How to Develop a Fair Revision Arthroplasty Bundle? Using Perioperative Complications and Readmissions to Investigate

BackgroundThe next frontier for value-based health care in total joint arthroplasty is revision surgery. Although the disparity in health care utilization between revision procedures compared with primary total hip and total knee arthroplasty (THA/TKA) procedures is recognized, no agreement regarding the risk adjustment necessary to make revision bundles fair to both payors and providers exists. The purpose of this study is to use the risk of perioperative complications and readmissions of patients undergoing revision THA/TKA to establish the foundations of a fair revision arthroplasty bundle.MethodsWe retrospectively evaluated a consecutive series of 484 aseptic THA/TKA revisions performed at our institution over a 12-month period and compared complications, length of stay, reoperations, and 90-day readmissions to a group of 802 consecutive patients undergoing primary THA/TKA.Results169 (34.9%) patients experienced major complications after revision THA/TKA compared with 176 (21.9%) patients undergoing primary THA/TKA (P < .001), (OR 1.91 CI 1.49-2.45, P < .001). Patients undergoing revision TKA were 3.64 times more likely to require hospitalization greater than 3 days (OR 2.59-5.12, CI 95%, P < .001), whereas patients undergoing revision THA were 4.46 times more likely to require hospitalization greater than 3 days (OR 2.89-6.87, CI 95%, P < .001). Revision patients were 3X more likely to have a 90-day readmission and 4X more likely to have a reoperation.ConclusionFor a revision bundle to be fair and widely adopted, either significant financial incentive must be instituted or the latitude given to exclude outliers from the final reconciliation. This must be adjusted to not disincentivize institutions from providing care for failed hip and knee arthroplasties.     

Complex fractures, do we operate on enough to gain and maintain experience?

Complex fractures are generally assumed by our profession to require adequate training and continuing practice to treat optimally. The quantity of complex fractures treated in individual hospitals and by or under the care of individual orthopaedic consultants may have implications regarding the quality of care for particular patients and also for the training of specialist registrars.A complex fracture was defined as a comminuted peri- or intra-articular fracture or segmental shaft fracture: fractures acknowledged at specialist fracture courses and by special trauma surgeons to require particular training and experience to treat optimally. The AO classification was used: most fractures were in AO groups B and C [M.E. Muller, S. Narazian, P. Koch, J. Schatzker, The Comprehensive Classification of Longbones, Springer, Berlin, 1990]. Theatre records were used to identify all operated orthopaedic trauma cases over a period of 1 year in one District General Hospital (DGH) and one University Hospital, each serving populations of over 300000 and for 6 months in one DGH (population approximately 300000). Radiographs and hospital records were reviewed by two orthopaedic surgeons and the number and type of complex fractures documented as defined above. In hospital A, 69 complex fracture operations were carried out under the care of six consultants in 12 months. In hospital B, 24 complex fractures were treated by five consultants over a 6-month period and in hospital C, 127 complex fractures were treated by 10 consultants over a 12-month period. Some consultants (different consultants for different fracture regions) did not operate on any complex fracture of the proximal, mid, or distal humerus; proximal, mid, or distal radius or ulna; proximal, mid, or distal femur; proximal, mid, or distal tibia; calcaneum; peri-prosthetic; Lisfranc; or talus fracture during the specific time period. Some consultants only treated one or two such fractures. Where two surgeons had developed an area of special interest and cross-referral were encouraged individual surgeons were operating on up to 25 complex cases in their area of interest.This audit has shown that individual complex fractures present infrequently to particular hospitals and surgeons. This finding raises questions about the optimal management of such fractures: are we maintaining a sufficient level of expertise, or should there be more cross-referrals to surgeons with a specific interest either in trauma or in a particular anatomical region?     

Anal Sphincter Repair in the Treatment of Anal Incontinence - When and How to Do it?

Anal incontinence is a disease of high prevalence. For many patients the disease causes severe stress and often results in social isolation. Whenever a sphincter lesion has been diagnosed by digital rectal examination and endosonographic access, anal sphincter reconstruction can be performed with the same results either in overlapping or in end-to-end suture technique. sing these procedures, in more than 60 % of patients the continence can be initially improved. However, benefit decreases after 5 years down to 40-50 %. The prognosis gets worse with increasing age and supplementary descending pelvic floor. Anal repair with reconstruction of internal and external sphincters is performed in neurogenic incontinence. This can be achieved by posterior or anterior anal repair (total pelvic floor repair). Nowadays these procedures are not common, due to unsuccessfulness. Instead, sacral nerve stimulation as a more expensive but less invasive method has displaced the anal repair on this indication. Interpretation of the published results remains delicate because of heterogenous evaluation criteria of postoperative outcome: subjective amelioration, postoperative satisfaction and quality of life, improvement of incontinence score or achievement of complete anal continence. However, it is proven that after immediate reconstruction of traumatic sphincter lesions the postoperative outcome is better than a two-step operation with primary ostomy.     

Revision to reverse total shoulder arthroplasty: do short stem and stemless implants reduce the operative burden compared to convertible stems?

BackgroundRevision of prior hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) to reverse shoulder arthroplasty (RSA) is a technically challenging procedure with high complication rates. The purpose of this study was to compare intraoperative complications between convertible humeral stems and nonconvertible humeral stems stratified by stem length for conversion of TSA or HA to RSA.Materials and methodsA multicenter retrospective analysis of patients undergoing revision of a primary TSA or HA to RSA was conducted. Patients were divided into 2 groups based on convertible or nonconvertible humeral stem design from the index surgery. The primary outcome measures were the following intraoperative variables and complications: total operative time, blood loss, intraoperative fracture, overall complication rate, and blood transfusions. Rates were compared between groups and analyzed according to primary stem length for the nonconvertible group.ResultsA total of 279 patients were included in the study, 70 with convertible stems and 209 with nonconvertible stems. About 70% of convertible stems were successfully retained. Operative time was similar between the 2 groups overall. Patients with nonconvertible stems had higher intraoperative blood loss (P = .0001), higher overall complication rate (P = .009), and greater risk of intraoperative fracture (P = .002). Revising stemless and short stems to RSA had significantly reduced operative time compared to standard length stems (97 and 116 minutes vs. 141 minutes, P < .0001 and P = .035, respectively). When revising stemless implants, there was a significantly lower rate of intraoperative fracture (3.6%) compared to short stems (24%, P = .004) and standard stems (23.4%, P = .001). When revising stemless implants to RSA, there was shorter operative time (P= .0001) and similarly low rate of intraoperative fracture (P= .820) compared to convertible stems.ConclusionIn revision of anatomic TSA to RSA, convertible stems lead to lower blood loss and intraoperative fracture rate compared to nonconvertible stems when broadly including all stem types. However, differences appear to be based on stem type. Among nonconvertible stems, revision of short stem and stemless implants are associated with reduced operative time compared to standard length stems. Revision of stemless implants to RSA is associated with the shortest operative time of all implant types as well as a similar rate of intraoperative fracture compared to convertible stems.Level of EvidenceLevel III; Retrospective Cohort Comparative Study     

How little pain and disability do patients with low back pain have to experience to feel that they have recovered?

Epidemiological and clinical studies of people with low back pain (LBP) commonly measure the incidence of recovery. The pain numerical rating scale (NRS), scores from 0 to 10, and Roland Morris disability questionnaire (RMDQ), scores from 0 to 24, are two instruments often used to define recovery. On both scales higher scores indicate greater severity. There is no consensus, however, on the cutoff scores on these scales that classify people as having recovered. The aim of this study was to determine which cutoff scores most accurately classify those who had recovered from LBP. Subjects from four clinical studies were categorized as ‘recovered’ or ‘unrecovered’ according to their self-rating on a global perceived effect scale. Odd ratios were calculated for scores of 0, 1, 2, 3 and 4 on the NRS and RMDQ to predict perceived recovery. Scores of 0 on the NRS and ≤2 on the RMDQ most accurately identify patients who consider themselves completely recovered. The diagnostic odds ratio (OR) for predicting recovery was 43.9 for a score of 0 on the NRS and 17.6 for a score of ≤2 on the RMDQ. There was no apparent effect of LBP duration or length of follow-up period on the optimal cutoff score. OR for the NRS were generally higher than those for RMDQ. Cutoffs of 0 on the NRS and 2 on the RMDQ most accurately classify subjects as recovered from LBP. Subjects consider pain more than disability when determining their recovery status.     

Comparison of routine computed tomography and plain X-ray imaging for malleolar fractures—How much do we miss?

PurposeMost patients with ankle arthrosis have a history of ankle fracture. Evaluation of malleolar fractures solely on X-ray may be insufficient to identify many pathologies that potentially contribute to ankle arthrosis, with a consequent poor prognosis. We investigated the pathologies that may be overlooked in malleolar fractures evaluated solely on plain X-ray.MethodsDuring 2012–2019, 65,479 patients attended our Emergency Department, of which 6508 complained of an ankle joint problem. X-rays indicated a fracture in 454 of these patients. Patients with isolated, simple fracture of the lateral or medial malleolus, or talus, or a history of surgery to this area were excluded; finally, 67 patients were enrolled (31 males, 36 females; mean age: 51,2 years (range: 9–83 years). Patients underwent X-ray imaging of both ankles in anterio-posterior, lateral, and Mortise views, as well as CT scans. Three independent observers with varied experience in diagnostic imaging (orthopaedic resident, experienced orthopaedic surgeon, and musculoskeletal radiologist) evaluated X-ray images blinded to CT scans. Their diagnoses were subsequently compared with CT findings.ResultsModeling results indicated that about 40% [95% CI: 32%, 50%] of pathologies may be overlooked based on X-ray evaluation, regardless of evaluator experience. The most frequently overlooked injuries were: Tillaux fracture, Pillon fracture, loose bodies and syndesmosis injury. All of that missed pathologies required dedicated treatment and could be easily missed with standard surgical approach.ConclusionEvaluation of malleolar fractures by X-ray only inevitably results in overlooking of many pathologies, despite the clinician’s experience. Routine CT scan can help to improve the accuracy of diagnosis, and thereby reduce the risk of ankle osteoarthrosis.     

How do we counsel men with obstructive azoospermia due to CF mutations?—a review of treatment options and outcomes

Obstructive azoospermia (OA) is a rare cause of male infertility, with Congenital Bilateral Absence of The Vas Deferens (CBAVD) being a major cause. A wealth of literature has established an irrefutable link between CFTR mutations and CBAVD, with CBAVD affecting almost all men with cystic fibrosis (CF) disease and a significant portion of men that are CFTR mutation carriers. In the past two decades, assisted reproductive technologies have made the prospect of fathering children a viable possibility in this subset of men, using a combination of sperm extraction techniques and intracystoplasmic sperm injection (ICSI). In order to assess techniques for sperm retrieval, as well as reproductive outcomes, a systemic search of the MEDLINE database was conducted for all articles pertaining to management options for CBAVD, and also all reports describing outcomes of these procedures in the CBAVD population. Both epididymal and testicular sperm extraction (TESE) are viable options for men with CBAVD, and though rigorous data are lacking, live birth rates range from 8% to 50% in most small retrospective series and subset analyses. In addition, there does not appear to be significant differences in the rate of live birth or complications and miscarriages between the various techniques, though further investigation into other factors that limit reproductive potential of men with CFTR mutations and CBAVD is warranted.     

Benign Gastric Schwannoma: How Long Should We Follow Up to Monitor the Recurrence? A Case Report and Comprehensive Review of Literature of 137 Cases

We aimed to explore the optimal follow-up time for benign gastric Schwannoma. Benign gastric Schwannoma is an uncommon type of gastric neoplasias. Most of the studies are case reports and case series. Although it is generally considered to be benign, the optimal follow-up time and the chance of recurrence have not yet been investigated fully. We presented a case of benign gastric Schwannoma and systematically reviewed published case series with follow-up data. Eight studies were included, totaling 137 patients (44 male and 93 female) with the median follow-up time ranging from 22–132 months across different studies. No recurrence had been recorded during the follow-up period. Benign gastric Schwannoma rarely recurs after complete surgical resection. Long-term survival will be expected in most patients.Key words: Schwannoma, Stomach, Survival, Follow-upGastrointestinal mesenchymal tumors are spindle-shaped tumors, originating from the gastrointestinal mesenchymal stem cells. Three major types are gastrointestinal stromal tumors (GIST), smooth muscle tumor (leiomyomas or leiomyosarcomas), and nerve sheath tumor (Schwannomas).¹ Gastric Schwannoma is a type of nerve sheath tumor that originates from the Schwann cells of peripheral nerves. The definite diagnosis of Schwannoma is based on postoperative immunohistochemical stain, which is usually S–100 positive. Surgical interventions are the mainstay for gastric Schwannoma and complete removal of the tumors could prevent recurrence. Here we present a case of gastric Schwannoma located in the lower segment of stomach and we discuss the issue of postoperative recurrence.     

Ankle fracture management using smartphone multimedia messaging service (MMS) imaging — How reliable and to what point?

BackgroundThe use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to support the safe utilisation of MMS.ObjectivesThe aim of this study was to correlate the performance of MMS imaging to picture archiving and communication systems (PACS) imaging within the setting of diagnosis and management of ankle fractures.MethodsThe ankle fracture radiograph series of 82 consecutive patients were evaluated by five orthopaedic consultant specialists. A questionnaire regarding diagnosis and preferred management was completed separately for each patient using smartphone and PACS images. Statistical analysis was performed using Intraclass Correlation Coefficient (ICC).ResultsAnkle fracture diagnosis showed strong to excellent correlation both inter- and intraobserver MMS vs PACS when using the Weber (0.815, 0.988), Anatomical (0.858, 0.988), and AO classification systems (0.855, 0.985). MMS was less reliable than PACS in determining many management options.ConclusionThe reliability of ankle fracture classification using MMS image viewing was not significantly different to interpretation on PACS workstations. Smartphone use in ankle fracture classification is supported by this study. Smartphone use was less accurate than PACS in devising management plans and future use should be limited to making only initial plans that must be corroberated with PACS and intraoperative findings prior to definitive fixation.     

APDS panel V—The APDS program director's survival guide: Session I—Organization and rules The structure and responsibilities of the surgical organizations: How do they fit into the program director's responsibilities?

The author reviews a number of surgical organizations, their structure, and responsibilities that are of importance to program directors in surgery. This “alphabet soup” includes the Accreditation Council for Graduate Medical Education, the Residency Review Committee for Surgery, the American Board of Medical Specialties, the American Board of Surgery, the Council of Medical Specialties Societies, the American College of Surgeons, and the Association of Program Directors in Surgery. Program directors should embrace these organizations as allies, not adversaries, in carrying out their responsibilities for graduate medical education.     

“I don't want financial support but verbal support.” How do caregivers manage children's access to and retention in HIV care in urban Zimbabwe?

Introduction

Children living with HIV experience particular challenges in accessing HIV care. Children usually rely on adult caregivers for access to care, including timely diagnosis, initiation of treatment and sustained engagement with HIV services. The aim of this study was to inform the design of a community-based intervention to support caregivers of HIV-positive children to increase children''s retention in care as part of a programme introducing decentralized HIV care in primary health facilities.

Methods

Using an existing conceptual framework, we conducted formative research to identify key local contextual factors affecting children''s linkages to HIV care in Harare, Zimbabwe. We conducted semi-structured interviews with 15 primary caregivers of HIV-positive children aged 6–15 years enrolled at a hospital clinic for at least six months, followed by interviews with nine key informants from five community-based organizations providing adherence support or related services.

Results

We identified a range of facilitators and barriers that caregivers experience. Distance to the hospital, cost of transportation, fear of disclosing HIV status to the child or others, unstable family structure and institutional factors such as drug stock-outs, healthcare worker absenteeism and unsympathetic school environments proved the most salient limiting factors. Facilitators included openness within the family, availability of practical assistance and psychosocial support from community members.

Conclusions

The proposed decentralization of HIV care will mitigate concerns about distance and transport costs but is likely to be insufficient to ensure children''s sustained retention. Following this study, we developed a package of structured home visits by voluntary lay workers to proactively address other determinants such as disclosure within families, access to available services and support through caregivers’ social networks. A randomized controlled trial is underway to assess impact on children''s retention in care over two years.