Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers.

This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median.

A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS.

In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS.

Balloon kyphoplasty (BKP) is a minimally invasive surgical technique used to correct kyphosis and vertebral compression fractures. BKP uses cement to fill a void created by the inflation of a balloon in a vertebra, it can be used as an alternative to vertebroplasty to reduce cement extravasation. Issues such as poor inter digitisation of the cement and the trabecular bone can arise with the BKP method. This can be due to a compacted layer created during the procedure which can cause complications post-surgery. The primary aim of this study was to investigate alternative cement application methods which could improve the mechanical strength of the bone-cement interface. Three alternative methods were investigated, and cylindrical bone-cement specimens were created for all methods (BKP and three alternatives). An important part of this study was to replicate the compacted layer created by the inflation of the balloon tamp in BKP. Synthetic trabecular bone specimens (Sawbones®, Pacific Research Laboratories, Vashon Island, Washington, USA) were pre-loaded in compression and the resultant compacted layers were found to replicate the compacted layers found in surgery. Mechanical testing was carried out with an MTS Model 858 Bionix^® Servohydraulic load frame using static tensile and torsion loads. Static tests revealed that two of the three alternative methods were an improvement on BKP, with a high statistical significance in relation to the mechanical performance of the bone-cement interface (P < 0.001). This data illustrates the potential to improve the standard BKP technique, in terms of bone-cement interface performance.

In 2011 health policy dictated a reduction in iatrogenic infections, such as Clostridium difficile (C. diff), this resulted in local change to antimicrobial policy in orthopaedic surgery. Previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change an increased number of patients appeared to suffer from acute kidney injury (AKI). We initially evaluated the incidence of AKI pre and post antibiotic change and found a correlation between the Flucloxacillin and AKI. We then made changes to antibiotic policy to mitigate the increased rates of AKI and proceeded to evaluate the outcomes.

In this prospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data obtained. The degree of AKI was classified according to the validated RIFILE criteria.

Evaluation showed a 4 fold decrease, from 13% to only 3%, in AKI after introduction of the modified antibiotic policy. C.difficile continues to be non-existent since this change.

Flucloxacillin obviously had a significant impact on this patient group. However, we have shown that with appropriate changes to antibiotic policy AKI associated morbidity can be significantly reduced. Dose dependent antibiotics will now be given based on weight and eGFR.

Summary Statement

Spinal flexibility in bending and axial torque has been shown to exhibit very modest changes with advancing disc degeneration. This study is the first to address the possible relationship in pure anterior shear and no clear relationship was observed.

Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation.

The use of patient reported outcome measures (PROMs) of function is increasing in popularity. Self reported outcome instruments are used to measure change in health status over time allowing for the collection of accurate and relevant data on the quality of healthcare services. With recent changes outlined by the government, it will become increasingly important for surgeons to be able to demonstrate, with quantitative data, positive benefit of the surgery they perform. This study demonstrates the effectiveness of, and issues involved with setting up a PROMs database in a busy orthopaedic unit.

We have previously shown that a high proportion of our orthopaedic patients have access to the Internet. Suitable patients were identified at foot and ankle clinics or from surgical lists, and the well validated Foot and Ankle Ability Measure (FAAM) regional scoring system was used. The FAAM is a self-reported, region specific, instrument consisting of 21-item activities of daily living (ADL) subscale and an eight-item sports subscale. This was completed pre-operatively and also online at six-months post operatively, using limesurvey, a free online survey with internet/email based responses.

The software was simple to use and took about 4 hours to develop. 77% of the patient cohort for the period of study had email access and the majority of patients without email were happy to have the questionnaire completed over the phone. This took approximately ten minutes per survey. Patients who did not conduct the study prior to their admission were able to fill it in on the ward using a laptop.

This project has demonstrated that the initiation and continuation of a PROMs data collection system is feasible in a busy orthopaedic unit, producing reliable data which will enable us to monitor and improve standards of clinical practice. We discuss the issues involved with its introduction and usage.

Introduction

Mortality rates following hip fracture are high. There are several scoring systems which aim to predict morbidity and mortality in hospital in-patients. The Nottingham Hip Fracture Score (NHFS) was devised to predict 30 day mortality following hip fracture.

Introduction

Mortality rates following hip fracture are high. There are several scoring systems which aim to predict morbidity and mortality in hospital in-patients. The Nottingham Hip Fracture Score (NHFS) was devised to predict 30 day mortality following hip fracture. Methods: All patients with hip fractures admitted over a 6 month period were reviewed. The NHFS was calculated for each patient and any associations between patient factors, NHFS, and outcome were investigated.

Purpose: The current gold standard for spinal arthrodesis, autologous bone graft harvested from the iliac crest, has several disadvantages including donor site morbidity, blood loss, delayed wound healing, and increased operative time. Our study explores a Demineralized Bone Matrix-Calcium Sulfate(DBM-CaSO4) composite graft with autologous bone marrow aspirate (BMA), and compares it to autologous iliac crest bone graft in lumbar and lumbosacral spinal fusions.

Method: A total of 80 patients were recruited for the study and randomised, via a computer-generated ran-domisation schedule, to autologous iliac crest bone graft (control) or DBM-CaSO4 composite graft with BMA (study) groups. Patients were evaluated at three-months, six-months, 12-months and 24-months post-operatively with questionnaires to evaluate clinical outcome (Oswestry disability questionnaire (ODI), visual analogue pain scales (VAS), and validated SF-36) and with posteroanterior and lateral x-rays of the spine to evaluate radiological outcome.

Results: At 24-months post-operatively, there were no statistical differences seen between the two groups based on the clinical outcomes measured. Average ODI values were 27.19 for the control group versus 22.68 for the study group (p > 0.05). The average back VAS pain for the control group was 3.50 versus 3.51 for the study group (p > 0.05). The SF-36 score was 89.22 for the control group versus 91.56 for the study group (p > 0.05). The average operative time was 115.7 minutes for the control group versus 104.2 minutes for the study group (p: 0.014). Average calculated blood loss was 571.9 cc for the control group versus 438.2 cc for the study group (p: 0.025). The Lenke score was 1.92 for the control group versus 2.66 for the study group (p: 0.004).

Conclusion: At two year follow-up, radiographic fusion was slightly higher in the ICBG. However, clinical outcomes were equivalent in both groups. Moreover, the DBM-CaSO4 and BMA composite graft offered the advantages of decreased blood loss and shorter operative time. Therefore, the DBM-CaSO4 and BMA composite graft represents a viable alternative to autologous iliac crest bone graft in carefully selected patients undergoing spinal arthrodesis.

We present a series of 16 patients requiring revision forefoot procedures in Musgrove Park Hospital, Taunton.

The primary procedures were carried out in a local Independent Sector Treatment Centre as part of a regional initiative to reduce waiting times to meet national targets. Several of these patients were primarily listed for surgery at our institution. The majority of the procedures performed were first ray procedures in the time period from February 2006 to February 2009.

We present a summary of the indications for these revision procedures and some of the issues surrounding the management of these patients. We also present a summary of the costs incurred by Musgrove Park Hospital as a result of this extra workload.

Introduction: Arthroscopic ankle arthrodesis has been shown in other studies to be a viable alternative to open arthrodesis for end stage arthritis. Its demonstrated advantages include comparable or better rates of fusion, reduced morbidity, shorter hospital stays, quicker times to union and reduced wound complications, especially in patients prone to wound healing problems. However, two main restrictions have been shown in the literature; its limited ability for deformity correction and the subsequent need for metalwork removal, commonly for pain or prominence.

Aims: This study sought to investigate the need for metalwork removal, with the specific question of whether the use of a headless screw fixation system reduces the need for subsequent metalwork removal for pain or prominence.

Materials and Methods: Between 2000 and 2007, 37 arthroscopic arthrodesis using the AcutrakTM headless screw fixation system were carried out by the senior author (AK). We reviewed the case notes of all these patients to determine tourniquet times, length of stay in hospital, time to clinical and radiological union, complication rates and the requirement for metalwork removal for pain or prominence.

Results: Of the 37 patients, 22 (59.5%) were male and 15 (40.5%) were female. The average age at surgery was 67 yrs (range 37–86 yrs), average duration of follow up was 37 months (range 6–94 months). The average tourniquet time was 84 minutes (60–120 minutes). The median length of stay was 2 days (1–5 days)

The average time to clinical union was 14 weeks (6–23 weeks) and the average time to radiological union was 16 weeks (6–37 weeks).

There were 6 (16%) non-unions in this series 2 of which were fibrous non-unions. Both patients with fibrous non-unions experienced minimal or no symptoms and did not require further intervention. Of the 4 other non-unions, 3 were revised using an open technique, the fourth patient again being minimally symptomatic and not wanting further surgery.

1 patient suffered a traumatic displacement of the arthrodesis, requiring an open revision which went on to successful union at 3 months.

There were no other complications in this series and, of note, there were no cases of metalwork removal for prominence or pain.

Conclusion: Headless screw fixation systems have the theoretical advantage of allowing the entire length of the screw to be buried in bone, thus eliminating the problem of metalwork prominence. This should therefore obviate the need for further surgery to remove the prominent screws. Our study corroborates this, with none of our patients requiring metalwork removal for prominence.

Introduction and aims: Minimal trauma fractures may be the first indication of osteoporosis [OP]. Available data suggests that the continuum of care [EDorthopaedic service-GP] is breaking down with respect to identification and treatment of osteoporosis. Our aim was to determine the extent of this breakdown in the Australasian context.

Methods: Observational retrospective cohort study of patients aged 50 years or over who were treated and discharged with wrist fracture due to minimal trauma. Data collected included demographics, fracture details, cause of injury, bone density testing and osteoporosis-related medication change. Outcomes of interest were the proportion of patients who underwent bone density testing and treatment in the follow-up period.

Results: 131 patients were studied; 83% were female with median age of 71 years. No patient was referred by ED or fracture clinic for bone density testing [0%, 95% CI 0–3.5%]. Telephone follow-up was obtained from 91 patients, of whom 28 [31%] reported having bone density testing after their fracture. 50% [14, 95% CI 32–67%] of these were found to have osteoporosis. Seven patients [8%] commenced treatment with a bisphosphonate and one [1%] commenced a selective oestrogen receptor modulator.

Conclusion: Follow-up of ‘at risk’ patients suffering minimal trauma wrist fractures treated in the ED is poor. Systems to improve identification and treatment of osteoporosis in this group are needed if future osteoporotic fractures and their consequences are to be avoided. Possible models will be put forward.

Rupture of an aneurysm of the common iliac artery is a rare cause of pain in the hip. We describe an elderly hypertensive patient with an aneurysmal rupture of the left common iliac artery who presented with unilateral hip pain masquerading as septic arthritis.