Avulsion of the proximal hamstring tendon from the ischial tuberosity is an uncommon but significant injury. Recent literature has highlighted that functional results are superior with surgical repair over non-surgical treatment. Limited data exists regarding the optimal rehabilitation regime in post-operative patients. The aim of this study was to investigate the early interim patient outcomes following repair of proximal hamstring tendon avulsions between a traditionally conservative versus an accelerated rehabilitation regimen. In this prospective randomised controlled trial (RCT) 50 patients underwent proximal hamstring tendon avulsion repair, and were randomised to either a braced, partial weight-bearing (PWB) rehabilitation regime (CR = 25) or an accelerated, unbraced, immediate full weight-bearing (FWB) regime (AR group; n = 25). Patients were evaluated preoperatively and at 3 months after surgery, using the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT), visual analog pain scale (VASP), Tegner score, and 12-item Short Survey Form (SF-12). Patients also filled in a diary questioning postoperative pain at rest from Day 2, until week 6 after surgery. Primary analysis was by per protocol and based on linear mixed models. Both groups, with respect to patient and characteristics were matched at baseline. Over three months, five complications were reported (AR = 3, CR = 2). At 3 months post-surgery, significant improvements (p<0.001) were observed in both groups for all outcomes except the SF-12 MCS (P = 0.623) and the Tegner (P = 0.119). There were no significant between-group differences from baseline to 3 months for any outcomes, except for the SF-12 PCS, which showed significant effects favouring the AR regime (effect size [ES], 0.76; 95% CI, 1.2-13.2; P = .02). Early outcomes in an accelerated rehabilitation regimen following surgical repair of proximal hamstring tendon avulsions, was comparable to a traditionally conservative rehabilitation pathway, and resulted in better physical health-related quality of life scores at 3 months post-surgery. Further long term follow up and functional assessment planned as part of this study.
Hamstring grafts have been associated with reduced strength, donor site pain and muscle strains following Anterior Cruciate Ligament Reconstruction (ACLR). Traditional graft fixation methods required both semitendinosus and gracilis tendons to achieve a graft of sufficient length and diameter, but newer techniques allow for shorter, broad single tendon grafts. This study seeks to compare the outcomes between Single Tendon (ST) and Dual Tendon (DT) ACLR, given there is no prospective randomised controlled trial (RCT) in the literature comparing outcomes between these options. In this ongoing RCT: (ANZ Clinical Trials Registry ACTRN126200000927921) patients were recruited and randomised into either ST or DT groups. All anaesthetic and surgical techniques were uniform aside from graft technique and tibial fixation. 13 patients were excluded at surgery as their ST graft did not achieve a minimum 8mm diameter. 70 patients (34 ST, 36DT) have been assessed at 6 months, using PROMS including IKDC2000, Lysholm and Modified Cincinnati Knee, visual analog scale for pain frequency (VAS-F) and severity (VAS-S), dedicated donor site morbidity score, KT-1000 assessment, and isokinetic strength. Graft diameters were significantly lesser in the ST group compared to the DT group (8.44mm/9.11mm mean difference [MD],-0.67mm; P<0.001). There was a significant and moderate effect in lower donor site morbidity in the ST group compared to the DT group (effect size [ES], 0.649; P = .01). No differences between groups were observed for knee laxity in the ACLR limb (P=0.362) or any of the patient-reported outcome measures (P>0.05). Between-group differences were observed for hamstrings strength LSI favouring the ST group, though these were small-to-moderate and non-significant (ES, 0.351; P = .147). ST (versus DT) harvest results in significantly less donor site morbidity and this is the first prospective RCT to determine this. There were no differences between ST and DT hamstring ACLR were observed in PROMs, knee laxity and hamstring strength. Younger female patients tend to have inadequate single tendon size to produce a graft of sufficient diameter, and alternative techniques should be considered. Further endpoints include radiological analysis, longer term donor site morbidity, revision rates and return to sport and will continue to be presented in the future.
Utilization of a patient management support system in our clinical pathway has been successfully demonstrated to both reduce the length of hospital stay after primary THA, as well as reducing the number of hospital readmissions. While successful in a general patient population, the ability of a patient management support system to reduce readmissions in subsets of high risk THA patients has not been evaluated. We identified all primary THAs performed at a single institution between 2013 and 2015. Patient sex, age at the time of surgery, race, ASA grade, and 120-day readmissions were retrieved from the patient medical record. Similar to previous studies, the patient's home address was used as a proxy for socioeconomic status, with the estimated median income of a given patient being estimated as the median household income for patients of similar ethnicity living within their zip code as reported in the 2014 U.S. Census. A binary regression was used to determine if a model of patient factors (age, sex, race, socioeconomic status, and/or ASA grade) could accurately predict 120-day readmission after primary THA. Age and socioeconomic status were treated as a continuous variable and all other factors were categorical in nature, and the individual effects of each categorical factor on readmissions were also assessed.INTRODUCTION
METHODS
Medicare intermediary denial of primary joint replacements has become common over the past couple of years. Our community hospital had a marked increase in denials following the assignment of a new intermediary. Our purpose is to document the initial impact of these denials. A retrospective review of the first 361 Medicare total joints (181 hips and 180 knees) after a new intermediary began processing claims was performed. Initial denial rate, positive response rate to first appeal, as well as delay in payments because of these denials were documentedPURPOSE:
METHODS:
Periprosthetic joint infections (PJI) continue to be a diagnostic challenge for orthopedic surgeons. Chronic PJI are sometimes difficult to diagnose and occasionally present in a subclinical fashion with normal CRP/ESR and/or normal joint aspiration. Some institutions advocate for routine use of intraoperative culture swabs at the time of all revision surgeries to definitively rule out infection. The purpose of this study is to determine whether routine intraoperative cultures is an appropriate and cost effective method of diagnosing subclinical chronic PJI in revision joint replacement patients with a low clinical suspicion for infection. We performed a retrospective chart review and identified 33 patients that underwent revision hip or knee replacement from a single surgeon over a five-month period. The AAOS guidelines for preoperative PJI workup were followed. 13 patients were diagnosed preoperatively with infection and excluded from the study. 20 patients underwent revision joint replacement and three separate cultures swabs were taken for each patient to help in determining true-positive cultures. Infectious Disease was consulted for all patients with any positive culture. Culture results were reviewed. At our hospital, the cost billed to insurance for a single culture is $1,458.58. We did not calculate the cost of the consultant fee. Three (15%) of the 20 revision arthroplasty patients had a single positive culture. Infectious Disease consultants diagnosed all three of these positive cultures as contaminants. None of the patients had a true-positive intraoperative culture. The total cost billed by the hospital to obtain these cultures in all 20 patients was $87,514.80 In our study, obtaining a set of three intraoperative cultures for those patients with a negative preoperative infection workup was not only cost prohibitive but did not diagnose a single subclinical infection. Studies to find other more reliable, accurate, and cost effective alternatives to diagnose PJI are warranted. In patients undergoing revision hip or knee arthroplasty with a low preoperative clinical suspicion for infection, it does not seem that routine intraoperative culture swabs are necessary or cost effective method for diagnosing subclinical periprosthetic joint infection.
