Indication for total knee arthroplasty based on preoperative functional score: Are we operating earlier?

BACKGROUND: The number of total knee arthroplasty (TKA) procedures performed annually is increasing for reasons not fully explained by population growth and increasing rates of obesity. The purpose of this study was to determine the role of patient functional status as an indication for surgery and to determine if patients are undergoing surgery with a higher level of preoperative function than in the past. METHODS: A systematic review and meta-analysis of the MEDLINE, Embase and Cochrane databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Functional status was assessed using the 36-Item Short Form Health Survey's physical component summary (PCS) score. Only primary procedures were included. Articles were screened by 2 independent reviewers, with conflicts resolved with a third reviewer. Meta-regression analysis was performed to determine the effect of time, age and sex on preoperative PCS score. Subgroup analysis was performed to compare results for the United States with those for the rest of the world. RESULTS: A total of 1502 articles were identified, of which 149 were included in the study. Data from 257 independent groups including 57 844 patients recruited from 1991 to 2015 were analyzed. The mean preoperative PCS score was 31.1 (95% confidence interval 30.6-31.7) with a 95% prediction interval of 22.8-39.5. The variance across studies was found to be significant (p < 0.001) with 99.01% true variance. Year of enrolment, age, the percentage of female patients and geographic region did not have any significant effect on preoperative PCS score. CONCLUSION: Patients are undergoing TKA with a level of preoperative function similar to their level of function in the past. Patient age, sex and location did not influence the functional status at which patients were considered to be candidates for surgery.

Patient Functional Status as an Indication for Primary Total Hip Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: The number of total hip arthroplasties performed per year is increasing for reasons not fully explained by a growing and aging population. The purpose of this study was to determine the role of patient functional status as an indication for surgery and determine if patients are undergoing surgery at a better functional status than in the past. METHODS: A systematic review and meta-analysis of the MEDLINE, EMBASE, and Cochrane databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Functional status was assessed using the 36-Item Short-Form Health Survey's Physical Component Summary score. Only primary procedures were included; revisions were excluded. Articles were screened by 2 independent reviewers with conflicts resolved with a third reviewer. Meta-regression analysis was performed to determine the effect of time, patient age, and gender. Subgroup analysis was performed to compare geographic regions. RESULTS: A total of 1504 articles were identified. Data from 172 groups representing 18,644 patients recruited from 1990 to 2013 and identified from 107 articles were included. The mean preoperative Physical Component Summary score was 31.2 (95% confidence interval 30.5-31.9) with a 95% prediction interval of 22.6-39.8. The variance across studies was statistically significant (P = .000) with 97.25% true variance. Year of enrollment, age, and the percentage of females were not found to have any significant effect. There were no differences between countries. CONCLUSION: Patients are undergoing total hip arthroplasty at a similar preoperative physical functional status as in the past. Patient age, gender, and location do not influence the functional status at which patients are indicated for surgery.

Development of an Acute Care Plastic Surgery Service in the Saskatoon Health Region: Effects on flexor tendon management.

BACKGROUND: The acute care surgery model has gained favour in general surgery, but has yet to be widely adopted in other specialties. An Acute Care Plastic Surgery (ACS) Service was recently implemented in the Saskatoon Health Region in an effort to improve trauma care. OBJECTIVE: To evaluate the impact of ACS on the management of flexor tendon lacerations. The authors hypothesize that ACS has resulted in more timely intervention, improved outcomes and decreased 'after hours' surgery. METHODS: A retrospective review of patients treated for flexor tendon lacerations from 2007 to 2013 was performed. Patients were stratified into two groups based on whether they received treatment before (group A) or after (group B) ACS implementation. Variables included dates and times of patient referral, consultation and tendon repair; postoperative complications; and admissions. A surgeon survey was administered on the perceived impact of ACS. RESULTS: Group A was more likely to have surgery performed after hours (P=0.0019) and be admitted to hospital (P=0.0211) compared with group B. Time from referral to consultation and injury-to-surgery interval were slightly increased post-ACS (Group B). Surgeons were highly satisfied with the new system, citing benefits to patients and surgeons. CONCLUSION: ACS was designed to improve trauma care, while favourably impacting surgeon workload. Surprisingly, the injury-to-surgery interval was slightly increased. However, this was not clinically significant and did not lead to increased postoperative complications. This finding was likely due to a favourable change in practice patterns observed after ACS implementation. ACS has resulted in fewer hospital admissions, decreased after-hours surgeries and improved surgeon satisfaction.

HISTORIQUE: Le modèle de chirurgie de courte durée est devenu populaire en chirurgie générale, mais ne s'est pas étendu aux autres spécialités. La région sanitaire de Saskatoon a récemment créé un service de chirurgie plastique de courte durée (CPCD) afin d'améliorer les soins des traumatismes. OBJECTIF: Évaluer les répercussions de la CPCD sur la prise en charge des lacérations du tendon fléchisseur. Les auteurs postulent que la CPCD favorise des interventions plus rapides, améliore les résultats cliniques et réduit les interventions après les heures ouvrables. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des patients traités en raison de lacérations du tendon fléchisseur entre 2007 et 2013. Les patients ont été répartis en deux groupes selon qu'ils avaient été traités avant (groupe A) ou après (groupe B) l'adoption de la CPCD. Les variables incluaient la date et l'heure de l'aiguillage des patients, de la consultation et de la réparation du tendon, les complications postopératoires et les hospitalisations. Les chirurgiens ont reçu un sondage pour faire connaître leur perception des répercussions de la CPCD. RÉSULTATS: Le groupe A était plus susceptible d'avoir subi la chirurgie après les heures ouvrables (P=0,0019) et d'avoir été hospitalisé (P=0,0211) que le groupe B. Le délai entre l'aiguillage et la consultation et entre la blessure et l'opération était légèrement plus long après l'adoption de la CPCD (groupe B). Les chirurgiens étaient très satisfaits du nouveau système et en citaient les avantages pour eux et pour les patients. CONCLUSION: La CPCD visait à améliorer les soins des traumatismes, tout en réduisant la charge de travail des chirurgiens. Fait surprenant, le délai entre la blessure et l'opération était légèrement plus long. Cette variable n'était toutefois pas significative sur le plan clinique et n'accroissait pas le nombre de complications postopératoires. Ces observations découlaient probablement de l'évolution positive des profils d'exercice après l'adoption de la CPCD. La CPCD a réduit le nombre d'hospitalisations et d'opérations après les heures ouvrables et accru la satisfaction des chirurgiens.