Cost-effectiveness and satisfaction following arthroscopic rotator cuff repair: does age matter?.

AIMS: The aim of this study was to investigate the influence of age on the cost-effectiveness of arthroscopic rotator cuff repair. PATIENTS AND METHODS: A total of 112 patients were prospectively monitored for two years after arthroscopic rotator cuff repair using the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the Oxford Shoulder Score (OSS), and the EuroQol five-dimension questionnaire (EQ-5D). Complications and use of healthcare resources were recorded. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). Propensity score-matching was used to compare those aged below and above 65 years of age. Satisfaction was determined using the Net Promoter Score (NPS). Linear regression was used to identify variables that influenced the outcome at two years postoperatively. RESULTS: A total of 92 patients (82.1%) completed the follow-up. Their mean age was 59.5 years (sd 9.7, 41 to 78). There were significant improvements in the mean DASH (preoperative 47.6 vs one-year 15.3; p < 0.001) and OSS scores (26.5 vs 40.5; p < 0.001). Functional improvements were maintained with no significant change between one and two years postoperatively. The mean preoperative EQ-5D was 0.54 increasing to 0.81 at one year (p < 0.001) and maintained at 0.86, two years postoperatively. There was no significant difference between those aged below or above 65 years of age with regards to postoperative shoulder function or EQ-5D gains. Smoking was the only characteristic that significantly adversely influenced the EQ-5D at two years postoperatively (p = 0.005). A total of 87 were promoters and five were passive, giving a mean NPS of 95 (87/92). The total mean cost per patient was £3646.94 and the mean EQ-5D difference at one year was 0.2691, giving a mean ICER of £13 552.36/QALY. At two years, this decreased further to £5694.78/QALY. This was comparable for those aged below or above 65 years of age (£5209.91 vs £5525.67). Smokers had an ICER that was four times more expensive. CONCLUSION: Arthroscopic rotator cuff repair results in excellent patient satisfaction and cost-effectiveness, regardless of age. Cite this article: Bone Joint J 2019;101-B:860-866.

Cracking the code: the accuracy of coding shoulder procedures and the repercussions.

BACKGROUND: Coding of patients' diagnosis and surgical procedures is subject to error levels of up to 40% with consequences on distribution of resources and financial recompense. Our aim was to explore and address reasons behind coding errors of shoulder diagnosis and surgical procedures and to evaluate a potential solution. METHODS: A retrospective review of 100 patients who had undergone surgery was carried out. Coding errors were identified and the reasons explored. A coding proforma was designed to address these errors and was prospectively evaluated for 100 patients. The financial implications were also considered. RESULTS: Retrospective analysis revealed the correct primary diagnosis was assigned in 54 patients (54%) had an entirely correct diagnosis, and only 7 (7%) patients had a correct procedure code assigned. Coders identified indistinct clinical notes and poor clarity of procedure codes as reasons for errors. The proforma was significantly more likely to assign the correct diagnosis (odds ratio 18.2, p < 0.0001) and the correct procedure code (odds ratio 310.0, p < 0.0001). Using the proforma resulted in a £28,562 increase in revenue for the 100 patients evaluated relative to the income generated from the coding department. CONCLUSION: High error levels for coding are due to misinterpretation of notes and ambiguity of procedure codes. This can be addressed by allowing surgeons to assign the diagnosis and procedure using a simplified list that is passed directly to coding.

Does diabetes affect outcome after arthroscopic repair of the rotator cuff?

We compared the outcome of arthroscopic repair of the rotator cuff in 32 diabetic patients with the outcome in 32 non-diabetic patients matched for age, gender, size of tear and comorbidities. The Constant-Murley score improved from a mean of 49.2 (24 to 80) pre-operatively to 60.8 (34 to 95) post-operatively (p = 0.0006) in the diabetic patients, and from 46.4 (23 to 90) pre-operatively to 65.2 (25 to 100) post-operatively (p = 0.0003) in the non-diabetic patients at six months. This was significantly greater (p = 0.0002) in non-diabetic patients (18.8) than in diabetics (11.6). There was no significant change in the mean mental component of the Short-Form 12, but the mean physical component increased from 35 to 41 in non-diabetics (p = 0.0001), and from 37 to 39 (p = 0.15) in diabetics. These trends were observed at one year. Patients with diabetes showed improvement of pain and function following arthroscopic rotator cuff repair in the short term, but less than their non-diabetic counterparts.

Cutting-edge design to improve cell viability in osteochondral grafts.

INTRODUCTION: Autologous osteochondral grafting is in widespread use for focal defects of articular cartilage. There is major concern over the nature of the tissue bridging graft elements and graft/recipient cartilage. Chondrocyte viability is thought to be an important determinant of the quality of repair. The aim of the current study was to compare the zone of death for osteochondral grafts harvested with the commercially available Acufex, and an osteotome with a specially designed cutting-edge. MATERIALS/METHODS: The circular osteotomes were the Acufex 4.5mm MP (Smith & Nephew) and the Lissimore, which has a different cutting-tip geometry and sharpness. These implements were used to harvest osteochondral plugs from macroscopically non-degenerate human lateral condyle explants obtained from the anterior femoral cuts of knee replacement surgery. Confocal laser scanning microscopy with vital staining was used to quantify the zone of marginal chondrocyte death for the entire perimeter of the plugs. RESULTS: The increase in cartilage plug diameter (reference the osteotome minimal internal diameter) was significantly greater for the Acufex (Mann-Whitney; n=5; P=0.0079), with the diameter (mm) increasing by 0.49+/-0.03 (10.9%), compared with 0.16+/-0.02 (3.3%) for the Lissimore. Osteochondral plugs had a significantly (Mann-Whitney; n=5; P=0.0079) lower mean margin of cell death with the Lissimore osteotome (117.8+/-8.97 microm) than the Acufex MP (315.3+/-5.90 microm). CONCLUSIONS: Cutting-tip profile is an important factor in determining the extent of marginal death in circular osteochondral grafts. We have designed and assessed an alternative cutting-tip, which caused significantly less marginal death than the commercially available Acufex. We conclude that there is scope for improvement of osteochondral harvest techniques.

Chondrocyte death associated with human femoral osteochondral harvest as performed for mosaicplasty.

BACKGROUND: Autologous osteochondral transfer is an option for the treatment of articular defects. However, there are concerns about graft integration and the nature of the tissue forming the cartilage-cartilage bridge. Chondrocyte viability at graft and recipient edges is thought to be an important determinant of the quality of repair. The purpose of the present study was to evaluate early cell viability at the edges of osteochondral grafts from ex vivo human femoral condyles. METHODS: Fresh human tissue was obtained from eleven knees at the time of total knee arthroplasty for the treatment of osteoarthritis. Osteochondral cylinders were harvested with use of a 4.5-mm-diameter mosaicplasty osteotome from regions of the anterolateral aspect of the femoral condyle that were macroscopically nondegenerate and histologically nonfibrillated. Plugs were assessed for marginal cell viability by means of confocal laser scanning microscopy. RESULTS: The diameter of the cartilaginous portion of the osteochondral plugs was a mean (and standard error of the mean) of 4.84 +/- 0.12 mm (as determined on the basis of three plugs). This value was approximately 300 microm greater than the measured internal diameter of the osteotome. There was a substantial margin of superficial zone cell death (mean thickness, 382 +/- 68.2 microm), with >99% cell viability seen more centrally (as determined on the basis of five plugs). Demiplugs were created by splitting the mosaicplasty explants with a fresh number-11 scalpel blade. The margin of superficial zone cell death at the curved edge was significantly greater than that at the site of the scalpel cut (390.3 +/- 18.8 microm compared with 34.8 +/- 3.2 microm; p = 0.0286). Similar findings were observed when the cartilage alone was breached and the bone was left intact, with the margin of superficial zone cell death being significantly greater than that obtained in association with the straight scalpel incision (268 +/- 38.9 microm compared with 41.3 +/- 13.4 microm; p = 0.0286). The margin of superficial zone cell death showed no increase during the time-period between fifteen minutes and two hours after plug harvest. A mathematical approximation of the mosaicplasty region suggested that early cell death of this magnitude affects about one third of the superficial graft area. CONCLUSIONS: The results of the present study suggest that mosaicplasty, while capable of transposing viable hyaline cartilage, is associated with an extensive margin of cell death that is likely to compromise lateral integration and articular reconstruction.

Humeral osteonecrosis leading to the early detection of a bronchial carcinoma.

The new Ionising Radiation (Medical Exposure) Regulations 2000 (IR (ME)ER) were implemented in January 2001. These regulations state that "the referrer must record in the patient's notes that a radiograph was taken and what it showed". As a result it is now incumbent upon the orthopaedic surgeon to document formally the findings of all requested radiographs. We present a case in which a left upper bronchial carcinoma was detected initially on a radiograph of the left shoulder. It highlights the importance of careful examination of the entire radiographic image and the documenting of the findings.

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

BACKGROUND: Hip fracture patients have a high risk of thrombo-embolic complications following surgical management. OBJECTIVES: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (up to March 2002), MEDLINE (1966 to March 2002), EMBASE (1980 to March 2002), CINAHL (1982 to February week 4 2002), Current Contents (1993 week 26 to 2002 week 12), reference lists of published articles and contacted trialists and other workers in the field. Date of most recent search: March 2002. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into five categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, heparin versus mechanical, and miscellaneous) and results pooled where possible. MAIN RESULTS: The 31 included trials involved at least 2958 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and five trials of 373 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (124/474 (26%) versus 219/519 (42%); relative risk (RR) 0.60; 95% confidence interval (CI) 0.50 to 0.71). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was no statistically significant difference in overall mortality (42/356 (12%) versus 38/374 (10%); RR 1.16; 95%CI 0.77 to 1.74). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Five trials, involving 487 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (16/221 (7%) versus 52/229 (22%); RR 0.31; 95%CI 0.19 to 0.51) and pulmonary embolism. Data were insufficient to establish any effect on the incidence of fatal pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or an overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin and low dose aspirin should be considered.

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

BACKGROUND: Hip fracture patients have a high risk of thromboembolic complications following surgical management. OBJECTIVES: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, Embase, and reference lists of published papers and books. We contacted trialists and other workers in the field. Date of most recent search: September 1996. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into four categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, and miscellaneous) and results pooled where possible. MAIN RESULTS: The 26 included trials involved 2600 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and four trials of 471 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (121/511 (24%) versus 203/519 (39%); Peto odds ratio 0.41; 95% confidence interval 0.31 to 0.55). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was a non significant increase in overall mortality in the heparin group (46/420 (11%) versus 35/423 (8%); Peto odds ratio 1.39; 95% confidence interval 0. 86 to 2.23). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Four trials, involving 442 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (12/202 (6%) versus 42/212 (19%); Peto odds ratio 0.24; 95% confidence interval 0.13 to 0.44). Although the limited data indicated a potential benefit, they were inadequate to establish any effect on the incidence of pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin should be considered.

Adult ankle fractures--an increasing problem?

The epidemiology of ankle fractures is changing. Increasing longevity has resulted in the highest age-specific incidence of ankle fractures being in women between 75 and 84 years of age. The introduction of the AO classification has facilitated analysis of the commonest fracture types. This survey of 1,500 ankle fractures, seen in a 3-year period in the Edinburgh Orthopaedic Trauma Unit, shows that the commonest ankle fractures are the B1.1 and A1.2 lateral malleolar fractures. Isolated malleolar fractures accounted for two thirds of the series, with bimalleolar fractures occurring in one fourth of the patients and trimalleolar fractures in the remaining 7%. Open fractures occurred in 2%.

Treatment of chronic rotator-cuff impingement by arthroscopic subacromial decompression.

We report a prospective study of 49 patients who had arthroscopic subacromial decompression for chronic rotator-cuff impingement. All patients were assessed preoperatively and at 3, 6 and 12 months using the modified UCLA shoulder score. The dominant arm was affected in 35 patients, but only 13 recognised overuse as a cause of their shoulder pain. Before operation, the UCLA shoulder score was poor or fair in all patients. After three months only 28% of patients had satisfactory relief of symptoms but at one year 85% of patients examined had a good or excellent result. Patients with calcific tendonitis recovered more quickly: 93% reported a good result at six months. We conclude that arthroscopic subacromial decompression is an effective form of treatment, but that patients should be warned that recovery from surgery may be prolonged.

Early open reduction and bone grafting for unstable fractures of the distal radius.

We describe a new technique for open reduction, bone grafting and fixation with a single Kirschner wire of unstable fractures of the distal radius. Of the 83 patients treated by this technique, most had regained volar tilt when seen at an average of 13 months after injury. Malunion was seen in 18 patients due either to poor placement of the graft and Kirschner wire or because of both volar and dorsal comminution. Assessment of hand and wrist function showed an average recovery of 63% of mass grip strength with an excellent return of specialised grip strength and range of movement. The advantages of this technique over closed methods include the ability to regain the volar tilt of the distal radius and to achieve reduction at any time before union of the fracture.

The epidemiology of tibial fractures.

We performed an epidemiological analysis of 523 fractures treated in the Edinburgh Orthopaedic Trauma Unit over a three-year period using modern descriptive criteria. The fractures were defined in terms of their AO morphology and their degree of comminution, location and cause. Closed fractures were classified using the Tscherne grading system and open fractures according to the Gustilo classification. Further analysis of fractures caused by road-traffic accidents and football was carried out. The use of the AO classification allowed the common fracture patterns to be defined. Correlation of the classification systems showed an association between the AO morphological system and the Tscherne and Gustilo classifications. The relative rarity of severe tibial fractures is indicated and it is suggested that in smaller orthopaedic units the infrequency of these fractures has implications for training and the development of treatment protocols.

Transcardiac echocardiography during invasive intramedullary procedures.

We performed transoesophageal echocardiography in 111 operations (110 patients) which included medullary reaming for fresh fractures of the femur and tibia, pathological lesions of the femur, and hemiarthroplasty of the hip. Embolic events of varying intensity were seen in 97 procedures and measured pulmonary responses correlated with the severity of embolic phenomena. Twenty-four out of the 25 severe embolic responses occurred while reaming pathological lesions or during cemented hemiarthroplasty of the hip and, overall, pathological lesions produced the most severe responses. Paradoxical embolisation occurred in four patients, all with pathological lesions of the femur (21%); two died. In 12 patients large coagulative masses became trapped in the heart. Extensive pulmonary thromboembolism with reamed bone and immature clot was found at post-mortem in two patients; there was severe systemic embolisation of fat and marrow in one who had a patent foramen ovale and widespread mild systemic fat embolisation in the other without associated foraminal defect. Sequential analysis of blood from the right atrium in five patients showed considerable activation of clotting cascades during reaming.

A technique for correct placement of the Wilson Cook oesophageal prosthesis in malignant tracheo-oesphageal fistula.

A simple technique is described for accurate placement of the Wilson Cook prosthesis in the management of malignant tracheo-oesophageal fistula. This cuffed tube permits effective occlusion of the fistula while earlier problems of oesophageal intubation (migration, erosion, etc.) are avoided.

CRP levels as a measure of surgical trauma: a comparison of different general surgical procedures.

Acute phase proteins are released into the circulation as part of the metabolic response to trauma. C reactive protein (CRP) has been shown to be the most specific and sensitive indicator of trauma. We measured pre- and postoperative CRP levels in patients undergoing varicose vein surgery, inguinal herniorrhaphy, laparoscopic cholecystectomy and open cholecystectomy. A significant difference is shown between the levels found in those undergoing varicose vein, hernia surgery or open cholecystectomy; however, there is no significant difference in the CRP levels between open and laparoscopic cholecystectomy.