Introduction

Total joint arthroplasty (TJA) is projected to be the most common elective surgical procedure in the coming decades, however TJA now accounts for the largest expenditure per procedure for Medicare and Medicaid provided interventions. This is coupled with increasing complexity of surgical care and concerns about patient satisfaction. The Perioperative Surgical Home (PSH) model has been proposed as a method to both improve patient care and reduce costs. The PSH model provides evidence-based protocols and pathways from the time of surgical decision to after postoperative discharge. PSH pathways can further be standardized with integration into electronic medical records (EMRs). The purpose of this study is to see if the implementation of PSH with and without EMR integration effects patient outcomes and cost.

Introduction

Regional anesthesia is commonly utilized to minimize postoperative pain, improve function, and allow earlier rehabilitation following Total Knee Arthroplasty (TKA). The adductor canal block (ACB) provides effective analgesia of the anterior knee. However, patients will often experience posterior pain not covered by the ACB requiring supplemental opioid medications. A technique involving infiltration of local anesthetic between the popliteal artery and capsule of knee (IPACK) targets the terminal branches of the sciatic nerve, providing an alternative for controlling posterior knee pain following TKA.

BACKGROUND

As the climate of medicine continues to change, physicians and healthcare administrations seek to improve both the quality of the care we provide patients, as well as reducing the cost at which we provide that care. Delivering value based care is of the utmost importance. The Perioperative Surgical Home (PSH) model is a multidisciplinary team approach to care that has shown success in reducing cost, length of stay, and admission to after care facilities. We sought to compare the results of total knee arthroplasty patients managed in the PSH rapid recovery model, to patients managed in a more traditional fashion.

Introduction

Perioperative dexamethasone has been shown to effectively reduce post-operative nausea and vomiting and aide in analgesia after total joint arthroplasty (TJA), however systemic glucocorticoid therapy is carries the theoretical risk of increased susceptibility to prosthetic joint infection (PJI), increased white blood cell (WBC) counts, and increased blood glucose levels. The purpose of this study is to determine the effect of dexamethasone on PJI, WBC count, and blood glucose levels in diabetic and non-diabetic patients undergoing TJA.

Background

The Perioperative Surgical Home (PSH) is a physician-led, patient centered, rapid recovery care delivery model that includes multi-specialty care teams and cost-efficient use of resources developed to deliver patient centered value based care. The purpose of this study was to compare a group of patients undergoing primary total hip arthroplasty (THA) managed in the PSH model to a matched group managed in a more traditional fashion with respect to clinical outcomes, complications, and costs.

Aim

Spinal infections with and without aSCI represent a severe disease with a high lethality rate of up to 17%. The current treatment recommendations include an antimicrobial therapy and if necessary in combination with operative procedures. Aims of this study are the analysis of risk factors and treatment concepts and to compare the outcome of patients suffering a spinal infection with and without an aSCI.

Background

The Perioperative Surgical Home (PSH) is a multi-disciplinary rapid recovery pathway aimed at transforming surgical care by delivering value and improving outcomes and patient satisfaction. Our institution developed a PSH pathway for total hip arthroplasty (THA) patients in March 2014. The Orthopaedic and Anesthesia Services co-managed the patients throughout the entire surgical process. Weekly meetings were held to discuss medical and social requirements for upcoming patients including disposition planning. All patients received day of surgery physical therapy, and anesthesia post-surgical pain control and medical co-management. We hypothesized that the PSH would provide enhanced care for THA patients. To our knowledge this is the first report on the PSH in a total joint population

Introduction

Knee osteoarthritis is a leading cause of disability around the world. Traditionally, total knee arthroplasty (TKA) is the gold standard treatment; however, unicompartmental knee arthroplasty (UKA) has emerged as a less-invasive alternative to TKA. Patients with UKAs participate earlier with physical therapy (PT), have decreased complications, and faster discharges (1, 2). As UKA has evolved, so has computer navigation and robotic technology. The Robotic Assisted UKA combines the less invasive approach of the UKA with accurate and reproducible alignment offered by a robotic interface (3)(Figure1).

A key part of a patient's satisfaction is perioperative pain control. Femoral nerve blocks (FNB) are commonly performed to provide analgesia, though they cause quadriceps weakness which limits PT (4). An alternative is the adductor canal block (ACB) which provides analgesia while limiting quadriceps weakness (4). The adductor canal is an aponeurotic structure in the middle third of the thigh containing the femoral artery and vein, and several nerves innervating the knee joint including the saphenous nerve, nerve to the vastus medialis, medial femoral cutaneous nerve, posterior branch and occasionally the anterior branch of the obturator nerve (5).

In a multi-modal approach with Orthopedic Surgery, Regional Anesthesia, and PT departments, an early goal directed plan of care was developed to study ACB in UKA with a focus on analgesia effectiveness and PT compliance rates.

Introduction: Open tibial fractures presenting to the 3 Northern Ireland trauma hospitals with over 36 months (2003–2006) were considered regarding the BAO/BAPS guidelines, which recommended joint orthopaedic/plastic management with definitive tissue coverage within 5 days.

Methods: Details of Gustillo-Anderson classification, method and timing of surgery, and complications were identified retrospectively from a regional database and patient notes.

Results: Of 111 patients with 115 fractures, 28 were Gustillo-Anderson grade 1, 21 were grade 2, 28 were grade 3a, 35 were grade 3b, and 3 were grade 3c. Grade 1 fractures were chiefly treated by IM nailing or cast. Most grade 2 and 3 injuries received IM nailing or external frames and primary closure within 5 days. Most grade 3b fractures were treated with external frames and tissue coverage after day 5, 46% having documented plastics referrals, and 20% receiving flaps All grade 3c fractures required amputation. Complications occurred in 42% of patients, mainly soft tissue infections (19%) and delayed union (10%) or non-union (12%). Only 42% of grade 3 injuries had documented referrals to plastics. Only 26% of patients were treated initially at the regional plastics unit (with orthpaedics on-site) but only 11% of patients required transfer for plastics input (chiefly for flaps).

Conclusions: Complications were common despite most patients meeting the guidelines regarding time to definitive surgery. With increasing Gustillo-Anderson grade the number of procedures increased and method of management changed for orthopaedic and plastics procedures. Many patients with Gustillo 3 injuries had no recorded referral to plastics.

Background: Intervertebral motion is often assumed to be altered with back pain, however, the patterns are inaccessible to measurement in live subjects. A method for digitally tracking and analysing fluoroscopic images of the vertebrae of subjects who are undergoing standardised passive motion has recently been brought into clinical use for the assessment of surgical fusions. We have studied the differences between the behaviour of spinal linkages in subjects who are asymptomatic, and those who have had fusion operations. This paper describes the reliability, ranges and qualitative features of intervertebral motion patterns in 27 asymptomatic subjects and 3 fusion patients.

Methods and results: Thirty asymptomatic male volunteer subjects aged 19–40, underwent 2 –20 second sessions of fluoroscopic screening during 80 degrees of lumbar spine bending within 20 minutes of each other. Intervertebral sidebending motion from L2–5 was measured in 27 subjects whose images were judged suitable for tracking. Approximately 120 digitised images throughout each motion sequence were analysed 5 times by 2 blinded observers for intervertebral range and each result averaged. The intra-subject biological error (RMS), for range of intervertebral motion was 2.75° for Observer1 and 2.91° for Observer 2. The interobserver error for tracking the same screenings was 1.86° (RMS). At almost all levels, these motion patterns were remarkably regular.

Four male patients aged 33, 44, 45 and 52 years, who had undergone different spinal stabilisation procedures consisting of flexible stabilisation (DNESYS), posterior instrumented fusion, and anterior interbody fusion with facet fixation were investigated. Images were acquired and analysed in the same way except that a larger number of images (500 per screening) was utilised in each case. Four operated levels and 2 adjacent levels were analysed. All motion patterns were easily distinguishable from those of the normal subjects. The PLIF and DYNESYS stabilisations demonstrated no motion at the instrumented levels. The anterior inter-body fusion-transfacet fixation patient was shown to have developed a pseudarthrosis.

Conclusions: Detailed lumbar intervertebral bending patterns in asymptomatic subjects were distinguishable from the fused and adjacent-to fused segments in operated patients. Results suggest that there is sufficient reliability in the method to evaluate lumbar intersegmental ranges and motion patterns for fusion assessment.

Background: The prospect of a second operative procedure following an apparently unsuccessful spinal fusion is an unwelcome one. Since 1987, we have worked to develop an objective method of measuring the motion between vertebrae from fluoroscopic images. Successive versions have been evaluated for their reliability and validity. However, only the current one combines sufficiently reduced operator interaction with acceptable error limitation to be operationally useful as a tool for reporting findings about graft integrity for spinal surgeons. The current work brings this to an advanced prototype stage.

Methods and results: The measurement of lumbar intervertebral coronal and saggital plane motion in vivo using this technique is in 3 stages: Fluoroscopic screening of patients lying on a passive motion table Co-ordinated real-time digital acquisition of the intensifier images.

Registration of the images of each vertebra by templates which are automatically tracked and whose output is converted to inter-vertebral kinematic parameters and averaged for display and reporting.

Results are currently displayed as inter-vertebral angles throughout the motion that indicate whether or not solid fusion has been achieved. The Instrument Measurement Error is quantifiable and will vary with image quality, but can be improved by averaging. The technology is applicable to any imaging system of sufficient speed and resolution and may, for example, be used with MR in the future.

Conclusions: An advanced prototype version of this device is now approaching readiness for service as a routine procedure for use by specially trained radiographers. Its limitations will be determined mainly by the quality of the intensifier images. This can be expected, in the future, to benefit from yet further advances in the technology.