Abstract

An important aspect of the governance of surgical services within a Healthcare Trust is the correct coding of elective procedures performed. Within the Trust, treatment codes are banded into specific healthcare resource groups (HRGs), which generate a predetermined income. Accurate coding and grouping of the treatments provided for patients is consequently vital to Trusts to ensure that they receive appropriate financial reward for the care provided, so ensuring they remain economically viable as a department.

We present a retrospective study investigating the accuracy of procedure coding, code allocation to HRGs, and the resultant cost consequences for all elective arthroscopic anterior cruciate ligament (ACL) repairs completed by one consultant over one financial year (01/01/2010-31/03/2011).

In this period a total of 55 ACL repairs were undertaken by the consultant. Data was available for 43 of these cases, all of which were repairs of traumatic ACL ruptures. The patients had an average age of 26.7 (17–55) years, all were ASA 1 and had no significant comorbidities. They were all booked for identical procedures, except one patient who required an allograft; 12 required meniscectomies. All 43 had an operation note completed by the operating consultant.

Within this trust patient and procedural codes were generated from electronic discharge letters (EDLs). We found that all 43 EDLs were completed accurately, contained full details of the procedures undertaken, and included relevant information such as complications, patient comorbidities, length of stay and the prescription of analgesics.

These 43 EDLs generated 15 different diagnostic codes and 10 different procedure codes, with a total of 35 different combinations of codes. These were then grouped into six different HRGs. These six HRGs generated income for the Trust, varying from £1880 to £3554 (mean £2670) for the procedures, with a total income of £114,823. We found that patient and procedure details, and the level of doctor completing the EDL did not significantly influence the HRG generated (P = 0.4)

Currently within the Trust, and nationally the HRG tariff for a routine ACL repair has not been agreed upon. The maximum possible tariff from an HRG for this procedure for a patient with no significant comorbidities is described as – ‘Reconstruction of intraarticular ligament – Major knee procedure for trauma’, generating an income of £5183 per case. Application of this tariff would have resulted in a total income of £222,869 for the 43 patients included in the present study a potential increase of earnings for the Trust of £108,046, for one elective procedure in one financial year.

The findings of this study reveal the potential for limitations in the governance of surgical services through inaccuracies in HRG coding, despite the availability of suitably detailed EDLs. It is suggested that Trusts should audit and, where indicated, ensure effective quality assurance of HRG coding in the interests of the governance of secondary care services.

The outcome and survivorship of osteotomy for medial compartment osteoarthritis are closely correlated to the changes in the weight bearing axis. Questions remain over the optimal correction when undertaking medial unicompartmental knee replacement (UKR).

Prospective data was collected on 50 patients (30F:20M) undergoing fixed bearing medial UKR which included pre-operative and 12 month Oxford Knee Scores and pre and post-operative weight-bearing long-leg radiographs.

The weight bearing axis was measured from the centre of the femoral head to the mid-point of the talus. The point at which this axis crossed the tibial plateau was expressed as a percentage of the width of that plateau - 0 (medial cortex) to 100% (lateral cortex).

Regression method and correlation coefficients were used to assess the relationship between the response and variables.

A significant correlation was seen between the 12 month score and the change in axis, which was maintained when the pre-operative score was adjusted for (p = 0.043 and 0.046 respectively). Larger changes in scores were seen with larger changes in axis (p = 0.046) when the pre-operative axis was adjusted for.

Higher BMIs reported worse scores at 12 months (p = 0.022) and a smaller overall change in score one year post-operatively (p = 0.037). This significance was improved when the pre-operative scores were adjusted (p = 0.017 and 0.017 respectively).

Proximity of correction of axis to the assumed contralateral normal was weakly correlated (p = 0.049) to the 12 month score, especially when BMI was corrected for.

These results suggest that the weight bearing axis and BMI do play a significant role in early patient outcomes following fixed bearing unicompartmental knee replacement.

We present a biomechanical cadaveric study investigating the effect of type II Superior Labrum Anterior Posterior (SLAP) lesions on the load-deformation properties of the Long Head of Biceps (LHB) and labral complex. We also report our assessment of whether repair of the type II SLAP lesion restored normal biomechanical properties to the superior labral complex.

Using a servo-controlled hydraulic material testing system (Bionix MTS 858, Minneapolis, MA), we compared the load-deformation properties of the LHB tendon with:

the LHB anchor intact;

Seven fresh-frozen, cadaveric, human scapulae were tested. We found that the introduction of a type II SLAP lesion significantly increased the toe region of the load deformation curve compared to the labral complex with an intact LHB anchor. The repair techniques restored the stiffness of the intact LHB but failed to reproduce the normal load versus displacement profile of the labral complex with an intact LHB anchor.

Of the two suture techniques, the mattress suture best restored the normal biomechanics of the labral complex.

We conclude that a type II SLAP lesion significantly alters the biomechanical properties of the LHB tendon. Repair of the SLAP lesion only partially restores the biomechanical properties. We hypothesise that repairs of type II SLAP lesions may fail at loads as low as 150N, hence the LHB should be protected following surgery.