Abstract

With the ever increasing rate of total hip replacement and life span of these patients, there has been an upward trend towards the incidence of peri-prosthetic fractures. Previous studies does suggest the implant cost to as high as 30% of the total reimbursement in primary hip arthroplasty but this figure is much higher in periprosthetic fractures where long stem revisions are commonly used

A prospective comparative study analyzing the total cost of hospital stay for a cohort of 52 consecutive patients with peri-prosthetic fractures of long bones treated in two hospitals from October 2007 to march 2009 was conducted. Demographic data, fracture classification and method of surgical treatment along with the length of hospital stay were recorded in detail. The total cost calculated was then compared to the range of reimbursement price based on HRG (human Resource Group) coding. The implant cost was determined from the buying cost by each institution.

52 patients were available for review. Average age of the patients operated was 78.5 years. 69 percent of the peri-prosthetic fractures in our series were around the proximal femur. The average cost of stay was £ 16453 (£ 1425- 26345). The reimbursement to the hospital ranged from £ 1983 to £ 8735.

Hospital source utilization for peri prosthetic fractures is quite high compared to the reimbursement being given to hospitals for treating such patients. This can be as low as £ 1500 as acute phase tariff to £ 9100 for elective revisions and the implant cost can vary from 50% to 200% of the total reimbursement cost. Current recording system for peri-prosthetic fracture is unclear resulting in discrepancy between resource utilization and reimbursement thus resulting in substantial financial losses for hospitals that perform these procedures.

The aim of this study was to evaluate the cost of implants used in a large series of peri-prosthetic femoral fractures and assess its financial impact in the era of Payment by Results

We evaluated the clinical demographic and economical data associated with 202 patients with peri-prosthetic fractures of the proximal femur in two orthopaedic centers of excellence. All fractures were classified preoperatively according to the Vancouver classification. The patients were followed up until radiographic confirmation of fracture union and post-operative outcome was recorded with reference to the patients’ mobility and any complications.

The mean age of the patients operated was 81.2 years (range 33–100 years). 55% of the patients in our series were graded type B3 and 25% type B2. 80% of all fractures underwent revision. 71 percent of the fractures united within 8.4 months. 112 patients had impaction femoral grafting. Our implant cost alone for revision varied from 1900 pounds to as high as 3500 pounds without taking in to account the cost of cement and allograft (femoral heads and struts).

Hospital resource utilization for peri-prosthetic fractures is quite high compared to the reimbursement received. This is due to hospital stay and rehabilitation needs, theatre utilization, implant cost and higher readmission rates. There are neither reference costs available nor any special tariffs for these complex fractures. The reimbursement for internal fixation of these fractures could range from £2336 to £4230 and for emergency revision hip replacement is £5928. More than 50% of the reimbursement money would just be necessary to meet the implant costs. For uncemented revisions this equation is even worse. Current HRG codes for the treatment of peri-prosthetic fractures are unrealistic and new treatment algorithms and special tariffs have to be introduced to help manage these fractures.

Introduction: Ever since the coding has been introduced in the NHS there has been lot of debate whether the trust is being paid accurately. There is no data available which compares the coding done by the surgeon and the one done by the coding department.

Material and Methods: A prospective study was done on 305 patients in an elective orthopedic hospital over a period of one month. All operations were coded separately by the operating surgeon and the coding department. The procedures included all upper and lower limb procedures other than elective hand, spine and paediatric procedures. The results were compared by an independent assessor in line with the national guidelines and the information originally available to clinical coders.

Results: The results showed a marked difference in reimbursement cost of complex procedures, revisions and co-morbidities as coded by the surgeon who took into consideration additional top ups which were available and these were often missed by the coding department. There was no difference in the primary hip and knee arthroplasty.

Conclusion: There is an increased need for correct coding as this can result in potential income consequences by applied tariffs. With the introduction of acute phase tariffs and marked difference in reimbursement to the trust if correct codes are not applied, there is an increased need for awareness for the coding and the top-ups available for complex procedures.

Introduction: Total Knee Replacement (TKR) is a routine and common orthopaedic operation. Approximately 600 TKRs are performed annually at Royal Bournemouth Hospital. Although contemporary advice is that these patients should have long-term follow-up, there is very little evidence to support this protocol that involves considerable resources. We have had a policy of early discharge from follow-up (6–12 weeks) for over 10 years.

Purposes of the study: To validate the efficacy of the policy of early discharge after total knee arthroplasty at 8–10 years post surgery and to identify whether this policy has made revision surgery more difficult or complex as a result of possible late presentation.

Methods: 798 consecutive patients who underwent primary Total and Unicompartmental knee arthroplasy at Royal Bournemouth Hospital during the period 1 April 1994 to 31 March 1996 were identified. Medical records and operative notes were analysed for all patients from this cohort who have had any further surgery on their index knee. The waiting lists were also checked to identify patients from this cohort waiting for further surgery.

Results: The mean age at index operation was 72 years (range 37 to 92 years). 39/798 patients (4.9%) have had revision surgery at 8–10 years follow-up. Many of the revisions were performed on patients with early problems and 15/39(38%) of the revisions were performed on patients who were rereferred to clinic. There was a 1.1% deep infection rate leading on to revision (9 knees).

8/39 of revisions were for resurfacing the patella (20%). One patient who had a complex patella fracture needing patellectomy later had further revision surgery for instability requiring posterior stabilised components. In no patient was the revision surgery compromised or made reconstructable due to delayed presentation. In total 3 patients required bone grafting of contained cavities and only 5 knees with aseptic loosening required revision implants with stems.

Conclusion: We do not accept the need for long-term follow-up of successful implants especially whilst using prostheses with a proven track record in elderly patients.

In a prospective study, we have evaluated the impact of psychological disturbance on symptoms, self-reported disability and the surgical outcome in a series of 110 patients with carpal tunnel syndrome. Self-reported severity of symptoms and disability were assessed using the patient evaluation measure and the Boston carpal tunnel questionnaire. Psychological distress was assessed using the hospital anxiety and depression scale.

There was a significant association between psychological disturbance and the pre-operative symptoms and disability. However, there was no significant association between pre-operative psychological disturbance and the outcome of surgery at six months. We concluded that patients with carpal tunnel syndrome should not be denied surgery because of pre-operative psychological disturbance since it does not adversely affect the surgical outcome.

Introduction: The aim of this study was to compare two methods of femoral fixation for four strand Hamstring (4SH) primary ACL reconstruction: namely a recently introduced suspensory fixation using absorbable polylactic acid cross pins versus our traditional method of anchor fixation.

Method: Forty-five consecutive patients, who had undergone primary ACL reconstruction using 4SH graft and the suspensory femoral fixation were prospectively evaluated by an independent observer. IKDC scores were recorded and laxity was assessed using cruciometer. These results were compared with a similar well-matched cohort of patients whose femoral fixation was with an anchor. Tibial fixation in both the groups was similar.

Results: No significant difference was noted between the two groups on comparison of IKDC scores or cruciometer readings at a minimum one-year follow-up.

Conclusions: This suspensory method of femoral fixation for a four-strand hamstring graft provided a secure fixation with satisfactory early clinical results. As this method of fixation is a new technique, further follow-up is needed for long-term validation.

Aims: This is a prospective study that evaluates the impact of psychological disturbance upon symptoms, self-reported disability and surgical outcome in patients with carpal tunnel syndrome. Methods: We recruited a consecutive series of 84 patients with a clinical diagnosis of carpal tunnel syndrome. Symptom severity and disability were assessed using the Boston carpal tunnel questionnaire (Levine et al 1993). Psychological distress was assessed using the Hospital Anxiety and Depression Scale (Zigmond & Snaith 1983). Questionnaires were administered before and six-weeks after open carpal tunnel decompression. Complete pre and postoperative data were available for 69/84 patients (82%). A statistical correlation of psychological distress with symptoms, self reported disability and surgical outcome was performed. Results: There was a signiþcant correlation between the psychological disturbance (the HAD score) and the pre-operative symptom severity (correlation coefþcient = 0.37, p < 0.04) and function scales (correlation coefþcient = 0.55, p < 0.0001) of the Boston carpal tunnel score. Self reported symptoms improved following surgery in 65/69 patients (94%). The mean symptom score improved from 3.01 pre-op to 1.69 post-op (p < 0.0001). Function and psychological distress improved signiþcantly following surgery. Conclusions: There was no signiþcant correlation between pre-operative psychological distress and the outcome of carpal tunnel decompression though there was signiþcant correlation with symptom severity.