Aims

The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up.

The purpose of this study was to measure the effect of the implementation of a LEAN continuous process improvement initiative on the waitlist in an ambulatory pediatric orthopaedic clinic.

LEAN is a set of principles that guide organizational thinking and form a comprehensive approach to continuous process improvement. In 2016, our health centre began its journey towards becoming a LEAN organization. The health centre's Strategy and Performance portfolio collaborated with the Orthopaedic Clinic Team to facilitate a Value Stream Analysis, which mapped the clinic process from referral to discharge from care. This informed the plan for targeted improvement events designed to identify and reduce non-value added activity, while partnering with patients and families to share their experiences with care in the clinic. Improvement events included: In-Clinic Patient Flow; Scheduling Process Review; Standardized Triage Process; Clinician Schedule; 5-S Large Cast and Sample Exam Rooms; Booking Orthopedics Clinic; and Travelling and Remote Care. During each event, solutions were identified to improve the patient experience, access, and clinic flow. These solutions have been standardized, documented, and continuously monitored to identify additional improvement opportunities. Comparison of wait-list and percentage of new patients seen within target window was performed from August 2017 to December 2018.

The LEAN initiative resulted in a 48% decrease in wait-list for new patients, which translated to an improvement from 39% to 70% of new patients seen within their target window. There was a 19% decrease in the 3400+ patient wait-list for follow-up appointments, an 85% reduction in follow-up patients waiting past their target date for an appointment, and the number of patients waiting over a year beyond their target appointment improved from over 300 patients to 0 patients. There was a 15% improvement in average length of clinic visit.

Without the addition of new resources, the implementation of a LEAN continuous process improvement initiative improved the waitlist for new patients in an ambulatory pediatric orthopaedic clinic by almost 50%. Solutions identified and implemented through the LEAN process have contributed to unprecedented improvements in access to care. In fulfilling one of the LEAN theory principles to “pursue perfection”, the paediatric orthopaedic clinic team has embraced a culture of continuous improvement and continues to use LEAN tools such as daily huddles and visual management to monitor solutions and identify gaps.

Morsellised bone graft is used extensively in revision arthroplasty surgery. The impaction technique at the time of surgery has a significant effect on the subsequent elastic and inelastic properties of the bone graft bed. Differences in values reported in the literature for the mechanical properties of morsellised cortico-cancellous bone (MCB) can be attributed to the different loading histories used during testing. We performed serial confined compaction tests to assess the optimum compaction strategy. Compaction of the samples was carried out using repeated standardised loading cycles. Optimal preparation of MCB is dependant on the force and frequency of compaction. The maximum compactive pressure the samples were subjected to was 3 N/mm² based on the clinical experience of Ullmark & Nilsson¹ in MCB preparation at the time of surgery. This paper presents the Young’s Modulus, E, vs. number of compaction cycles and inelastic strain, ^ie, vs. number of compaction cycles curves for MCB. Qualitative and quantitative descriptions of the material behaviour of MCB are developed. The importance of frequent percussive episodes prior to implant insertion is illustrated.

MCB was also found to exhibit significant visco-elastic response, with stress relaxation under displacement controlled loading continuing for several hours following initial load application. Bone graft substitutes do not at present exhibit a similar beneficial shock absorbing visco-elastic response.

Our experiments indicate that the material properties of MCB are dependent on the force of impaction and the number of impactions applied with a hammer at the time of surgery. A minimum of 10 to 20 compaction episodes, or hammer blows are required for MCB to achieve 60 to 70% of its long term predicted stiffness.

Recent years have seen a decided swing from the longstanding inpatient model of rehabilitation to an outpatient model for all branches of medicine in Australia. This swing has been largely cost-driven and is unlikely to change.

This paper reports on the development of a Paediatric Spinal Outreach Team (ORT) in New South Wales (NSW). The ORT was formed in 1993 and consists of a nurse, physiotherapist, occupational therapist and a social worker. It functions in close collaboration with the two children’s hospitals in Sydney. Approximately 10–11 new cases of paraplegia/quadriplegia occur in children/adolescents (up to 18 years of age) in NSW each year (population approx. 6 million). Their therapeutic needs change with growth, development and maturation. Families in regional NSW have special requirements and web-site information services (distance education) will play an important role for them in the future. Integration with an organisation which provides ancillary services is essential for a comprehensive, state-wide programme.

It is suggested that a comparable service would play an equally important role in other countries. Case studies to demonstrate savings to be made with this type of service need to be done to secure recurrent government funding.