The purpose of this study was to define the risk and incidence of eventual ankle arthroplasty or fusion after documented ankle fracture in a large cohort, and compare that rate to matched healthy patients from the general population.

The Ontario health insurance plan (OHIP) physician billing database, Institute for Clinical Evaluative Sciences (ICES) Physician Database, the Canadian Institute for Health Information (CIHI) databases, Discharge Abstract Database (DAD) and Same Day Surgery (SDS) were used to identify patients treated surgically and non-surgically for ankle fractures. Each patient was matched to four individuals from the general population (13.5 million) with no documented prior treatment for ankle fracture, according to age, sex, income, and urban/rural residence. Fusion and replacement incidence was compared using time-to-event analysis (Kaplan-Meier). A Cox Proportional Hazards model was used to explore the influence of patient, provider and surgical factors on time to surgery.

We identified 45,444 (58.8% female, mean age 48.7 years) and 140, 629 (53.9% female, mean age 47.1 years) patients who had undergone open reduction internal fixation (ORIF) or non-operative management of an ankle fracture (NOA), respectively. Among ORIF patients, n=237 (0.5%) and n=69 (0.15%) patients underwent fusion or arthroplasty after a median 2.8 and 6.9 years, respectively. Among non-operatively treated ankle fractures, n=198 (0.14%) and n=36 (0.03%) patients underwent fusion or arthroplasty after a median of 3.2 and 5.6 years, respectively. Surgical treatment (vs. non-operatively treated fracture), older age, greater co-morbidity and a history of infection post fracture significantly increased the risk of eventual fusion or arthroplasty (HR 3.6 (3.1–4.3), p < 0 .001, HR 1.01 (1.01–1.02), p=0.009, HR 1.2 (1.1–1.3), p < 0 .001, HR 11.3 (6.8–18.7), p < 0 .001, respectively). Compared to matched controls, the risk of fusion/arthroplasty was not independent of time, following an exponential decay pattern. ORIF patient risk was 20 times greater than the general population in the first three years post-ORIF, and approached the risk of non-operatively treated patients (HR 4.5 (95CI: 3.5–5.8), p < 0 .0001) by approximately 14 years out from injury on time and comorbidity adjusted KM curves.

Rates of fusion/arthroplasty are very low after ORIF and non-operative treatment of an ankle fracture in the general population of a public healthcare system. Utilization patterns suggest fusion is more common earlier, and arthroplasty remote, which may be a factor of patient age, injury severity, and complications from initial injury/surgery. Patients who underwent ORIF have >20 times the risk of fusion/arthroplasty in the short-term, however, the risk decreases over time eventually approaching that of non-operatively treated patients (∼4.5x the general population) when compared to non-fractured controls.

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations).

Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions.

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion.

MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden.

Patient satisfaction is an important measure of patient-centered outcomes and physician performance. Given the continued growth of the population undergoing surgical intervention for osteoarthritis (OA), and the concomitant growth in the associated direct costs, understanding what factors drive satisfaction in this population is critical. A potentially important driver not previously considered is satisfaction with pre-surgical consultation. We investigated the influence of pre-surgical consultation satisfaction on overall satisfaction following surgery for OA.

Study data are from 1263 patients who underwent surgery for hip (n=480), knee (n=597), and spine (n=186) OA at a large teaching hospital in Toronto, Canada. Before surgery, patient-reported satisfaction with information received and degree of input in decision-making during the pre-surgical consultation was assessed, along with expectations of surgery (regarding pain, activity limitation, expected time to full recovery and likelihood of complete success). Pre- and post-surgery (6 weeks, and 3, 6, and 12 months) patients reported their average pain level in the past week (0–10, 10 is worst). At each follow-up time-point, two pain variables were defined, pain improvement (minimal clinically important difference from baseline ≥2 points) and ‘acceptable’ pain (pain score ≤ 3). Patients also completed a question on satisfaction with the results of the surgery (very dissatisfied/dissatisfied/somewhat satisfied/very satisfied) at each follow-up time point. We used multilevel ordinal logistic regression to examine the influence of pre-surgery satisfaction with consultation on the trajectory of satisfaction over the year of recovery controlling for expectations of surgery, pain improvement, acceptable pain, socio-demographic factors (age, sex, and education), body mass index, comorbidity, and depressive symptoms (Hospital Anxiety and Depression Scale).

Mean age of the sample was 65.5 years, and over half (54.3%) were women. Overall, 74% and 78.9% of patients were satisfied with the information received and with the decision-making in the pre-surgical consultation, respectively, no significant differences were found by surgical joint (p=0.22). Post-surgery, levels of satisfaction varied very little over time (6 weeks: 92.5% were satisfied and 66.4% were very satisfied, 1 year: 91.1% were satisfied and 65.6% were very satisfied). Results from a model including time, surgical joint, satisfaction with consultation and control factors indicated that being satisfied with the information received in the pre-surgical consultation was associated with higher odds of being more satisfied after surgery (OR: 1.2, 95% CI: 1–1.4). Additionally, spine and knee patients were more likely to be dissatisfied than hip patients (OR: 3.2, 95% CI: 2.1–4.9 and OR: 2.5, 95% CI: 1.8–3.4 for spine and knee patients respectively). Achieving pain improvement (OR: 1.7, 95% CI: 1.3–2.4) and acceptable pain (OR: 2.5, 95% CI: 1.6–3.9) were both significantly associated with greater satisfaction. Pre-operative expectations were not significantly associated with post-surgery satisfaction.

Findings highlight the important role of pre-surgery physician-patient communication and information on post-surgery satisfaction. This points to the need to ensure organizational provisions that foster supportive and interactive relationships between surgeons and their patients to improve patients' satisfaction. Findings also highlight that early post-recovery period (i.e. <= 3 months) as a key driver of longer-term satisfaction.

Purpose

Elective ACLR is indicated for symptomatic instability of the knee. Despite being a common procedure, there are numerous surgical techniques, graft and fixation choices. Many have been directly compared in randomized trials and meta-analyses. The typical operation is arthroscopic-assisted, uses autograft tendon and screw fixation. Research in elective joint replacement surgery has demonstrated an inverse relationship between surgeon volume and revision and complication rates. How patient demographics, provider characteristics and graft/fixation choices influence ACLR revision rates has not been reported on a population level. We hypothesized that ACLR using tendon autograft and screw fixation performed by high volume surgeons will have the lowest rate of revision. In contrast, the risk of contralateral ACLR in the same cohort will be influenced only by patient factors.

Purpose

Femoral nerve blockade (FNB) can provide prolonged postoperative analgesia and facilitate rehabilitation following major knee surgery while minimizing opioid-related adverse effects. However, anecdotal data have implicated FNB in post-operative falls, presumably due to a block-related reduction in quadriceps strength. Age, gender and knee replacement surgery have also been previously identified as risk factors for falls in the acute postoperative orthopaedic inpatient setting. We hypothesized that the use of FNB would be an independent predictor of an inpatient fall following total knee replacement (TKR).

Purpose

Factors that contribute to early and late re-operation after cruciate reconstruction (CR) have not been evaluated on a population level in a public health system. After surgery patients are at risk for knee stiffness, infection or early graft failure prompting revision. Long-term, ipsilateral revision CR, contralateral CR and potentially even joint replacement may occur. Population research in total joint replacement surgery has demonstrated an inverse relationship between complication/failure rates and surgeon procedural volume. We hypothesized that in Ontario, younger patient age and lower surgeon volume would increase the risk of short and long-term re-operation after CR.

The primary objective of this study was to determine if surgical treatment for spinal stenosis is comparable to total hip and knee arthroplasty in improving patients’ self-reported quality of life. An age, sex and time of surgery matched cohort of patients who had undergone elective primary one-two level spinal decompression (n=90) with (n=26 /90) or without fusion for spinal stenosis (n=40 with degenerative spondylolisthesis) and elective primary total hip (n=90) and knee (n = 90) arthroplasty for osteoarthritis were compared. The primary outcome measure was the preoperative and two year postoperative Medical Outcomes Study Short Form-36 (SF-36) questionnaire.

There was no significant difference in the mean pre-operative Physical Component Summary (PCS) / Mental Component Summary between groups [Spine −32/43; Hip − 30/45; Knee 31/46 (p > 0.5)]. With the exception of the knee MCS (p=0.2), postoperative scores were significantly improved for all groups [Spine −40/53; Hip − 43/51; Knee 39/48 (p < 0.001)]. Overall the hip surgery had the great impact on PCS and the spine surgery on MCS.

Studies have shown the significant impact on overall patient quality of life and cost-effectiveness of primary total joint arthroplasty. The results of this unique study show that surgical intervention for spinal stenosis has a similar positive effect at two year follow up. This study provides data that supports the need advocacy regarding waiting time initiatives and surgical resources for the treatment of patients with symptomatic spinal stenosis with a similar demographic to those with primary OA of the hip or knee.

Aim of the study: to determine if WOMAC pain and function outcomes and patient satisfaction are maintained after the institution of a new standardised care pathway for people undergoing primary hip or knee replacement (TJA).

Twenty-three institutions partnered to design and implement a care pathway to provide a seamless transition from acute to rehabilitation sectors by pre-surgery streaming of patients to inpatient or home-LOS were tracked against bench marks of minimum 50% discharged home and an inpatient rehab stay of seven days. Subjects were recruited to the evaluation pre-surgery completing the WOMAC. Follow-up WOMAC and satisfaction questionnaires were completed three months later. The sample of five hundred ensured that the 99% confidence interval (CI) of the mean for each of WOMAC pain and function would be within two and five points respectively of the results of a randomised trial where TJA patients received home-based or inpatient rehabilitation.

On average greater than 50% of people were discharged home from acute care and over 50% of those individuals receiving inpatient rehab were discharged in seven days, with 80% discharged by day ten. 349 (73%) of those accrued (mean age 69 222 females) completed three month follow-up Those discharged home have mean pain and physical scores of 82.7 and 78.7% (where high scores are better pain relief and function) and those receiving inpatient rehab have pain and function scores of 78.6 and 72.4%. These values are within our a priori CI for outcome. 13% reported dissatisfaction with rehabilitation planning and care.

This model of care has achieved the goals of increasing the proportion of people discharged home following TJA and decreased rehabilitation LOS with increased system capacity for rehabilitation. The patient outcomes are maintained.

The purposes of this study were to determine the effect of severity, wait times and patient perspective on outcomes and to create an eivdence-based prioritization tool.

Patients who received a primary hip or knee replacement were followed forward from decision date for surgery to one-year follow-up (N = 4437) and outcomes assessed according to baseline severity. At decision date for surgery, patient baseline severity was captured using the WOMAC disability questionnaire. Twelve to eighteen months after surgery, a questionnaire (WOMAC, satisfaction) was sent to patients to compare pre- and post-operative data.

The chance of a good outcome from TJR surgery gets worse as wait times get longer. Baseline severity affects outcome more than wait times. Patients with a baseline WOMAC less then 30/100 should have surgery within three months (20% patients) If surgery cannot be done within three months, then three priority levels are recommended: Priority I – One month maximum: catastrophic hip or knee joint conditions – complications that are an immediate threat to independence. Priority II – three months maximum: extreme pain and disability because of hip or knee joint condition that will be a threat to role and independence within three months (baseline WOMAC less than or equal to 30/100). Priority III – six months maximum: severe pain or disability because of hip or knee joint condition, but role and independence not threatened (baseline WOMAC over 30/100).

The priority levels and wait time thresholds recommended in this study are the result of an analysis of pre-operative severity scores, the length of the wait and post-operative outcomes and are consistent with data from other sources.

The purpose of this study is to compare the efficacy of home based vs. inpatient rehabilitation following total joint arthroplasty (TJA). Primary outcome was the self-reported WOMAC pain and function score that was used to evaluate a stratified random sample of two hundred and thirty-two patients. Despite concerns about early hospital discharge there was no difference in functional outcomes at the primary endpoint (twelve weeks post TJA) between the group receiving home based vs. inpatient rehab. Given that home- based rehab is less expensive; we would recommend the use of home based rehab protocols following elective primary TJA.

Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes. The aim of this RCT was to compare the efficacy of home based vs. inpatient rehab following Total Joint Arthroplasty (TJA).

Despite concerns about early hospital discharge there was no difference in functional outcomes twelve weeks post TJA between the group receiving home based vs. inpatient rehab.

With no significant difference in functional outcomes, less expensive home based rehabilitation protocols are recommended following elective total joint arthroplasty.

We randomized two hundred and thirty-two patients to either home based or inpatient rehab following TJA using block randomization techniques. All patients at a tertiary referral centre and large volume community hospital undergoing primary elective total hip or knee arthroplasty for osteoarthritis or inflammatory arthritis were eligible. Standardized care pathways were followed for both procedures. All patients were evaluated at baseline (two weeks prior to surgery) and twelve weeks post surgery using standardized questionnaires including history, physical exam, demographics and WOMAC pain and function (the primary endpoint). In total one hundred and fifteen received a total hip and one hundred and seventeen a total knee arthroplasty; there were eighty-five men and one hundred and forty-seven women with a mean age of sixty-seven (range thirty-eight to eighty-nine) years. The groups were similar at baseline for patient demographics and WOMAC scores. At follow-up (twelve weeks post TJA) there was no statistically significant difference in WOMAC scores.

Hospital and surgeon volume is inversely associated with perioperative mortality, dislocation and infection rates following total hip replacement (THR). This study evaluated the relationship between hospital/surgeon volume on early failures requiring revision in a sample of 6826 Medicare beneficiaries in 1995–1996. The primary outcome for the analysis was the time between the primary THR and the first revision. After adjustment for sociodemographic/clinical variables, patients of low volume surgeons in centers with a caseload less than one hundred THR/year were twice as likely to be revised compared with patients in high volume centers by high volume surgeons.

The purpose of this study was to determine whether hospital/surgeon volume is associated with early failures requiring revision.

Patients of low volume surgeons have considerably higher rates of early failure, especially within the first year following surgery.

This study highlights the importance of including surgeon volume among factors that influence referrals for elective THR.

We analyzed claims data of 6826 Medicare beneficiaries, who underwent elective primary THR in 1995–1996 in OH, PA and CO. Hospitals were stratified into, low (< 12 THR/year), medium (12–100 THR/year) and high (> 100 THR/year) volume groups. Low volume surgeons performed fewer than twelve primary THR/ yr. Associations between rates of revisions/surgeon volume were determined by risk ratios after adjusting for hospital volume, patient age, poverty status, gender and comorbidities. We examined whether the effect of surgeon volume on revision rates differed across yearly time intervals. Of patients who had primary THR in 1995–96, two hundred and seventy-one (4%) had at least one revision by the end of 1999, one hundred and twenty-six (46%) of those occurring within the first year after the surgery. Cumulative rates of revision ranged from 2.3% for primary THR in high volume centers performed by high volume surgeons to 5.9% for patients who had primary THR performed by low volume surgeons in low volume centers. Further analysis revealed that the effect of surgeon volume was striking in the first year after the surgery (RR: 2.34; 95%CI: 1.47– 3.78) and was not evident in the subsequent years (RR: 1.08; 95%CI: 0.73–1.58).

The purpose of this study is to evaluate prospectively the comprehension of a specific, detailed and fully informative consent in a standardized manner using a validated tool. The Deaconess Informed Consent Comprehension Test, a set of standardized questions related to eight domains of informed consent was used to survey nearly one hundred patients in a randomized controlled trial (RCT) over a year. The results of our survey demonstrate the lack of comprehension of respondents regarding most of the domains of “informed” consent. This study highlights the limitations of informed consent and the need of alternative concepts, such as entrustment/valid consent.

The purpose of this study was to evaluate prospectively the comprehension of a specific, detailed and fully informative consent in a standardized manner using a validated tool.

The results of our survey clearly demonstrate the lack of comprehension of the respondents regarding most of the domains of the “informed” consent. We are therefore concerned about the moral value of such consent.

This study highlights the importance of discussing the limitations of informed consent and the need of alternative concepts, such as entrustment and valid consent.

We surveyed nearly one hundred patients enrolled in a randomized controlled trial (RCT) over a year. All received their own copy of a specific, detailed, fully informative explanatory letter, the consent form and a patient’s guide to medical research. The Deaconess Informed Consent Comprehension Test, a set of standardized questions related to eight domains of informed consent, was used to evaluate the comprehension of research participants. Although over half of the research participants had retained a copy of the explanatory letter, the consent form and the guide, nearly 40% did not understand the purpose of the RCT. An overwhelming majority (greater than 90%) failed to identify the risks/discomforts associated with the study, while almost 60% of respondents could not identify potential benefits of their participation in the RCT. A mere 56% could provide a clear explanation of randomization. However, over 75% could identify the appropriate persons/process in case they had queries or concerns about the study.

Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes. This study compares the efficacy and patient satisfaction of home- based verses inpatient rehabilitation following total joint arthroplasty (TJA). Despite concerns about early hospital discharge there was no difference in functional outcomes and in patient satisfaction with procedure at the primary endpoints, between the groups receiving home based verses inpatient rehabilitation.

This study compares the efficacy and patient satisfaction of home- based verses inpatient rehabilitation following total joint arthroplasty (TJA).

Given that home- based rehab is less expensive, we would recommend the use of home based rehab protocols following elective primary TJA.

Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes.

The groups were similar at baseline for patient demographics and WOMAC scores. At the six weeks, twelve weeks and one- year follow-up post TJA there was no statistically significant difference in WOMAC pain, physical function, stiffness and overall WOMAC scores. Both groups showed a trend of decrease in pain, stiffness, restriction in physical function over the follow-up period. Similarly, patient satisfaction scores at six, twelve weeks and one year did not show a statistically significant difference between the home versus inpatient group (P> 0.05)

Two hundred and thirty-four patients were randomized to either home based or inpatient rehabilitation following TJA, using block randomization techniques. Standardized care pathways were followed for both procedures. All patients were evaluated at baseline (two weeks prior to surgery), six weeks, twelve weeks and one- year post surgery using standardized questionnaires. Primary outcomes were the self-reported WOMAC pain and function score and satisfaction in terms of improvement in pain and function.

Despite concerns about early hospital discharge there was no difference in functional outcomes and in patient satisfaction with procedure at the primary endpoints, between the groups receiving home based verses inpatient rehabilitation.

Funding: PSI

1069 primary hip arthroplasty (THA) (416 males) and 1846 revision (798 males) patients were matched for sex, age and date of primary THA. Data were collected via retrospective chart review. Time to revision averaged 9.5 years. Revision THA patients were younger at primary THA (55 vs. 64 years), had a higher body mass index (27 vs. 30) and more frequently had a cemented acetabulum (p< 0.0001). After controlling for institution, earlier time to revision was predicted by younger age at primary THA, secondary OA or dysplasia, increased BMI, posterior surgical approach, cemented acetabulum, and small femoral head size (28 mm) (p< 0.05).

To determine whether patient (age, gender, underlying disease, body mass index), surgical (surgical approach), and prosthetic (cemented vs. uncemented acetabular or femoral component, femoral head size) factors predict time to revision arthroplasty of primary total hip arthroplasty (THA).

Patients who are younger when undergoing primary THA, have secondary osteoarthritis (OA) or dysplasia, are obese, and have a cemented acetabulum with a small femoral head by a posterior approach are at increased risk for revision THA.

This study identified important, potentially modifiable patient, surgical and prosthetic factors that are adverse predictors of outcome.

For the period 1980 to 2000, 1069 primary hip arthroplasty patients (416 males) and 1846 revision arthroplasty (798 males) patients were matched for sex, age and date of primary THA within two years. Revision THAs for infection were excluded. Data were collected via retrospective chart review. Time to revision THA averaged 9.5 years. In univariate analysis, patients who had revision THA were younger at primary THA (55 vs. 64 years, p< 0.0001), had a higher body mass index (BMI) (27 vs. 30, p< 0.0001), and more frequently had a cemented acetabulum (p< 0.0001). After primary THA, fewer patients who went on to revision arthroplasty had orthopaedic complications (6.5 vs. 16.5%). After controlling for institution, earlier time to revision was predicted by younger age at primary THA, underlying joint disease of secondary OA or dysplasia, increased BMI, posterior surgical approach, cemented acetabulum, and small femoral head size (28 mm) (multivariate Cox model, p< 0.05).

Funding: This work was supported in part by a grant from the Canadian Orthopaedic Foundation and The Arthritis Society

Purpose: To evaluate the benefits of standardization on the reliability of the physical examination of the hip by rheumatologists and orthopaedic surgeons

Methods: Six subjects with mild to severe hip osteoarthritis (OA) were examined by 6 examiners (4 rheumatologists, 2 orthopedic surgeons) experienced in the assessment of hip OA using a 6x6 Latin square design. Subjects were examined, followed by a standardization meeting and, a day later, by post-standardization examinations. 33 hip examination maneuvers were evaluated, including range of motion, pain, tenderness, muscle strength, leg length and gait. The order of examinations was randomized for each examiner. For dichotomous signs, agreement was calculated as the prevalence-adjusted bias-adjusted kappa (PABAK). Ordinal and continuous variables were analyzed by ANOVA, using the proportion of variance due to rheumatologists to calculate a reliability coefficient (Rc).

Results: Subjects’ mean age was 61 years (range 49–65), mean BMI was 24 (range 21–30), mean WOMAC pain on walking was 52 mm (range 21–81mm). 23/33 (70%) hip examinations were reliable after standardization. Two new items resulted from the standardization meeting. Pre-/post-standardization reliability for select hip examinations using PABAK were as follows: Gait 0.06/0.52; pain on internal rotation 0.60/0.52; pain on external rotation 0.24/0.72; pain on flexion 0.46/0.82; Patrick test for hip pain 0.78/0.80; Thomas test 0.60/0.88; Trendelenburg test 0.36/0.06. Pre-/post-standardization reliability for select hip examinations using Rc were as follows: hip flexion strength 0.83/0.95; hip abduction strength 0.90/0.86; hip adduction strength 0.87/0.86; ROM internal rotation (supine) 0.87/0.94; ROM external rotation (supine) 0.87/0.80.

Conclusions: Moderate to very good agreement was present for many hip examinations prior to standardization. Improved reliability was achieved after standardization for many but not all hip assessments. This will be important for improved outcome studies of early hip OA.

Purpose: The primary objective of this study was to determine if surgical treatment for spinal stenosis is comparable to total hip arthroplasty in improving patients’ self-reported quality of life.

Methods: An age, sex and time of surgery matched cohort of patients who had undergone elective primary 1–2 level spinal decompression (n=90) with (n=30/90) or without fusion for spinal stenosis (n=40 with degenerative spondylolisthesis) and elective primary total hip arthroplasty for osteoarthritis (n=90) were compared. The primary outcome measure was the preoperative and one year postoperative Medical Outcomes Study Short Form-36 (SF-36) questionnaire.

Results: The mean Physical Component Summary (PCS) / Mental Component Summary (MCS) for the stenosis compared to hip patients were 32.0/43.3 vs. 30.5/46.2 preoperatively (analysis between groups: p = 0.2/0.1) and 39.1/47.3 vs.44.1/46.1 postoperatively (analysis between groups: p = 0.003/0.4). The pre- and postoperative PCS significantly improved for both groups (p < 0.0001);however, the pre- and postoperative MCS improved in the stenosis group only (p = 0.04).

Conclusions: Studies have shown the significant impact on overall patient quality of life and cost-effectiveness of primary total hip arthroplasty. The results of this unique study show that surgical intervention for spinal stenosis also has a very positive overall effect on patients’ self-reported quality of life at one year follow up. This study provides data that supports the need for a long term prospective study and advocacy regarding waiting time initiatives and surgical resources for the treatment of patients with symptomatic spinal stenosis with a similar demographic to those with primary OA of the hip.

This study (n=126, mean age=68.8 years, males=62) evaluated pre-operative WOMAC pain and physical function, age, gender, general health status, revision severity classification, number of revisions, comorbidity and unilateral vs. bilateral surgery as predictors of WOMAC pain and physical function at twenty-four months post revision hip arthroplasty. Pain improved from 9.3 to 3.6 and physical function improved from 35.4 to 17.1. No factors were predictive of patient function. Decreased pain was predicted by less pain pre surgery (p=0.01) and being male (p=0.04).

To determine if pre-operative WOMAC pain and physical function, age, gender, general health status (SF-36), revision severity classification, number of revisions, comorbidity and unilateral vs. bilateral surgery are predictive of WOMAC pain and physical function at twenty-four months post revision hip arthroplasty.

Physical function at twenty-four months is not independently predicted by the pre-treatment factors evaluated in this study. Male patients with less pain pre surgery and little comorbidity have less pain post surgery.

With the exception of pre-treatment pain, the pre-treatment factors tested in this study provide minimal guidance in identifying factors that might be modified to enhance patient outcome.

This prospective cohort study included one hundred and twenty-six patients (mean age=68.8 years, males: females=62:64) who had revision for other than infection or peri-prosthetic fracture. On average from pre-surgery to twenty-four months post-surgery, WOMAC pain improved 9.3 to 3.6 and physical function improved from 35.4 to 17.1. In univariate analysis (t-test, p< 0.05), males tended to have better function (19.6 vs. 14.7) and reported less pain (4.4 vs. 2.8). No other factors were significant in univariate analysis. None of the a priori factors noted above were independently predictive of patient function at twenty-four months in the multivariate model (F=2.06, p=0.04, R²=0.16). Decreased pain with activity at twenty-four months independently was predicted by having less pain pre surgery (p=0.01), being male (p=0.04) and having fewer comorbidities (p=0.07) in the multi-variate model (F=2.9. p=0.004, R²=0.21).

Funding: This work was supported by a grant from The Arthritis Society

This study examined the effect of seven vs. five day physiotherapy on hospital LOS for total joint replacement (TJR) patients. 1055 consecutive TJR patients were studied. Seven day PT significantly reduced LOS for TJR patients (0.73 days) and the subgroup of total hip replacement patients (0.80 days). Decreases in TJR LOS reduced hospital costs by $100,000. Older patients and patients with greater co-morbidities had a longer LOS with both five and seven day PT, but their LOS was less with seven day PT. This study provides strong evidence for providing seven day PT for TJR patients.

The purpose of this study was to determine the effect of five vs. seven day/week physiotherapy (PT) on acute care, length of stay (LOS) for TJR patients.

The inpatient discharge abstract database was used to retrospectively identify TJR patients who were admitted on January 1, 2000 or later and discharged by March 31, 2002 or earlier. Patients were excluded if they died in hospital or were discharged to another acute care facility. PT was enhanced from five to seven days/week on March 10, 2001. This date was used to divide patients into PRE and POST (enhanced PT) groups. Differences in LOS (PRE vs. POST) were analyzed for all TJR, and separately for THR (total hip replacement) and TKR (total knee replacement) patients, using t-tests. Potential interactions between group (PRE, POST) and age (young < 70 yrs, old ≥ 70 yrs), gender, and co-morbidity were analyzed with two-way ANOVA’s (group x other variable). LOS acute care savings were calculated using the unit-specific per diem cost.

1055 patients were studied. LOS was significantly reduced for TJR (0.73 days) and THR (0.80 days) patients. TJR decreases in LOS reduced acute care costs by $100,000. Age and co-morbidity had significant main effects but no interaction on LOS.

LOS and hospital costs were reduced for TJR patients with seven day PT. The fact that a decrease in LOS was seen in a large sample, in both young and old patients and patients with and without comorbidities, provides strong evidence to support seven day PT for TJR patients.

We report 11 patients having revision of total hip arthroplasty using massive structural allografts for failure due to sepsis and associated bone loss. All patients had a two-stage reconstruction and the mean follow-up was 47.8 months (24 to 72). Positive cultures were obtained at the first stage in nine of the 11 patients, with Staphylococcus epidermidis being the most common organism. The other two patients had draining sinuses with negative cultures.

There was no recurrence of infection in any patient. The mean increase in the modified Harris hip score was 45 and all the grafts appeared to have united to host bone. Two patients required additional procedures, but only one was related to the allograft. Complications included an incomplete sciatic nerve palsy and one case of graft resorption. Our results support the use of massive allografts in failed septic hip arthroplasty in which there is associated bone loss.

We report two cases in which arthrodesed knees were revised to total arthroplasties after the use of soft-tissue expanders. Case 1 had had multiple operations on her knee and had been arthrodesed for septic arthritis two years earlier. Case 2 had had knee arthrodesis for severe osteoarthritis 18 years before revision. In both patients, tissue expanders were used to increase the soft tissues available for cover and to help to mobilise the extensor mechanism. The operations were made much easier, and in both patients a range of motion from 0 degrees to 90 degrees was achieved at operation.