The cost analysis using the clinical practice guideline and cost minimization analysis in orthopaedic inpatients under universal coverage policy admitted to Siriraj Hospital.

Objective: The hospital revenues are decreasing from the government policy in the universal coverage while increasing the hospital expenses . The cost analysis is a very important tool for the strategic plan in the hospital expenses reduction with standard quality. This study wanted to investigate the cost of 12 orthopaedic diseases using the clinical practice guideline (CPG) at maximum length of stay (LOS) and to compare the cost before and after utilization management in cost minimization analysis in orthopaedic inpatients under the universal coverage policy. Methods: Part 1, The CPG with maximum LOS was studied in detail and the cost analysis was performed using the formula C = S+I+X+P+O+L+A+R while C = unit service cost/case, S = service cost, I = instrument cost, X= X-ray cost, P = prosthetic cost, O = operating cost, L = laboratory cost, A = anesthetic cost, R = recovery room cost. Part 2, the cost minimization analysis (CMA) before and after utilization management was studied in 2 groups. Group A consisted of 236 cases which were studied after utilization management from June 1, 2003 to February 24, 2005. Group B consisted of 89 cases from June 1, 2002 to May 31, 2003 which were studied before utilization management was introduced in the department. The cost of both groups were compared. Results: The cost of the 12 orthopaedic diseases ranged from 13,036.10 baht/case for 3 days LOS in club foot surgery to 99,532.73 baht/case for 21 days LOS in total hip replacement surgery. The reduction of 1 day LOS reduces the service cost by an average 1,844.26 baht. The CMA found that after utilization management in group A, the CMA in the average cost reduction was 3,274.45 baht/case with an average 2.07 days reduction in length of stay. Both groups had the same outcomes. Conclusion: The cost analysis was done in 12 orthopaedic diseases using CPG. The usefulness with cost reduction was found after implementation of utilization management.

Comparison of modified posteromedial release and complete subtalar release in resistant congenital clubfoot: a randomized controlled trial.

OBJECTIVE: To compare the surgical results of modified posteromedial release with modified complete subtalar release in resistant congenital clubfoot in a randomized controlled trial MATERIAL AND METHOD: Eighty six children with 128 clubfeet, at an average of 5.9 months old (3-12 months) were operated on between 1996 and 2006 by a single surgeon. They were randomized into two groups. Group A, the modified posteromedial release was performed on 47 children with 69 clubfeet from 26 boys and 21 girls. Group B, the modified complete subtalar release was performed on 39 children with 59 clubfeet from 22 boys and 17 girls. Both groups received the same postoperative protocols. The mean follow up time was 15.1 months in group A (3-90 months) and 23.7 months in group B (3-120 months). RESULTS: There were no statistically significant differences of both groups between age, sex, side, bilaterality, and Dimeglio pre-operative evaluation. Most of the children ended up with satisfactory appearance of feet without major complications, neurovascular injuries, talonavicular dislocation, or avascular necrosis of the talus. Mild forefeet adduction was found in 10 feet in group A and in 5 feet in group B but allfeet were flexible and reducible to normal alignment of the feet. Two feet in group A and one foot in group B were re-operated by soft tissue release without bone surgery and had fair results. Four feet in group A and two feet in group B got soft tissue infection and resolved in a few weeks by dressing and antibiotics. The postoperative mean Ponseti score was 89.6 (75-100) points in group A and 88.2 (70-98) points in group B without statistically significant difference (p = 0.25). The Turco postoperative evaluation of both groups was not statistically significantly different (p = 0.17). The good and excellent results from Ponseti score was 85.5% in group A and 89.9% in group B. The correlation coefficient (r) between Ponseti and Turco evaluation was 0.81. CONCLUSION: The clinical and statistical significant difference were not found in the surgical results of modified posteromedial release and modified complete subtalar release in resistant clubfeet.

Medical utilization review by indicators “ORTHOPAEDICS” in orthopaedic inpatients under universal coverage policy admitted to Siriraj Hospital.

Objective: Utilization review is very important especially in universal coverage policy. In Siriraj Hospital the utilization review began in 2002, and the Department of Orthopaedic Surgery developed the indicators “ORTHOPAEDICS” to assess the appropriateness of medical utilization. This study is designed to study the effectiveness of medical utilization review by using indicators “ORTHOPAEDICS” in orthopaedics, public inpatients under universal coverage policy in terms of expenses, the appropriateness, length of hospital stay and the satisfaction of the patients. Methods: 301 orthopaedic inpatients were divided in 2 groups: Group A included 149 patients, 100 men and 49 women. Their average age was 32.7 years old. From June 1, 2003 – May 31, 2004, each patient was prospectively reviewed regarding their daily utilization in terms of expenses, appropriateness of medical utilization by using indicators “ORTHOPAEDICS”. Their length of hospitalization was measured, as well as and their satisfaction evaluated. Group B was the control which included 152 patients, 98 men and 54 women. Their average age was 34.8 years old. No intervention was performed and the data was collected only in expenses and the length of hospital stay for each patient retrospectively from June 1, 2002– May 31, 2003. The expenses and the length of hospital stay of both groups were compared and analyzed. The appropriateness in Group A was studied by using indicators “ORTHOPAEDICS” which were: O = Operation; R = Relative weight rate; T = Type of treatment; H = Hospital stay; O = Occurrence of complication; P = procedures; A = admission; E = expenses; D = drugs; I = Investigation; C = Care map according to CPG of 12 diseases; S = Satisfactions score from 0-10 minimum to maximum, by asking the patients about the satisfaction in term of results of treatment. Results: The total expenses per patient in group A was 24,566.74 baht but in group B was 30,484.53 baht. The expense in group A was 5,917.79 baht reduction which was statistically significant difference (P<0.05). The average length of hospital stay in group A was 8.24 days, whereas in group B was 10.93 days. It reduced 2.69 days after utilization review was implemented. The appropriateness of utilization was found in the procedures, drugs and investigation without inappropriateness (0%). The inappropriateness in admission was 26.9% because the physician forgot to take blood examination and laboratory investigation before admission and it was done in the ward without any effect the treatment. And the average satisfaction score in group A was 9.6. Conclusion: “ORTHOPAEDICS” was useful and helpful indicator to significantly reduce the expense per patient and the length of hospitalization without reducing patient satisfaction and quality of treatment.

Validity and reliability test of parent's satisfaction in children with closed totally displaced supracondylar humeral fracture.

OBJECTIVE: To construct a questionnaire with validity and reliability test of the parents' satisfaction in children with closed totally displaced supracondylar humeral fractures and to compare the satisfaction score between group A, closed reduction and pinning and group B,open reduction and pinning. MATERIAL AND METHOD: The questionnaire was developed in 19 items 5 dimensions 1. The deformity 2. The doctor and nursing care 3. The cosmetic results 4. The range of motion of the elbow 5. The complications. The content validity was approved by 5 experts. In item score. From 1996 to 2004, the parents of the children with fractures were included.Sixteen parents gave the satisfaction score 2 times by 1 month interval after 6 months from the initial injuries. Nine parents were in group A and 7 parents were in group B. The reliability test by Cronbach's alpha was done. The satisfaction score was compared between group A and group B. RESULTS: The average item score was 0.86 (0.6-1). The Cronbach's alpha was 0.6482 in group A and 0.8037 in group B. The mean parents satisfaction score were 81.4 in group A and 70.0 in group B with statistical significant difference (P = 0.008). CONCLUSION: The questionnaire had good validity and reliability and could be helpful in decision making for the choice of the treatment. The closed reduction should be done first from the parent's point of view.

Early proximal tibial valgus osteotomy as a very important prognostic factor in Thai children with infantile tibia vara.

OBJECTIVES: To find the effectiveness of the early surgery (2-3 years of age)as a very important prognostic factor affecting the outcomes in Thai children with infantile tibia vara and all the prognostic factors including the usefulness of arthrographic study in correcting the deformity. MATERIAL AND METHOD: From 1994 to 2004, sixteen children aged average 3.61 years old (2.08-7.0) were treated in Siriraj Hospital and diagnosed as infantile tibia vara by Langenskiold radiographic staging were included in the present study and retrospectively reviewed with an average of 6.4 years follow up (range 6 month - 11.1 years). All cases were initially treated by surgery because of low compliance for brace or brace failure. They consisted of 3 boys and 13 girls. There were 24 legs including the bilateral involvement in 8 cases (2 boy and 6 girls). After arihrography, the midshaft fibular osteotomy was performed then the proximal tibial dome-shaped valgus osteotomy was done and fixed with 2 pins.The desired position was 12 degree knee valgus . The patients were divided in two groups, 1)group A,the successful group with the knee becoming normal without any deformity after single osteotomy, 2)group B,the recurrent group with recurrence of the varus deformity required further corrective osteotomies to make normal axis of the knee. All variables were analyzed and compared between group A and group B. The general characteristics and radiographic findings were recorded in 1)age, 2)sex, 3)side, 4)weight in kilogram and in percentage of normal or overweight(obesity) compared with the standard Thai weight chart, 5)tibiofemoral angle (TFA) pre and postoperative treatment, 6) metaphyseal diaphyseal angle (MDA), 7)the medial physeal slope angle (MPS, 8)The preoperative arthrographic articulo-diaphyseal angle (ADA), 9.arthrographic articulo-medial physeal angle (AMPA). RESULTS: There were 14 legs in group A and the remaining 10 legs were in group B (average 2.4 operations). All cases healed in good alignment of the legs without major complication. All patients who were operated on early before 3 years old were 100% cured by single osteotomy in group A(11 legs).Arthrography was useful in evaluating the knee joint and drawing the angle. Considering the prognostic factors affecting the outcomes after surgery, there were 6 prognostic factors . First, the age less than 3 years old (P<0.001). Second, the normal weight (P<0.047). Third, the Langenskiold stage 1-2 (P=0.002). Fourth, the MPS angle equal or less than 59 degree (P < 0.001). Fifth, the ADA preperative angle equal or less than 18 degrees (P<0.001). Sixth and the last factor, the TFA angle postoperative treatment, equal or more than 10 degrees valgus (mean 13 degrees valgus) (P=0.009).In multivariate analysis with stepwise logistic regression of these 6 prosnostic factors, the MPS angle had the most important significance. The proximal tibial valgus osteotomy was a very important factor(P < 0.001). CONCLUSION: The 6 prognostic factors and usefulness of arthrography were identified. The authors suggest that surgery should be performed early in Thai children who have met these criterias 1)age of the patients more than 2 years old, 2)Langenskiold roentgenographic characteristics of infantile tibia vara stage 2 or more at the time of diagnosis, 3)Low compliance for brace treatment.or brace failure but not more than 3 years old. The surgery should not be delayed more than 3 years of age by waiting for effectiveness of brace treatment in Thai children with infantile tibia vara. The early proximal valgus dome- shaped osteotomy was a very important controllable prognostic factor by surgeon decision.

Normal values for the radiological measurement of the adult Thai foot and comparison with the values in common foot problems.

To find normal radiological values for measuring the adult Thai foot. Material & Methods : One hundred and six films of both feet while standing in AP and lateral views including 32 men and 74 women age from 19 to 77 years old were studied. There were 5 groups of studied group 1, 58 people with normal feet, group 2, 11 people with a diagnosis of tendoarchillis tendinitis, group 3, 22 people with a diagnosis of plantar fasciitis, group 4, 10 people with a diagnosis of an accessory articular bone group 5, 5 people with a diagnosis of hallux valgus. The radiological measurements in AP view were the talocalcaneal angle (TCAP), the talo-first metatarsal angle (TF) the calcaneofifth metatarsal angle (CF), the first metatarsophalangeal angle (M1P1) the first metatarso-second metatarsal angel (M1M2), the first metatarsofifth metatarsal angle (M1M5), the forth metatarso fifth metatarsal angle (M4M5) and the first proximal phalanx - distal phalanx angle (P1D1). In a lateral view the angles measured were the talocalcaneal (TC lat), tibiotatar (TIT), the tibiocalcaneal (TIC), the calcaneal pitch (CP), and the Bohler angle (BA). Results : There were no statistical significant difference of the angles between 5 group of feet except M1P1. The normal values in mean angle in AP view for left and right feet were 17.89o, 17.58o, for TCAP, -0.79o, 0.15o, for TF, 6.86o, 7.45o for CF 11.69o, 10.68o for M1P1, 9.33o, 9.20o for M1M2, 26.41o, 27.00o for M1M5, 8.64o, 8.76o for M4M5, 11.57o, 10.86o for P1D1. The mean angle in lateral view for left and right feet were 38.33o, 38.72o for TClat, 104.4o, 106o for TIT, 63.54o, 67.48o for TIC, 17.52o, 17.45o for CP, 30.53o, 34.46o for BA angle. Conclusion: The normal values in radiological measurement of adult Thai foot can be used to evaluate the result of the treatment in foot deformities. The problem in common foot problems such as plantar fasciitis etc. were in the soft tissue not in the structure of the bone.

The radiographic measurement of the foot in normal Thai children.

To find the normal values of the foot x-ray in Thai children. Materials & Methods: Thirty-one Thai children, 17 bys, 14 girls with the age ranged from 3 months to 5 years old without any foot deformities had the x-ray of the foot taken in AP and lateral view in maximum correction according to Simon’s technique and were measured the talo calceneal (TCAP), Talo first metatarsal (T-F), calcaneo-fifth metatarsal (C-F) in AP view, talo calcaneal (TClat), tibio-talar (TIT), tibiocalcaneal (TIC) in lateral view and talo calcaneal index (TI). Results: No statistical significant difference in the angles between boys and girls, left and right foot (P>0.05). The normal values of foot x-ray were 29.4o, 6.16o, 2.36o for the mean angles of talocalcaneal, talofirst metatarsal and calcaneofifth metatarsal in AP view and 44.47o, 92.97o, 48.67o for the mean angles of talocalcaneal, tibiotalar and tibiocalcaneal in the lateral view. The mean talocalcaneal index was 76.92o. Conclusion: This normal values can be useful as the standard to compare and evaluate the foot after treatment.

The results of modified posteromedial release in true clubfoot.

The results of surgical treatment of true clubfoot by modified posteromedial release were analysed. Each foot was evaluated according to Turco and Imhauser evaluation. Material and Methods : There were 69 patients, 47 boys and 22 girls. The patients age ranged from 3 months to 4 years. The bilateral involvement was in 32 patients. There were totally 101 feet to be operated after failure of casting with average 15.52 months follow up. Results : The good and excellent results by Turco and Imhauser evaluation after second operation were 89.11%. There were 3 cases (6 feet) who got second operation because of incomplete correction. The superficial wound infection rate was 5.94% but resolved completely without changing the outcomes. The comparison between sex, side, age had no statistical significant difference (P > 0.05). There was high correlation between Turco and Imhauser score (r = 0.861, 0.854 for left and right foot). Conclusion : The modified posteromedial release can be used as the treatment of choice for the children with true clubfoot and failure of conservative treatment.

The cost effectiveness analysis in the treatment of closed totally displaced supracondylar humeral fracture in children comparing closed reduction and pinning with open reduction and pinning: A ramdomized controlled trial.

To analyse the cost and the effects in terms of the difference in Baumann's angle of the fracture side from the normal side and to compare between closed and open reduction group. To compare the satisfaction, the complication rates and the range of motions between two groups of treatment and to consider the treatment of choice for closed totally displaced supracondylar humeral fracture. Material and Methods: A randomized controlled trial was performed on 20 patients, all with closed totally displaced supracondylar humeral fracture less than 13 years old. Ten cases were in group A closed reduction and pinning and 10 cases were in group B open reduction and pinning. Results: The general characteristics in both groups are not differect in age (mean+ S.D.) = 6.9+ 3.1, 6.3+ 2.8. P = 0.66, 95% CI -2.2, 3.4), sex, side, displacement and nerve injury preoperatively. All cases healed with good range of motion and results. The Baumann's angle difference = 2.53+ 1.8 in group A and 2.09+ 1.7 in group B with no statistical significant difference (P = 0.44, 95% CI = -1.2, 2.08) and also no difference in satisfaction and complications. The total cost, however in provider's perspective and parents' perspective were significantly higher in open reduction group than closed reduction group (P = 0.029, <0.001 respectively). Conclusion: Closed reduction should be considered first as the treatment of choice because of lower cost. In case of failure, open reduction can be performed and wil achieve good results by the experienced surgeon.

The mechanical and clinical studies of vicryl rapide for skin closure in pediatric orthopaedic patients.

To study mechanical and clinical results of Vicryl rapide for skin closure in pediatric orthopaedic patients. Materials and Methods: A mechanical study was performed with four groups of 38 pieces of Vicryl rapide 5 cm. length 3/0 were tested in maximum load, stress, strain, energy, elastic and elongation under Shimadzu universal testing machine, in dry and wet by water, day 1 and 14, with and without knot. The descriptive clinical study was performed in 166 children,109 boys, 57 girls, mean age 6 years old, follow up in 2 years. The surgeon’ s perspective in knot - security, handling, breaking strength, wound healing and the parents’ perspective in satisfaction of the scar were recorded. Results: The mechanical study showed that there was no significant statistical difference in strength between Vicryl rapide 3/0 left at room temperature from day 1 to 14 in both the dry and wet groups (P = 0.698) compared max load. There was significant statistical difference in strength between Vicryl rapide 3/0 with knot and without knot. The breaking point occurred at the knot (P < 0.001). In the clinical study, the surgeon used the Vicryl rapide with good knot-security, sufficient-handling and fairly good breaking strength. The infection rate was 1.2% with no wound disruption, no stitched off procedure. The parents’ satisfaction was 95.2% Conclusion: Vicryl rapide can be very useful for skin closure in pediatric orthopaedic patients. There is no need for stitched off and reduces the cost and fear for the children. There is also high satisfaction with resulting scar.

Multiple pterygium syndrome (escobar syndrome).

Escobar (multiple pterygium) syndrome is a rare autosomal recessive disorder characterized by short stature, multiple pterygium, joint contractures, vertebral fusions and minor facial anomalies. There is extreme phenotypic variability. The etiologic and genetic basis of multiple congenital pterygium is very heterogenous. Mutidisciplinary approach includes primary care physician or pediatrician, orthopedist, physical therapist and plastic surgeon. We report a case of multiple pterygium syndrome most likely the first reported case in Thailand that still alive and have had successful operative treatment of the spine and left foot. This 5-year-old Thai girl with short stature, ptosis of both eyelids, antimongoloid slant of palpebral fissures, hypertelorism, micrognathia, flat facies with emotionless expression, pterygium at neck, axillae, antecubital, popliteal, thumbs in palms, talipes equinovarus deformity, scoliolordosis at thoracic spine was described. She went through successive operations : plastic surgical correction of ptosis of both eyelids; anterior spinal fusion at thoracic spine; postero medical release at left foot with good result.