Aims. This study aims to assess the feasibility of conducting a pragmatic, multicentre randomized controlled trial (RCT) to test the clinical and cost-effectiveness of an informal caregiver training programme to support the recovery of people following hip fracture surgery. Methods. This will be a mixed-methods feasibility RCT, recruiting 60 patients following hip fracture surgery and their informal caregivers. Patients will be randomized to usual NHS care, versus usual NHS care plus a caregiver-patient dyad training programme (HIP HELPER). This programme will comprise of three, one-hour, one-to-one training sessions for the patient and caregiver, delivered by a nurse, physiotherapist, or occupational therapist. Training will be delivered in the hospital setting pre-patient discharge. It will include practical skills for rehabilitation such as: transfers and walking; recovery goal setting and expectations; pacing and stress management techniques; and introduction to the HIP HELPER Caregiver Workbook, which provides information on recovery, exercises, worksheets, and goal-setting plans to facilitate a ‘good’ recovery. After discharge, patients and caregivers will be supported in delivering rehabilitation through three telephone coaching sessions. Data, collected at baseline and four months post-randomization, will include: screening logs, intervention logs, fidelity checklists, quality assurance monitoring visit data, and clinical outcomes assessing quality of life, physical, emotional, adverse events, and resource use outcomes. The acceptability of the study intervention and RCT design will be explored through qualitative methods with 20 participants (patients and informal caregivers) and 12 health professionals. Discussion. A multicentre recruitment approach will provide greater external validity across population characteristics in England. The mixed-methods approach will permit in-depth examination of the intervention and trial design parameters. The findings will inform whether and how a definitive trial may be undertaken to test the effectiveness of this caregiver intervention for patients after hip fracture surgery. Cite this article: Bone Jt Open 2021;2(11):909–920

This study describes the development and initial validation of a new disease-specific outcome measure of health status and burden of care in children with severe cerebral palsy. The instrument, Caregiver Priorities and Child Health Index of Life with Disabilities(CPCHILD), has thirty-six items spanning six domains:. Personal care/ADLs,. Positioning/Mobility,. Communication/Social interaction,. Comfort/Emotions & Behaviour,. Health,. Quality of life and additionally. Caregiver’s perspective on the Importance of these items to the child’s quality of life. The CPCHILD is a reliable and valid measure of caregivers’ perspectives on the health status, functional limitations, and well-being of children with severe cerebral palsy. Develop and validate a disease-specific measure of health status and well-being of children with severe cerebral palsy. The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) was constructed from recommendations of caregivers, health care providers, and review of other measures. The CPCHILD has thirty-six items spanning six domains. Items are rated on an ordinal scale. Standardized scores (0–100) are reported for each domain and in total. Primary caregivers(n=77) of children(5–18yrs) with cerebral palsy, categorized by the Gross Motor Function Classification System (GMFCS) level completed the CPCHILD. Caregivers of children with severe cerebral palsy(GMFCS-IV & V), also completed the PEDI, the CHQ, and a second administration of the CPCHILD two weeks after the first. The mean CPCHILD scores for children with severe cerebral palsy(GMFCS-V) was fifty-nine (Range:35–93) and did not demonstrate the floor effects of the PEDI and CHQ. The mean CPCHILD scores for children in GMFCS levels I to V were 22.0, 38.2, 23.0, 44.5.8 and 59.3 respectively (p < 0.0001 by ANOVA). Reliability was tested in the 41/52 caregivers who reported no health status change between the twoadministrations of the CPCHILD. The intraclass correlation coefficient(ICC) was 0.94(95% CI: 0.90–0.97). Children with severe cerebral palsy often undergo interventions to improve quality of life and ease burden of care. The CPCHILD seems to be a reliable and valid measure of caregivers’ perspectives on the health status, functional limitations, and well-being of these children. Further validation in a larger mutli-centred study is planned. Funding:. Paediatric Orthopaedic Society of North America (POSNA) research grant award. Bloorview MacMillan Foundation

Aims. The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. Methods. This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results. Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion. The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP. Cite this article: Bone Jt Open 2023;4(8):580–583

Hip displacement is the second most common deformity in children with cerebral palsy (CP). A displaced, and particularly a dislocated hip, can have significantly adverse effects on an individual. Surgical intervention to correct progressive hip displacement or dislocation is recommended for children with CP. Success of surgical intervention is often described using radiological outcomes. There is evidence that surgical treatment for displaced or dislocated hips decreases pain and hip stiffness and improves radiological outcomes. However, there is no information in the literature regarding the impact of surgical treatment on the health related quality of life (HRQOL) in these children. The aim of our study was to examine the impact of surgical treatment of hip displacement or dislocation on HRQOL in children with CP.

This prospective longitudinal cohort study involved children attending a tertiary care hospital orthopaedic department. Children with CP between the ages of 4 and 18 years, with hip displacement/dislocation, defined as a Reimer's migration percentage (MP) of >40% on a pre-operative x-ray, and undergoing surgical reconstruction were eligible for inclusion. Quality of life was measured pre-operatively and post-operatively using the CPCHILD Questionnaire.

Twelve patients (one child was GMFCS level III, 4 were level IV, and 7 were level V), aged 4.0 to 17.3 years, were assessed pre-operatively and then again at least six months post-operatively. All underwent unilateral (5) or bilateral (7) reconstructive hip surgery. The migration percentage of hips undergoing reconstruction was reduced by an average of 52% (9–100%). The average change in CPCHILD score showed an increase of 6.4 points [95% CI: −1.4–14.2].

In this pilot study, no significant change was noted in HRQOL following reconstructive hip surgery, despite a marked reduction in Reimer's MP. However, only 4 of 12 parents reported that their child had daily pain pre-operatively. A larger sample size will be required to draw more accurate conclusions from these findings. There is an evident need for a multicentre study examining this issue in a larger patient population in order to determine the long-term impact of different hip interventions on quality of life in children with CP.

At-home softcast removal with no routine clinical follow-up has shown to be safe and effective following paediatric orthopaedic trauma. It minimises clinician contact time and reduces cost. However, there is limited data on the caregiver experience. Retrospective analysis of paediatric fractures requiring application of circumferential softcast that was later removed at home. Two time points were included: (1)July–September 2022, (2)February–April 2023. Demographics data included age, fracture classification, angulation, manipulation requirement, complications or unplanned re-attendance. Caregivers were given an information leaflet on cast removal. Caregivers completed a telephone Likert questionnaire reviewing time taken to remove cast, qualitative descriptors of cast removal and overall satisfaction. 77 families were contacted at mean 93 days post injury. Mean age was 7.5 years. 41(53%) were distal radius and 20(26%) both-bone forearm fractures. The remaining were hand, elbow or tibia injuries. 40(52%) injuries required manipulation under procedural sedation with mean sagittal angulation 24 degrees. 13(17%) patients re-attended with cast problems. Caregivers estimated a mean 13 minutes to remove cast. 83% found it ‘extremely’ or ‘somewhat’ easy. 75% were ‘extremely’ or ‘somewhat’ satisfied. 71% were ‘extremely’ or ‘somewhat’ likely to recommend at-home cast removal. Qualitative descriptors ranged from from ‘traumatising’ to ‘fun’ and ‘straightforward’. The experience at our tertiary centre confirms at-home softcast removal with no further orthopaedic follow-up is safe and feasible, even in those requiring manipulation under sedation. The majority of families reported a positive experience; this however is not universal. Adequate patient information resources are integral to a positive caregiver's experiences

The objectives of this study are to ascertain primary caregivers' understanding of risks associated with home trampoline use; to educate caregivers in regard to documented literature based risks associated with home trampoline use; and to evaluate if this information will have any influence on their future regulation of home trampoline use for their children. One hundred primary caregivers of patients treated in the paediatric orthopaedic surgery outpatient clinic at London Health Sciences centre were surveyed. All caregivers in clinic were invited to participate. The only exclusion criteria was the inability to provide consent. Caregivers' baseline perceptions on the risks associated with home trampoline use were assessed using a questionnaire. Caregivers then received an information pamphlet outlining documented trampoline safety data. They were then sent the same questionnaire to complete within one week of reading the pamphlet. Using our research electronic database capture (Redcap), the results of the surveys were compiled and analysed using spss 22, paired t-test and repeated measures anova. A sample size of 55 was calculated to result in a power of 80%. Of primary caregivers surveyed, 36% owned a home trampoline, and only 5% had personal experiences with their child sustaining a trampoline injury. Pre-education, when caregivers were asked on a scale of one (not dangerous) to 10 (very dangerous) how dangerous they felt a trampoline was for their child, the average response was six. Post-education, this number changed to eight. Providing education to primary caregivers significantly changed their perceptions on all sections of the questionnaire, yet 47% of primary caregivers were willing to allow their child to use a trampoline at home despite their new understanding of trampoline injury and safety. Providing education to primary caregivers significantly changed their perceptions on all trampoline safety questions, indicating effective comprehension. Despite caregivers' understanding of the risks associated with home trampoline use, approximately half of the study population continue to permit this activity for their children. There is potential to reduce paediatric orthopaedic injuries associated with home trampoline use if safer trampoline related practices are implemented based on information provided

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction

Acute Haematogenous Osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Previous research on sequelae from AHO rarely considers outcomes more than two years following treatment. This study aims to establish the quality of life of patients diagnosed with AHO in childhood up to 13 years after diagnosis, evaluating the impact on social, emotional, physical, and school function. Children treated for AHO between 2008–2018 at a tertiary referral centre in New Zealand were identified. PedsQL™ questionnaires were conducted via phone with either the child or primary caregiver and responses analysed. 40 patients met inclusion criteria, were contactable by phone, and consented to participate. The mean age was 7 years (range 0–15) and most were female (60%). Health related quality of life (HRQOL) was scored as a percentage with most participants scoring >80% (n=27). Those who do experience reduced quality of life following treatment for AHO were likely to complain of pain, stiffness, or anxiety. The impact of significant childhood illness on mental health was not adequately captured by the PedsQL™ but was highlighted in qualitative feedback. We conclude that the majority of children treated for AHO reported excellent health-related quality of life up to 13 years following treatment although an negative impact on mental health was reported using qualitative analysis. A refined scoring system is needed to assess the long-term impact of musculoskeletal infection

Child abuse is an essential discussion within society and poses many challenges. The international literature describes patient and family based risk factors and suspicious injuries. We have created a protocol for the identification and investigation of children with suspected non-accidental injuries. The paediatric orthopaedic ward experiences many children being delayed in the ward once fit for discharge. This study aimed to quanitify those delayed discharges and describe the demographics and risk factors for abuse within the local population. After obtaining ethics clearance, we conducted a retrospective review of records from the Teddy Bear Clinic, as well as admission records. The study examined demographic characteristics, family, injury characteristics and referral to Child Welfare. The delay of discharge from hospital was quantified and was compared to those characteristics. Records were collected from 1 January 2015 to 31 December 2021. Seventy-nine complete records were included. There were 40 males and 39 females with an average age of 20 months. 75.9% were under 36 months old. 94.1% of the cases sustained lower limb fractures. Fifty-two cases had a delayed discharge. The delay ranged from 1 to 233 days. There was an association between an age less than 36 months and delayed discharge. There were no significant correlations between caregiver characteristics and delayed discharge. The later the completion of investigations, the more likely there would be a delay. There was also a significant correlation between referral to Child Welfare and delayed discharge. Children under 36 months on this remain at highest risk for non-accidental injury. Delayed discharge was associated with age less than 36 months, upper limb fractures and referral to Child Welfare. Despite the delayed discharge, most children returned to the same home environments

The increased demand for total hip arthroplasty (THA) is having a significant impact on healthcare resources, resulting in increased interest in outpatient care pathways to reduce resource consumption. This study compared costs between patients who underwent outpatient THA using a Direct Anterior (DA) approach compared to a Direct Lateral (DL) approach to understand the effect of surgical approach on resource use. We conducted a prospective randomized controlled trial for DA patients undergoing primary THA. We compared patients in the outpatient arm of the trial to a prospective cohort of outpatient DL approach THAs. We recorded all costs including: equipment, length of stay in hospital, and laboratory or other medical tests. Following discharge, participants also completed a self-reported cost diary recording resource utilization such as emergency department visits or subsequent hospitalizations, tests and procedures, consultations or follow-up, healthcare professional services, rehabilitation, use of pain medications, informal care, productivity losses and out of pocket expenditures. We report costs from both Canadian public health care payer (HCP) and a societal perspective. The HCP perspective includes any direct health costs covered by the publicly funded system. In addition to the health care system costs, the societal perspective also includes additional costs to the patient (e.g. physiotherapy, medication, or assistive devices), as well as any indirect costs such as time off paid employment for patients or caregivers. We included 127 patients in the DA group (66.6 years old) and 51 patients in the DL group (59.4 years old) (p<0.01). There were no statistically significant differences in costs between groups from both the healthcare payer (DA= 7910.19, DL= 7847.17, p=0.80) and societal perspectives (DA= 14657.21, DL= 14581.21, p=0.96). In patients undergoing a successful outpatient hip replacement, surgical approach does not have an effect on cost from in hospital or societal perspectives

Introduction and Aims: In order to evaluate the hypothesis that ‘Botulinum A Toxin (BoNT-A) improves function and health-related quality of life in patients and their caregivers’, the experience of a single institution that performed over 7500 injections in 515 patients was evaluated to provide safety data, injection guidelines, and current indications. Method: This retrospective review utilised a computerised database that contains information from open-label trials (n=6), double-blind randomised trials (n=4), and cumulative treatment experience in 1100 children and adults with cerebral palsy. Standardised data collected over the past 15 years was analysed with respect to indications, complications, dosage, function, health-related quality of life of patients and their caregivers, rehabilitation (WeeFIM), gross motor function classification (GMFCS), and response rates. Pharmacoeconomic analysis was performed by linking with state Medicaid data. Results: BoNT-A is safe and well tolerated. There were no systemic side effects in dosages ranging from four to 25 units per kilogram body weight. Standardised injection techniques included dilution from 10 to 100 units per cc with a maximum dose of six units per kilogram in a single muscle and 25 units per kilogram in a single patient. The maximum dose was 600 units. Short-term response rates were 65–70%; intermediate response rates 45–50%. The most frequent complications were soreness of the injection site (15%) and transient weakness (2%). Ninety-five percent of injections were performed in the office without conscious sedation. Five percent were performed under general anaesthesia or with conscious sedation. Based on these data, current indications include dynamic tone interfering with caregiver function (e.g., equinus gait), painful spasticity, post-operative spasticity, and pain management. Contraindications are failure to respond to previous injections. Pharmacoeconomic analysis diminished cost and improved function and quality of life of patients and/or caregivers. Conclusion: Botulinum A Toxin is a safe and cost-effective drug in patients with cerebral palsy. Response rate is 50–70%. Optimal results are obtained with appropriate intramuscular localisation and sufficient volume to saturate neuromuscular junctions

During the last decade primary total hip arthroplasty surgery (THA) has increased with 30% in Sweden. Current law guarantees the patient a right to treatment within 90 days. The public health system has had difficulties meeting the increasing demand. Therefore, in 2012 a systematic review of the patients planned for THA was initiated at Sahlgrenska University Hospital's joint replacement unit. In late 2013 the value-based health care (VBHC) management was introduced in our unit. In 2012 a systematic approach based on the Fast-Track concept was implemented in the joint replacement unit. In 2013 a workgroup consisting of health care professionals involved in the treatment of THA patients was created to improve chosen outcome parameters. During 2011–2016 the number of elective THA has increased from 317 to 486. The cost per patient has decreased from 75,000 SEK to 65,000 SEK. Length of stay has decreased from 5.9 days to 2.5 days. Satisfaction with outcome of surgery one year after THA increased from 76% to 88%. The number of adverse events decreased from 29% to 11%. Number of re-operations within 2 years decreased from 2,7% to 1,9%. Fast-Track and VBHC management was initially received with modest enthusiasm in our unit, and was regarded as means to increase production whilst possibly endanger the well-being of the patients. By using continuous feedback using the data collected it was possible to effectively communicate to patients and caregivers that the patients benefitted from the implementation. VBHC primary aim is to improve patient outcomes and synergetically improve cost and process measurements. This should be appealing to both caregivers and administrators. Focusing on improvement of outcomes after THA combined with VBHC management has contributed to improvement in quality of care and availability of treatment whilst decreasing cost per patient

Introduction. Several hexapod external fixator devices are used in the treatment of bone fracture and deformity corrections. One characteristic of all of them is the requirement for manual adjustment of the fixator struts. The purpose of this study was to introduce a novel robotic system that executes automatic adjustment of the struts. Materials and Methods. Ten patients were treated for various bone deformities using a hexapod external fixator with Auto Strut system, which implemented automatic adjustment of the fixator struts. Patients arrived at the clinic for follow during the correction period until the removal of the hardware. During each visit, the progress of the correction was assessed (clinically and radiographically) and reading of the strut scale numbers was performed. Results. All patients completed the treatment plan during the follow up period achieving all planned correction goals. Healing of the bone ranged between approximately one to seven months. Duration of distraction ranged between 10 and 90 days. The distraction index ranged between 8 and 15 days/cm. The length of distraction varied between 1 and 6 cm. The planned corrections were fully attained in all patients who completed the treatment (n=10). No device related adverse events were reported. One patient was not available for registration of struts length, one patient switched to manual struts due to personal preference.48 struts of eight patients were recorded, 94% of the final strut number readings presented a displacement of 0–1 mm, three struts (6%) had 2–3 mm displacement due to inter-observer reading errors. indicating high precision of the automatic adjustment. Conclusions. This study presents preliminary result, showing that Auto Strut can successfully replace the manual strut adjustment providing important advantages that benefit the patient, the caregiver and the surgeon

Chronic spastic hip dislocation in patients with spastic quadriplegia can lead to restricted range of movement and severe pain, inability to sit, respiratory and urinary infections, perineal hygiene problems and decubitus ulceration. The Castle procedure is designed to relieve pain and prevent these complications. This investigation evaluates whether the Castle procedure succeeds as a salvage procedure in a pediatric population. Patients with cerebral palsy who had undergone a proximal femoral resection according to Castle’s description were identified. Exclusion criteria included age over nineteen years at time of surgery, acute hip dislocation, and diagnoses other than cerebral palsy. Eight children completed a chart and radiographic review, and a clinical review. A staff physician evaluated range of motion, apparent discomfort of the child, and the state of the perineal skin. A questionnaire was given the primary caregiver assessing post-operative improvement in pain, sitting duration, infections, ulcers, ease of postoperative care, and overall satisfaction. Five males and three females with mean age at surgery of 13 ± 1 years, and an average follow-up of 42 ± 13 months were enrolled. All had proximal migration of the residual femur to at least the midpoint of the acetabulum. The average heterotopic ossification score post-op was Brooker one with no symptoms. Five of eight had mild discomfort, with two having moderate to severe discomfort. Five had reduced pain post-op such that they didn’t require analgesics, and were able to sit the entire day. One had a urinary infection post-op, and two had recurrent pneumonias and decubitus ulcerations postop. One child underwent a revision resection for pain and proximal migration, and one was rehospitalised for failure to thrive and pain control. Seven of eight caregivers were somewhat or very satisfied with the procedure, but only five of eight would recommend it to others. Problems identified by the caregivers included treatment failure, difficulty with post-operative care, and significant leg length discrepancy. The Castle procedure is a successful salvage in severe spastic hip disease, but not universally so. Education concerning potential outcomes and rehabilitation period is also essential in achieving satisfaction

Septic Arthritis (SA) is considered a surgical urgency/ emergency by physicians around the world. As our understanding grows, and improved diagnostic algorithms are developed, it has become apparent that competing interests in terms of accurately diagnosing concurrent osteomyelitis may supercede rapid surgical intervention when the imaging is timely. Nevertheless, even in cases of isolated SA, many patients will require repeat surgery. We aimed to assess factors which could predict this. A multicenter retrospective redcap database was created involving 20 pediatric centers from the CORTICES study group with the goal of better understanding pediatric musculoskeletal infection (PMSKI). All patients who met inclusion for the database were considered, surgeons for each site determined through imaging and chart review which patients met the diagnosis of isolated SA. Patients with concomitant abscesses or osteomyelitis were expressly excluded. Appropriate non parametric statistics were used to assess univariate significance. Multivariable logistic regression was used to assess clinical factors associated with an increased likelihood of more than one surgery. Receiver characteristics operating curve (ROC) analysis was used to determine optimal cutoffs to discriminate between children who required more than one surgery compared to those who required only one surgery. A probability algorithm was developed for the number of clinical factors present and the likelihood requiring more than one surgery following SA diagnosis. “Four hundred and fifty-four patients with isolated SA were analyzed from 20 US hospitals. Patients were 5.4 +/− 4.8 years old at admission, and the cohort was 56% male. Of the 454 patients, 47 (10.4%) needed more than one surgery. Bivariate comparisons across surgery groups found significant differences in minimum platelet count (pplatelet, a patient has a 0.3% reduction in the odds of needing more than one surgery (OR=.997; p=0.04). For each additional ten units of CRP, a patient has a 0.1% increase in the odds of needing more than one surgery (OR=1.001; p<0.001). Our predictive algorithm found that children with both risk factors had a 64% chance of requiring multiple surgeries. Higher CRP values and lower platelet values indicate more severe disease in isolated SA with a greater likelihood of repeat surgery. Higher CRP and lower platelet counts may portend multiple surgeries and caregivers of children with isolated SA should be advised as such

Aims: The purpose of this retrospective study was to determine if open reduction, with pelvic and femoral osteotomy, for a dislocated hip in children with severe spastic quadriplegia alters the function or symptoms of the patient and to determine radiographic factors that correlate with sypmtoms. Methods: The validated Pediatric Evaluation of Disability Inventory (PEDI) and a self-constructed questionnaire asking about pain, hygiene, sitting status and ambulatory status were sent to the caregivers of 52 patients who were operated on. Radiographs were reviewed for changes in centre edge angle, acetabular index, migration index and femoral head defect. Results: 27 caregivers completed the questionnaires. Complete pre-operative radiographs and radiographs from latest follow-up were available in 42 patients and complete radiographs and completed questionnaires were available for 21 patients. The average age at surgery was 9 years with a mean follow-up of 5.5 years. The results of the PEDI did not change signiþcantly following surgery. The second questionnaire showed an improvement of hygiene care for 11 patients, weight bearing for transfers for seven, sitting status for 10 and sitting tolerance for 18. Pain improved for 17 and deteriorated for two patients. There was no correlation between radiographic measures and function or symptoms. Conclusions: Open reduction with pelvic and femoral osteotomy for dislocated hips in children with severe cerebral palsy can result in a decrease in pain and a modest improvement in function

Arthroplasty registries have played a key role in the treatment of patients with various joint diseases and conditions since their conception. Swedish hip and knee arthroplasty registries were initiated in late 1970's. The main aim of registries was to create feedback to surgeons. During the last two decades with introduction of patient reported outcomes, data from registries have been increasingly used to compare caregivers and to improve quality of health care. According to the Swedish Hip Arthroplasty Register (SHAR) Sahlgrenska University Hospital had been underperforming during years 2006–2012. In order to improve the outcomes a systematic data driven approach using local and national registries, based on value based management was undertaken. Representatives from all categories of healthcare staff and patients were invited to join a newly initiated group. The group was asked to define which measurement that contributed most to improve healthcare. Data from SHAR and local registries were used and seventeen different areas of improvement were identified. Several workgroups were initiated. Between years 2013 and 2017 there was an increase of 60% in the annual volume of elective THAs. The length of stay decreased from 6.4 days to 1.8 days. Satisfaction with outcome of surgery increased from 76% to 90%. Adverse events decreased from 28% to 10%. The risk of re-operations within 2 years decreased from 2.4% to 1.9%. Data from a national and a local registry were used to identify and implement changes in a large university hospital. Engaging member of staff and creating a graphical tool for continuous feedback drastically improved the quality of care whilst increasing the availability of hip replacements and reducing costs. This project demonstrates the power of registry data and a patient centered approach in engaging staff and improving healthcare

Background. Total Knee Arthroplasty (TKA) provides patients with significant improvements in quality of life. Subjective patient reported outcome measures (PROMs) are traditionally used to measure preoperative functional status and postoperative outcomes. However, there are limitations to PROMs. In particular, they provide virtually no functional information in the first 3 weeks after surgery, which could be used to guide the patient's recovery. Newly available wearable electronic sensors make it possible to: 1) measure important functional outcomes following TKA; 2) guide the patient's physical therapy (PT); and 3) provide real-time functional and clinical information to the provider. Compliance with PT after TKA is a challenge. Patients cite time, transportation, and cost as deterrents to PT appointments. However, an intensive PT program is essential in TKA. Surface sensor devices may be able to increase PT compliance by guiding patients through exercises at home. Additionally, these devices can transmit PT progress in real-time to the providers, allowing them to monitor and assist the patient's recovery. Our study investigates the feasibility of using a surface sensor device (TracPatch™) on patients following TKA. We sought to answer the following questions: 1) Will patients tolerate the device; 2) Will patients comply with device instructions; 3) Will patients be able to use the smart phone application; 4) Will the device collect, transmit, and store data as it was designed? We believe these fundamental questions must be answered as we enter the era of personal sensor-measured functional outcomes. Methods. 20 patients undergoing primary, unilateral TKA were enrolled in this IRB approved study. At the pre-surgical visit, patients were given instructions for the device and smart phone application. Each patient used the device in the week prior to surgery, and data was collected. The device was again applied in the operating room. For 3 weeks post-operatively, the device collected functional data, along with WOMAC, OKS, KSS, PROMIS, and VAS pain scores. A satisfaction survey was collected on the device. Results. The study results emphasize the importance of clear device instructions. Using the sensor and phone application prior to surgery was very helpful. The device was surprisingly well tolerated. Older patients were able to use the device without significant difficulty. Virtually all patients found the device helpful and, often fun. Physical therapists felt that the devices helped personalize the therapy program. The functional information from the device was much more helpful in guiding care in the first 3 weeks following surgery than PROM scores. Conclusion. It is anticipated that sensor devices of the kind tested in this study will have a major impact on the care of TKA patients. The purpose of this study was not to measure that impact. Our goal was to examine the factors that optimize the use of these devices. It is critical that clear device instructions be given to patients. Office procedures must be established to monitor use of the devices. If protocols are established for their use, surface sensors have the potential to provide invaluable information to TKA patients and caregivers

Introduction. Early functional recovery following total hip arthroplasty (THA) has the potential to increase patient satisfaction and reduce resource utilization. The direct anterior approach (DA) has been shown to provide earlier recovery compared to the direct lateral (DL) approach based on functional tests and outcome scores. There are limited studies that objectively evaluate functional recovery comparing the two approaches in the early post-operative period. Activity trackers have emerged as a valid tool to objectively quantify physical activity levels and potentially better assess functional status compared to commonly reported functional questionnaires. The purpose of this study is to measure physical activity levels in patients undergoing THA with the DA approach and compare these to THA with the direct lateral approach in the immediate postoperative period. Methods. In a tertiary academic center we prospectively enrolled patients with primary OA that were eligible for a primary THA undergoing either the DA or the DL approach using the same prosthesis. Patients with comorbidities precluding them from ambulation, diagnoses of AVN or RA or undergoing bilateral THA were excluded. The number of steps walked per day were measured using wristband activity tracking technology for one week preoperatively, the first 2 weeks postoperatively and for 1 week leading up to their 6-week follow-up appointment. The University of California, Los Angeles (UCLA) activity score was also collected at the same two time points. Demographics were analyzed with descriptive statistics. A non-parametric Mann Whitney U test was used to determine whether a difference in physical activity levels exist between the DA and DL approach groups in the first 2 weeks and 6 weeks postoperatively. Results. One hundred and thirty-nine patients with primary OA were enrolled. Seventeen were withdrawn prior to beginning the study (7 – patient requested, 5 – could not work the activity tracker, 5 – health issues). Following enrolment 29 patients were withdrawn due to lack of data available for analysis. There were 53 patients in the DA group and 40 patients in the DL group. Patient demographics including age and gender were similar in both groups. Body mass index was higher in the DL group (32.4 ± 6.9) compared to the DA group (28.2 ± 3.9) (p=0.001). There was no difference in the average steps taken per day or the UCLA score between the two groups preoperatively. The UCLA score and the overall average steps walked collected at 2 weeks postoperatively were significantly higher in the DA group compared to the DL group (median 4(1–6) vs. 3(2–6), p<0.001 and median 1641(329 – 8678) vs. 890(87 – 4347), p<0.001) respectively. When each postoperative day was evaluated individually, the DA group had a greater number of steps per day for the entire two weeks. At 6 weeks, the average number of steps taken by the DA group (median 4734 (1703 – 16605) () were greater than those taken by the DL group (median 3534 (462–8665) ± 2263) (p=0.007). A similar finding was demonstrated for the UCLA with the DA having greater self-reported activity levels (median 6 vs. 4, p<0.001). Discussion/Conclusions. The DA approach provided faster functional recovery in the immediate postoperative period compared to the DL approach as measured by a wristband activity tracker. DA approach patients walked a greater number of steps at both 2 weeks and 6 weeks. Further examination regarding the economic implications of the improved early function from the perspective of the patient, caregiver, and care payer is indicated

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.