Background

Specifically designed control interventions can account for expectation effects in clinical trials. For the interpretation of efficacy trials of physical, psychological, and self-management interventions for people living with pain, the design, conduct, and reporting of control interventions is crucial.

Aims

The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS).

With observed success and increased popularity of growth modulation techniques, there has been a trend towards use in progressively younger patients. Younger age at growth modulation increases the likelihood of complete deformity correction and need for implant removal prior to skeletal maturity introducing the risk of rebound deformity. The purpose of this study was to quantify magnitude and identify risk factors for rebound deformity after growth modulation.

We performed a retrospective review of all patients undergoing growth modulation with a tension band plate for coronal plane deformity about the knee with subsequent implant removal. Exclusion criteria included completion epiphysiodesis or osteotomy at implant removal, ongoing growth modulation, and less than one year radiographic follow-up without rebound deformity. Mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), hip-knee-ankle angle (HKA), and mechanical axis station were measured prior to growth modulation, prior to implant removal, and at final follow-up.

Sixty-seven limbs in 45 patients met the inclusion criteria. Mean age at growth modulation was 9.8 years (range 3.4–15.4 years) and mean age at implant removal was 11.4 years (range 5.3–16.4 years). Mean change in HKA after implant removal was 6.9O (range 0O–23 O). Fifty-two percent of patients had greater than 5O rebound and 30% had greater than 10O rebound in HKA after implant removal. Females less than ten years and males less than 12 years at time of growth modulation had greater mean change in HKA after implant removal compared to older patients (8.4O vs 4.7O, p=0.012). Patients with initial deformity greater than 20O degrees had an increased frequency of rebound greater than 10O compared to patients with less severe initial deformity (78% vs 22%, p=0.002).

Rebound deformity after growth modulation is common. Growth modulation at a young age and large initial deformity increases risk of rebound. However, rebound does not occur in all at risk patients, therefore, we caution against routine overcorrection. Patients and their families should be informed about the risk of rebound deformity after growth modulation and the potential for multiple surgical interventions prior to skeletal maturity.

Purpose: Elective total hip and knee replacement surgeries are effective procedures for patients suffering from hip and knee disease. The demand for joint replacements is expected to rise as the life expectancy of Canadians increases; thus putting a heavy burden on healthcare. In an effort to reduce the acute hospital length of stay (LOS) the Alberta Orthopaedic Society, with the Alberta Bone and Joint Health Institute, three Alberta health regions (Calgary, Capital and David Thompson) and Alberta Health and Wellness created an evidence based new care continuum for hip and knee replacement. The LOS through the new care continuum compared to the current conventional approach was evaluated. In addition patient characteristics that could potentially predict the LOS were evaluated.

Method: The study design was a randomized, controlled trial. Consenting subjects were randomized to receive care through either the new care continuum (intervention) or the existing “current conventional approach” (control). Acute hospital LOS was calculated as the difference between the date and time the patient was admitted to the date and time the patient was discharged. Data was collected on patient characteristics potentially associated with acute hospital LOS.

Results: Intervention patients demonstrated a significantly shorter acute hospital LOS than the control patients, 4.66 and 5.95 days respectively. Further analysis of the data using a generalized linear model indicated that several patient characteristics were associated with a shorter/longer wait for consultation and surgery. Married patients had a statistically significant shorter LOS than single patients (IRR=0.89, p=0.001). Whereas older patients (IRR=1.01, p=< 0.001), patients with increased comorbidity (IRR= 1.03, p=0.001), and patients with an ASA of ≥ 3 (IRR= 1.22, p=< 0.001) resulted in a significantly longer LOS.

Conclusion: This study indicated that an evidence based healthcare continuum for the delivery of hip and knee replacements was successful in significantly reducing acute care LOS. Reducing the LOS using the new care continuum could potentially help alleviate the strain on limited healthcare resources and the savings could be reinvested to increase the numbers of joint replacement performed. Furthermore, an understanding of patient characteristics that influence acute hospital care LOS should be used to model surgical case mixing to further improve efficiencies.

Purpose: Total hip and knee replacements are recognized as effective surgical interventions for severe arthritis. Increasing demand for these services has led to increasing waits for both consultation and surgery. The Alberta Orthopaedic Society, with the Alberta Bone and Joint Health Institute, the Calgary Health Region, the Capital Health Region, the David Thompson Health Region and Alberta Health and Wellness carried out an analysis and an evidence based redesign of the care continuum for hip and knee replacement surgery in an effort to reduce wait times and improve the quality of service for patients.

Method: The study design was a randomized, controlled trial. Consenting subjects were randomized to receive care through either the new care continuum or the existing “current conventional approach”.

Results: During the 12 month study, 1570 patients received surgery. The mean wait for an orthopaedic consultation for intervention patients was 106 days compared to 200 days for the control patients. The mean wait for hip or knee surgery for intervention patients was 157 days compared to 408 for the control patients. Further analysis of the data using a generalized linear model utilizing negative binomial regression indicated that several patient characteristics were associated with a shorter/longer wait times. The less the severity of the disease pre-surgery was associated with a longer wait for a consult (IRR=1.01, p=< 0.001). Longer waits for surgery were statistically associated with less disease severity (IRR=1.004, P=0.019), documented delay (due to non-arthritic medical concerns or patient request for delay, IRR=1.61, p=< 0.001), increased comorbidity (IRR=1.03, p=0.015), and smoking (IRR=1.30, p=0.020).

Conclusion: The results of this study confirm that a redesigned joint replacement new care continuum with a standardized primary care referral process to centralized, specialized joint replacement clinics without established backlogs can help reduce wait times in Canada.

Introduction and Aims: Traditional treatment for adolescent hyperkyphosis, including Scheuermann’s disease, has included apical anterior spine release/fusion (ASF) prior to posterior instrumented fusion. We wished to reassess the need for ASF when using a posterior column shortening technique with a threaded rod compression instrumentation system.

Method: PSF-only group: 17 patients, mean age 15.7 years (range 12.8–18.5), underwent posterior column shortening by chevron-shaped lamina resection and fusion using hybrid hook/screw, dual 4.8mm threaded compression rod instrumentation (TRI). A/PSF group: seven patients, mean age 15.4 years (14–16.8), underwent open or endoscopic ASF followed by posterior TRI. Fourteen of 24 patients had strict Sorensen criteria of Scheuermann’s. At mean follow-up of 30 months (range 24–56), patients were assessed for amount and maintenance of correction, sagittal balance, and evidence of pseudoarthrosis.

Results: Mean pre-operative measured kyphosis in PSF-only was 79.6 degrees (range 67–90), and was corrected to 38.2 degrees (22–55) post-operative, and 37.1 degrees (22–50, 53%) at final follow-up. In the A/PSF group, pre-operative kyphosis was 79.0 degrees (62–93), corrected to 41.6 degrees (34–48) post-operative, and was 42.6 degrees (25–48, 46%) at final follow-up. There was no difference in the amount of correction (p=.28) or its maintenance between the two groups. Similarly, there were no differences between groups in assessing pre-operative and final T2-12 kyphosis (p=.13), T12-S1 lordosis (p=.98), or C7 sagittal balance (p=.10). The mean T10-L2 sagittal alignment was improved in the PSF-only patients (final kyphosis 7.8°) vs. 18.9° in the A/PSF patients (p=.04). There was a greater correction of Voutsinas’ index (PSF-only=.08, A/PSF=.15, p=.01) for the posterior-only group. No patient lost > eight degrees correction (range 12–8) between immediate post-operative and final follow-up, and no instrumentation complications occurred.

Conclusion: Using posterior column shortening and larger diameter (4.8mm) threaded rods with hooks cephalad to the apex and screws caudal, we have found no advantage in correction from preliminary anterior apical release, nor a difference in maintenance of correction. ASF is unnecessary when adolescent hyperkyphosis/Scheuermann’s is treated by this technique.