Enhanced hip fracture management: use of statistical methods and dataset to evaluate a fractured neck of femur fast track pathway-pilot study.

The increasing elderly population and subsequent rise in total hip fracture(s) in this group means more effective management strategies are necessary to improve efficiency. We have changed our patient care strategy from the emergency department (ED), acute orthopaedic wards, operating theatre, post-operation and rehabilitation, and called it Fracture Neck of Femur Fast Track Pathway. All clinical data and actions were captured, integrated and displayed on a weekly basis using 'signalfromnoise' (SFN) software. The initial four months analysis of this project showed significant improvement in patient flow within the hospitals. The overall length of stay was reduced by four days. Time in ED was reduced by 30 minutes, and the wait for rehabilitation reduced by three days. Overall time in rehabilitation reduced by 3-7 days depending on facility. On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved in this period, with projected savings of NZD700,000. No adverse effects were seen in mortality, readmission and functional improvement status. Fractured neck of femur has increasing clinical demand in a busy tertiary hospital. Length of stay, co-morbidities and waiting time for theatres are seen as major barriers to treatment for these conditions. Wait for rehabilitation can significantly lengthen hospital stay; also poor communication between the individual hospital management facets of this condition has been an ongoing issue. Lack of instant and available electronic information on this patient group has also been seen as a major barrier to improvement. This paper demonstrates how integration of service components that are involved in fractured neck of femur can be achieved. It also shows how the use of electronic data capture and analysis can give a very quick and easily interpretable data trend that will enable change in practice. This paper indicates that cooperation between health professionals and practitioners can significantly improve the length of stay and the time in which patients can be returned home. Full interdisciplinary involvement was the key to this approach. The use of electronic data capture and analysis can be used in many other health pathways within the health system.

The Relationship Between Preoperative Clinical Presentation and Quantitative Magnetic Resonance Imaging Features in Patients With Degenerative Cervical Myelopathy.

BACKGROUND: Degenerative cervical myelopathy encompasses a group of conditions resulting in progressive spinal cord injury through static and dynamic compression. Although a constellation of changes can present on magnetic resonance imaging (MRI), the clinical significance of these findings remains a subject of controversy and discussion. OBJECTIVE: To investigate the relationship between clinical presentation and quantitative MRI features in patients with degenerative cervical myelopathy. METHODS: A secondary analysis of MRI and clinical data from 114 patients enrolled in a prospective, multicenter study was conducted. MRIs were assessed for maximum spinal cord compression (MSCC), maximum canal compromise (MCC), signal changes, and a signal change ratio (SCR). MRI features were compared between patients with and those without myelopathy symptoms with the use of t tests. Correlations between MRI features and duration of symptoms were assessed with the Spearman ρ. RESULTS: Numb hands and Hoffmann sign were associated with greater MSCC ( P < .05); broad-based, unstable gait, impairment of gait, and Hoffmann sign were associated with greater MCC ( P < .05); and numb hands, Hoffmann sign, Babinski sign, lower limb spasticity, hyperreflexia, and T1 hypointensity were associated with greater SCR ( P < .05). Patients with a T2 signal hyperintensity had greater MSCC and MCC ( P < .001). CONCLUSION: MSCC was associated with upper limb manifestations, and SCR was associated with upper limb, lower limb, and general neurological deficits. Hoffmann sign occurred more commonly in patients with a greater MSCC, MCC and SCR. The Lhermitte phenomenon presented more commonly in patients with a lower SCR and may be an early indicator of mild spinal cord involvement. Research to validate these findings is required.

Access to orthopaedic spinal specialists in the Canterbury public health system: quantifying the unmet need.

AIM: The aim of this project was to determine the unmet need within the public health system for patients referred for elective Orthopaedic Specialist Spinal assessment and treatment in the Canterbury District Health Board (CDHB) region. METHODS: Between January 2014 and January 2015 data was collected from all elective referrals to the CDHB Orthopaedic Spinal Service. During this period, the number of available outpatient appointments was set by the CDHB. Within this clinical capacity, patients were triaged by the four consultant surgeons into those of most need based on the referral letter and available radiological imaging. Those unable to be provided with a clinical appointment were discharged back to their GP for ongoing conservative care. Of those patients that received specialist assessment and were considered in need of elective surgical intervention, a proportion were denied treatment if the surgery was unable to be performed within the government determined four-month waiting time threshold. RESULTS: During the study period, 707 patients were referred to the CDHB orthopaedic spinal team for elective specialist assessment. Of these, 522 (74%) were declined an outpatient appointment due to a lack of available clinical time. Of the 185 patients given a specialist assessment, 158 (85%) were recommended for elective surgery. Ninety-one (58%) were denied surgery and referred back for ongoing GP care due to unavailable operating capacity within the four-month waiting list threshold. Within this group of 91 patients, 16 patients were declined on multiple occasions (14 patients twice and two patients on three occasions). CONCLUSIONS: This study quantifies the unmet need for both Spinal Orthopaedic Specialist assessment and, if warranted, surgical management of elective spine conditions within the Canterbury public health system. It highlights the degree of rationing within the public health system and its failure to adequately provide for the Canterbury Public.

Detecting Facet Joint and Lateral Mass Injuries of the Subaxial Cervical Spine in Major Trauma Patients.

STUDY DESIGN: Radiologic imaging measurement study. PURPOSE: To assess the accuracy of detecting lateral mass and facet joint injuries of the subaxial cervical spine on plain radiographs using computed tomography (CT) scan images as a reference standard; and the integrity of morphological landmarks of the lateral mass and facet joints of the subaxial cervical spine. OVERVIEW OF LITERATURE: Injuries of lateral mass and facet joints potentially lead to an unstable subaxial cervical spine and concomitant neurological sequelae. However, no study has evaluated the accuracy of detecting specific facet joint injuries. METHODS: Eight spinal surgeons scored four sets of the same, randomly re-ordered, 30 cases with and without facet joint injuries of the subaxial cervical spine. Two surveys included conventional plain radiographs series (test) and another two surveys included CT scan images (reference). Facet joint injury characteristics were assessed for accuracy and reliability. Raw agreement, Fleiss kappa, Cohen's kappa and intraclass correlation coefficient statistics were used for reliability analysis. Majority rules were used for accuracy analysis. RESULTS: Of the 21 facet joint injuries discerned on CT scan images, 10 were detected in both plain radiograph surveys (sensitivity, 0.48; 95% confidence interval [CI], 0.26-0.70). There were no false positive facet joint injuries in either of the first two X-ray surveys (specificity, 1.0; 95% CI, 0.63-1.0). Five of the 11 cases with missed injuries had an injury below the lowest visible articulating level on radiographs. CT scan images resulted in superior inter- and intra-rater agreement values for assessing morphologic injury characteristics of facet joint injuries. CONCLUSIONS: Plain radiographs are not accurate, nor reliable for the assessment of facet joint injuries of the subaxial cervical spine. CT scans offer reliable diagnostic information required for the detection and treatment planning of facet joint injuries.

Does Magnetic Resonance Imaging Improve the Predictive Performance of a Validated Clinical Prediction Rule Developed to Evaluate Surgical Outcome in Patients With Degenerative Cervical Myelopathy?

STUDY DESIGN: Ambispective study. OBJECTIVE: To determine whether MRI parameters improve the predictive performance of a validated clinical prediction rule used to assess functional outcomes in surgical patients with DCM. SUMMARY OF BACKGROUND DATA: Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in the elderly worldwide. A clinical prediction rule was developed to discriminate between patients with mild myelopathy postoperatively (mJOA ≥ 16) and those with substantial residual neurological impairment (mJOA < 16). Recently, a separate magnetic resonance imaging (MRI)-based prediction model was created. However, a model exploring the combined predictive value of imaging and clinical variables does not exist. METHODS: One hundred and fourteen patients with MRIs were examined from a cohort of 278 patients enrolled in the AOSpine CSM-North America Study. Ninety-nine patients had complete preoperative imaging and postoperative outcome data. MRIs were evaluated for the presence/absence of signal change on T2- and T1-weighted images. Quantitative analysis of the T2 signal change was conducted and maximum canal compromise and cord compression were calculated. The added predictive performance of each MRI parameter to the clinical model was evaluated using receiver operator characteristic curves. RESULTS: The model developed on our subsample yielded an area under the receiver operator curve (AUC) of 0.811 (95% CI: 0.726-0.896). The addition of imaging variables did not significantly improve the predictive performance. Small improvements in prediction were obtained when sagittal extent of T2 hyperintensity (AUC: 0.826, 95% CI: 0.743-0.908, 1.35% increase) or Wang ratio (AUC: 0.823, 95% CI: 0.739-0.907, 1.21%) was added. Anatomic characteristics, such as maximum canal compromise and maximum cord compression, did not improve the discriminative ability of the clinical prediction model. CONCLUSION: In our sample of surgical patients, with clinical and image-evidence of DCM, MRI parameters do not significantly add to the predictive performance of a previously published clinical prediction rule. It remains plausible that combinations of the strongest clinical and MRI predictors may yield a similar or a superior prediction model. LEVEL OF EVIDENCE: 3.

Role of magnetic resonance imaging in predicting surgical outcome in patients with cervical spondylotic myelopathy.

STUDY DESIGN: Ambispective, retrospective cohort study from prospectively collected data. SUMMARY OF BACKGROUND DATA: Cervical spondylotic myelopathy is the commonest cause of spinal cord impairment in the elderly population worldwide. Although magnetic resonance imaging (MRI) is the primary imaging modality for confirming the diagnosis, its role in predicting surgical outcome remains unclear. METHODS: Two hundred seventy-eight patients with 1 or more clinical signs of myelopathy were enrolled; and they underwent decompression surgery. Complete baseline clinical and MRI data were available for 102 patients. MRI parameters measured included presence/absence of signal change on T1 and T2, T2 signal quantitative factors, and anatomical measurements. A dichotomized postoperative modified Japanese Orthopedic Association (mJOA) score at 6 months was used to characterize patients with mild myelopathy (≥16) and those with substantial residual neurological impairment (<16). Univariate analysis assessed the relationship between baseline parameters and outcome. Multivariate logistic regression was conducted after a conceptual division of variables into 3 groups: T1 signal analysis, T2 signal analysis, and anatomical measurements. RESULTS: Baseline mJOA (P<0.001; odds ratio [OR]=1.644, 95% confidence interval [95% CI]: 1.326-2.037), maximum canal compromise (MCC) (P=0.0322; OR=0.965, 95% CI: 0.934-0.997), T2 hyperintensity region of interest area (P=0.0422; OR=0.67; 95% CI: 0.456-0.986), and sagittal extent (P=0.026; OR=0.673; 95% CI: 0.475-0.954) were significantly associated with outcome univariately. The final model was comprised of T1 hypointensity (P=0.029; OR=0.242; CI: 0.068-0.866), MCC (P=0.005; OR=0.940; CI: 0.90-0.982) and baseline mJOA (P<0.001; OR=1.743; CI: 1.353-2.245), yielding an area under the receiver operating characteristic curve (AUC) of 0.845. CONCLUSION: Baseline mJOA is a strong predictor of postsurgical outcome in cervical spondylotic myelopathy at 6 months. However, a model inclusive of MCC and T1 hypointensity assessment provides superior predictive capacity. This suggests that MRI analysis has a significant role in predicting surgical outcome. LEVEL OF EVIDENCE: 3.

Does orthopedic training compromise the outcome in total hip arthroplasty?

BACKGROUND: This study compares the outcomes of total hip arthroplasty surgery performed by a consultant with those performed by supervised and unsupervised orthopedic trainees. METHODS: We reviewed 6 years of patient data from the New Zealand Joint Registry in patients undergoing total hip arthroplasty comparing the outcome measures of revision surgery and Oxford hip score at 6 months with the experience of the primary surgeon. RESULTS: Over the study period 35,415 patients underwent elective total hip arthroplasty; 30,344 performed by a consultant, 2982 by a supervised trainee and 1067 by an unsupervised trainee. There was an overall revision rate of 0.77 per 100 component years. The revision rate was 0.75 (95% confidence interval [CI] 0.68-0.82) for consultants, 0.97 (95% CI, 0.72-1.28) for supervised trainees and 0.70 (95% CI, 0.36-1.22) for unsupervised trainees with no significant differences. There was no significant difference in the reason for revision surgery between the 3 groups. CONCLUSIONS: The mean Oxford hip score was higher for consultants at 40.70 compared with 38.95 and 38.27 for supervised and unsupervised trainees respectively. These results are reassuring and indicate orthopedic training does not adversely compromise arthroplasty patient outcomes.