route used at our center while the other half were triaged to be assessed at the RASC. Outcome measures consisting of the Simple Shoulder Test and SF-12 were recorded at the initial consultation and at follow up appointments. Cost benefit analysis was conducted using time driven activity based costing methods (TD-ABC). From January to August of 2021, 123 new patients were triaged for RASC assessment. On average, the RASC gets 10 new referrals per month. As of September 2021, there are 65 patients still on waitlist for RASC assessment with 58 having been assessed. Of the 58, 11% were discharged through the RASC, 48% pursued private physiotherapy, 14% had injections, 19% proceeded on for surgical consultation, and 8% did not show. Over time same time period, approximately 15 new patients were seen in consultation by the surgeon's office. Thirty-five responses were obtained from RASC patients during their initial intake assessment. The average age of respondents was 54.7 with 21 females and 14 males. Median SF-12 scores in the physical dimension (PCS-12) for RASC patients were 36.82 and mental (MCS-12) 49.38927. Median Simple Shoulder Test scores measured 6. Of the patients who responded to the follow up questionnaires after completing physiotherapy at the RASC, both the SF-12 and Simple Shoulder Test scoring improved. Median PCS-12 measured 47.08, MCS-12 of 55.87, and Simple Shoulder Test measured 8. RASC assessments by PT saved $172.91 per hour for consultation and $157.97 per hour for patient follow ups. Utilization of a physiotherapy led rapid access shoulder clinic resulted in improvements in patient outcomes as measured by the SF-12 and Simple Shoulder Test as well as significant direct cost savings. Proper triage protocols to identify which patients would be suitable for RASC assessment, buy-in from physiotherapists, and timely assessment of patients for early initiation of rehabilitation for shoulder pain is paramount to the success of a RASC system at our centre. Future research direction would be geared to analyzing a larger dataset as it becomes available


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_13 | Pages 86 - 86
1 Dec 2022
Lex J Abbas A Oitment C Wolfstadt J Wong PKC Abouali J Yee AJM Kreder H Larouche J Toor J
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It has been established that a dedicated orthopaedic trauma room (DOTR) provides significant clinical and organizational benefits to the management of trauma patients. After-hours care is associated with surgeon fatigue, a high risk of patient complications, and increased costs related to staffing. However, hesitation due to concerns of the associated opportunity cost at the hospital leadership level is a major barrier to wide-spread adoption. The primary aim of this study is to determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency. Secondly, we sought to evaluate the associated financial impact of the DOTR, with respect to both after-hours care costs as well as the opportunity cost of displaced elective cases. This was a retrospective cost-analysis study performed at a single academic-affiliated community hospital in Toronto, Canada. All patients that underwent the most frequently performed orthopedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a four-year period from 2016-2019 were included. Patient data acquired for two-years prior and two-years after the implementation of a DOTR were compared, adjusting for the number of cases performed. Surgical duration and number of day-time and after-hours cases was recorded pre- and post-implementation. Cost savings of performing trauma cases during daytime and the opportunity cost of displacing elective cases by performing cases during the day was calculated. A sensitivity analysis accounting for varying overtime costs and hospital elective case profit was also performed. 1960 orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR. After accounting for the total number of each procedure performed, the mean weighted reduction was 31.4% and the mean time saved was 29.6 minutes per surgery. The number of daytime surgical hours increased 21%, while nighttime hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2,476. Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Through the regular scheduling of a DOTR at a single hospital in Canada, the number of surgeries occurring during daytime hours increased while the number of after-hours cases decreased. The same surgeries were also completed nearly one-third faster (30 minutes per case) on average. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Notably, the savings partially stem from decreased OR time as well as decreased nurse overtime. Widespread implementation can improve patient care while still remaining financially favourable


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_12 | Pages 82 - 82
1 Dec 2022
Hitchon S Milner J Holdsworth D Willing R
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Revision surgeries for orthopaedic infections are done in two stages – one surgery to implant an antibiotic spacer to clear the infection and another to install a permanent implant. A permanent porous implant, that can be loaded with antibiotics and allow for single-stage revision surgery, will benefit patients and save healthcare resources. Gyroid structures can be constructed with high porosity, without stress concentrations that can develop in other period porous structures [1] [2]. The purpose of this research is to compare the resulting bone and prosthesis stress distributions when porous versus solid stems are implanted into three proximal humeri with varying bone densities, using finite element models (FEM). Porous humeral stems were constructed in a gyroid structure at porosities of 60%, 70%, and 80% using computer-aided design (CAD) software. These CAD models were analyzed using FEM (Abaqus) to look at the stress distributions within the proximal humerus and the stem components with loads and boundary conditions representing the arm actively maintained at 120˚ of flexion. The stem was assumed to be made of titanium (Ti6Al4V). Three different bone densities were investigated, representing a healthy, an osteopenic, and an osteoporotic humerus, with an average bone shape created using a statistical shape and density model (SSDM) based on 75 cadaveric shoulders (57 males and 18 females, 73 12 years) [3]. The Young's moduli (E) of the cortical and trabecular bones were defined on an element-by-element basis, with a minimum allowable E of 15 MPa. The Von Mises stress distributions in the bone and the stems were compared between different stem scenarios for each bone density model. A preliminary analysis shows an increase in stress values at the proximal-lateral region of the humerus when using the porous stems compared to the solid stem, which becomes more prominent as bone density decreases. With the exception of a few mesh dependent singularities, all three porous stems show stress distributions below the fatigue strength of Ti-6Al-4V (410 MPa) for this loading scenario when employed in the osteopenic and osteoporotic humeri [4]. The 80% porosity stem had a single strut exceeding the fatigue strength when employed in the healthy bone. The results of this study indicate that the more compliant nature of the porous stem geometries may allow for better load transmission through the proximal humeral bone, better matching the stress distributions of the intact bone and possibly mitigating stress-shielding effects. Importantly, this study also indicates that these porous stems have adequate strength for long-term use, as none were predicted to have catastrophic failure under the physiologically-relevant loads. Although these results are limited to a single boney geometry, it is based on the average shape of 75 shoulders and different bone densities are considered. Future work could leverage the shape model for probabilistic models that could explore the effect of stem porosity across a broader population. The development of these models are instrumental in determining if these structures are a viable solution to combatting orthopaedic implant infections


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_12 | Pages 86 - 86
1 Dec 2022
Grant M Bokhari R Alsaran Y Epure LM Antoniou J Mwale F
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Degenerative disc disease (DDD) is a common cause of lower back pain. Calcification of the intervertebral disc (IVD) has been correlated with DDD, and is especially prevalent in scoliotic discs. The appearance of calcium deposits has been shown to increase with age, and its occurrence has been associated with several other disorders such as hyperparathyroidism, chondrocalcinosis, and arthritis. Trauma, vertebral fusion and infection have also been shown to increase the incidence of IVD calcification. Our data indicate that Ca. 2+. and expression of the extracellular calcium-sensing receptor (CaSR) are significantly increased in mild to severely degenerative human IVDs. In this study, we evaluated the effects of Ca. 2+. and CaSR on the degeneration and calcification of IVDs. Human donor lumbar spines of Thompson grade 2, 3 and 4 through organ donations within 24 hs after death. IVD cells, NP and AF, were isolated from tissue by sequential digestion with Pronase followed by Collagenase. Cells were expanded for 7 days under standard cell culture conditions. Immunohistochemistry was performed on IVD tissue to validate the grade and expression of CaSR. Free calcium levels were also measured and compared between grades. Immunocytochemistry, Western blotting and RT-qPCR were performed on cultured NP and AF cells to demonstrate expression of CaSR, matrix proteins aggrecan and collagen, catabolic enzymes and calcification markers. IVD cells were cultured in increasing concentrations of Ca. 2+. [1.0-5.0 mM], CaSR allosteric agonist (cincalcet, 1 uM), and IL-1b [5 ng/mL] for 7 days. Ex vivo IVD organ cultures were prepared using PrimeGrowth Disc Isolation System (Wisent Bioproducts, Montreal, Quebec). IVDs were cultured in 1.0, 2.5 mM Ca. 2+. or with cinacalcet for 21 days to determine effects on disc degeneration, calcification and biomechanics. Complex modulus and structural stiffness of disc tissues was determined using the MACH-1 mechanical testing system (Biomomentum, Laval, Quebec). Ca. 2+. dose-dependently decreased matrix protein synthesis of proteoglycan and Col II in NP and AF cells, similar to treatment with IL-1b. (n = 4). Contrarily to IL-1b, Ca. 2+. and cincalcet did not significantly increase the expression of catabolic enzymes save ADAMTS5. Similar effects were observed in whole organ cultures, as Ca. 2+. and cinacalcet decreased proteoglycan and collagen content. Although both Ca. 2+. and cinacalcet increased the expression of alkaline phosphatase (ALP), only in Ca. 2+. -treated IVDs was there evidence of calcium deposits in NP and AF tissues as determined by von Kossa staining. Biomechanical studies on Ca. 2+. and cinacalcet-treated IVDs demonstrated decreases in complex modulus (p<0.01 and p<0.001, respectively; n=5), however, only Ca. 2+. -treated IVDs was there significant increases stiffness in NP and AF tissues (p<0.001 and p<0.05, respectively; n=3). Our results suggest that changes in the local concentrations of calcium and activation of CaSR affects matrix protein synthesis, calcification and IVD biomechanics. Ca. 2+. may be a contributing factor in IVD degeneration and calcification


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_10 | Pages 40 - 40
1 Jun 2023
Al-Omar H Patel K Lahoti O
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Introduction. Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results. Materials & Methods. We have treated 20 (22 limbs – 2 patients requiring staged bilateral corrections) patients for distal femoral varus and valgus deformities with CWDFO between 2019 and 2022. Out of these 4 patients (5 limbs) requiring large corrections of distal femoral angular deformities were treated with Neutral Wedge (NW) technique. 3 patients (four limbs) had distal femoral valgus deformity and one distal femoral varus deformity. Indication for NW technique is an angular deformity (varus or valgus of distal femur) requiring > 12 mm opening/closing wedge correction. We approached the closing side first and marked out the half of the calculated wedge with K – wires in a uniplanar fashion. Then an external fixator with two Schanz screws is applied on the opposite side, inserting the distal screw parallel to the articular surface and the proximal screw 6–7 cm proximal to the first pin and at right angles to the femoral shaft mechanical axis. Then the measured wedge is removed and carefully saved. External fixator is now used to close the wedge and over correct, creating an appropriate opening wedge on the opposite side. A Tomofix (Depuoy Synthes) plate is applied on the closing side with two screws proximal to osteotomy and two distally (to be completed later). Next the osteotomy on the opposite side is exposed, the graft is inserted. mLDFA is measured under image intensifier to confirm satisfactory correction. Closing wedge side fixation is then completed followed by fixation of opposite side with a Tomofix or a locking plate. Results. 3 patients (4 limbs) had genu valgum due to constitutional causes and one was a case of distal femoral varus from a fracture. Preoperative mLDFA ranged from 70–75° and in one case of varus deformity it was 103°. We achieved satisfactory correction of mLDFA in (85–90°) in 4 limbs and one measured 91°. Femoral length was not altered. JLCA was not affected post correction. Patients were allowed to weight bear for transfers for the first six weeks and full weight bearing was allowed at six weeks with crutches until healing of osteotomy. All osteotomies healed at 16–18 weeks (average 16.8 weeks). Patients regained full range of movement. We routinely recommend removal of metal work to facilitate future knee replacement if one is needed. Follow up ranged from 4 months to 2 yrs. Irritation from metal work was noted in 2 patients and resolved after removing the plates at 9 months post-surgery. Conclusions. NWDFO is a good option for large corrections. We describe a technique that facilitates accurate correction of deformity in these complex cases. Osteotomy heals predictably with uniplanar osteotomy and dual plate fixation. Metal work might cause irritation like other osteotomy and plating techniques in this location


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_6 | Pages 14 - 14
1 May 2021
Barnard L Karimian S Shankar V Foster P
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Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant