[Translated article] Influence of claims on the management of an orthopaedic surgery and traumatology service.

INTRODUCTION: Claims constitute one of the main sources of information to evaluate the perceived quality in healthcare centres, being Orthopaedic and Traumatology Surgery (OTS) one of the specialties with greater probability of receiving them due to its high surgical demand generating long waiting lists. OBJECTIVES: To display the evolution of the filed claims addressed to the OTS department, to classify the reasons stated in the complaint, and to identify the opportunities for improvement derived from the forementioned. METHODOLOGY: Descriptive, observational and retrospective epidemiological study. The target population has been configured by those citizens who have submitted a claim addressed to the OTS Service of a University Hospital of Barcelona from 2014 to 2018. In reference with the classification of claims, it has been used the reasons established by the public service CatSalut: assistance, treat, information, organisation, documentation and hospitality/habitability/comfort. RESULTS: OTS service received a total of 424 claims during the study period, showing an overall rate of 3.18 claims per 100 assistance episodes considered. The main reasons for claiming were organisational (73%) and assistance (20%). No claims regarding dissatisfaction of hospitality/habitability/comfort were registered. A noticeable decrease in the number of claims submitted is observed since 2016. CONCLUSION: Actions in the management of waiting lists and standardised information procedures that improve the doctor-patient relationship have been identified as measures of improvement to reduce the claim presentation rate.

Influence of claims on the management of an orthopaedic surgery and traumatology service. / Influencia de las reclamaciones en la gestión asistencial de un servicio de cirugía ortopédica y traumatología.

INTRODUCTION: Claims constitute one of the main sources of information to evaluate the perceived quality in healthcare centres, being Orthopaedic and Traumatology Surgery (OTS) one of the specialties with greater probability of receiving them due to its high surgical demand generating long waiting lists. OBJECTIVES: To display the evolution of the filed claims addressed to the OTS department, to classify the reasons stated in the complaint, and to identify the opportunities for improvement derived from the forementioned. METHODOLOGY: Descriptive, observational and retrospective epidemiological study. The target population has been configured by those citizens who have submitted a claim addressed to the OTS Service of a University Hospital of Barcelona from 2014 to 2018. In reference with the classification of claims, it has been used the reasons established by the public service CatSalut: assistance, treat, information, organisation, documentation and hospitality/habitability/comfort. RESULTS: OTS service received a total of 424 claims during the study period, showing an overall rate of 3.18 claims per 100 assistance episodes considered. The main reasons for claiming were organizational (73%) and assistance (20%). No claims regarding dissatisfaction of hospitality/habitability/comfort were registered. A noticeable decrease in the number of claims submitted is observed since 2016. CONCLUSION: Actions in the management of waiting lists and standardised information procedures that improve the doctor-patient relationship have been identified as measures of improvement to reduce the claim presentation rate.

Usefulness of histology for predicting infection at the time of hip and knee revision in patients with rheumatoid arthritis.

INTRODUCTION: It remains unclear whether rheumatoid arthritis might be a cause of false positive of the histology for the diagnosis of prosthetic joint infection. Our aim was to evaluate the usefulness of the histology for the diagnosis of infection during hip and knee prosthesis revision in patients with rheumatoid arthritis. MATERIALS AND METHODS: All patients with the diagnosis of rheumatoid arthritis (RA) undergoing hip or knee revision surgery (total or partial) were retrospectively reviewed. Positive histology was considered when ≥ 5 neutrophils per high-power field (400×) were found in at least five separate microscopic fields. Patients who presented ≥ 2 positive cultures for the same microorganism or the presence of fistula were considered as "true positives". RESULTS: Thirty-two hip (n = 12) and knee (n = 20) revision procedures were performed. Sensitivity, specificity, positive and negative predictive value of the histology were 50%, 78.6%, 25% and 91.7%, respectively. Six out of the eight patients presenting with positive histology had negative cultures (75.0% of false positives). CONCLUSIONS: Our results suggest that, in the context of RA, negative histological results have a very high negative predictive value. RA poses false positive histology results for the diagnosis of infection during hip and knee revision when conventional cultures are used for diagnosis of infection.

Hip prostheses in young adults. Surface prostheses and short-stem prostheses. / Las prótesis de cadera en el adulto joven. Prótesis de superficie y prótesis de vástago corto.

The poor results obtained in young patients when using a conventional prosthesis led to the resurgence of hip resurfacing to find less invasive implants for the bone. Young patients present a demand for additional activity, which makes them a serious challenge for the survival of implants. In addition, new information technologies contribute decisively to the preference for non-cemented prostheses. Maintaining quality of life, preserving the bone and soft tissues, as well as achieving a very stable implant, are the goals of every hip orthopaedic surgeon for these patients. The results in research point to the use of smaller prostheses, which use the metaphyseal zone more and less the diaphyseal zone, and hence the large number of the abovementioned short stem prostheses. Both models are principally indicated in the young adult. Their revision should be a more simple operation, but this is only true for hip resurfacing, not for short stems.

Five cases of acrometastasis to the hand from a carcinoma and review of the literature.

Metastases in the hand bones are a rare form of cancer presentation. Their appearance as a sign of carcinoma is even rarer and is associated with a poor prognosis. While amputation is recommended in cases of isolated metastases in patients with at least a few months of survival, radiation therapy may be useful for treating pain and partially restoring function. We conducted a retrospective review of 5 consecutive patients (2 male, 3 female; mean age of 46 years) presenting with metastases in the hand bones who had lung (n=2), skin, uterus and kidney cancers. Conservative treatment was performed in three cases, transmetacarpal amputation in one case and distal phalanx amputation in one case. All patients died within a few months of the diagnosis (mean: 5.2months). Because acrometastases generally are related to widespread disease, the prognosis of patients with acrometastases is poor. These cases illustrate the rapid progression of the disease when acrometastases in the hand are present.

Comparison of bacterial results from conventional cultures of the periprosthetic membrane and the synovial or pseudocapsule during hip revision arthroplasty.

INTRODUCTION: Bacterial identification is essential to diagnose and treat a revision for prosthetic loosening of an infected hip. The purpose of this study was to determine whether conventional cultures from the periprosthetic membrane are superior to synovial/pseudocapsule samples in the diagnosis of infection in hip revision arthroplasty. MATERIALS AND METHODS: We performed a prospective study including all hip revisions from October 2009 to October of 2011. Once the implants were removed and prior to the administration of the antibiotic prophylaxis, six periprosthetic samples from different sites were sent to the laboratory for culturing: two periprosthetic fluid samples, two solid material (synovial/pseudocapsule) samples and two swabs. Once the six samples were taken, antibiotic prophylaxis was administered and just as the implant was removed, two more solid samples of the periprosthetic membrane were obtained. RESULTS: Of a total of 86 hip revision surgeries, 22 were considered septic revisions postoperatively, of which 16 resulted in positive cultures. Of these 16 revisions, 14 obtained the same microbiologic diagnostic when considering either the synovial/pseudocapsule culture results or the solid membrane sample. CONCLUSIONS: We conclude that the membrane sample for a conventional culture is not superior to the synovial/pseudocapsule sample in detecting microorganisms.

Long-term outcome of acute prosthetic joint infections due to gram-negative bacilli treated with retention of prosthesis.

OBJECTIVE: To update the clinical information of the 47 patients with a prosthetic joint infection due to Gram-negative bacilli included in a previous study and to reassess the predictors of failure after a longer follow-up. METHODS: Using the electronic files of our hospital, all the information regarding readmissions to the hospital, new surgical procedures and the reason for the new surgery (infection, aseptic loosening), and the last visit in the hospital were registered. The medical chart of the 35 patients that were considered in remission in the previous publication was reviewed. RESULTS: In 30 patients no clinical evidence of failure was detected and no additional surgery on the previously infected prosthesis was necessary and they were considered in long-term remission. In 5 cases a late complication was identified. One case had a reinfection due to coagulase-negative staphylococci after 22 months from the open debridement and required a 2-stage revision surgery. The other 4 cases developed an aseptic loosening and it was necessary to perform a 1-stage exchange. Receiving a fluoroquinolone when all the Gram-negatives involved in the infection were susceptible to fluoroquinolones was the only factor associated with remission in the univariate analysis (p=0.002). CONCLUSION: After a long-term follow-up, our results support the importance of using fluoroquinolones in acute PJI due to Gram-negative bacilli.

Comparison of a low-pressure and a high-pressure pulsatile lavage during débridement for orthopaedic implant infection.

INTRODUCTION: The aim of our study was to compare the effectiveness of high-pressure pulsatile lavage and low-pressure lavage in patients with an orthopaedic implant infection treated with open débridement followed by antibiotic treatment. PATIENTS AND METHODS: Patients with an orthopaedic implant infection requiring open débridement from January 2008 to August 2009 were randomized prospectively to a low-pressure or a high-pressure pulsatile lavage arm. Relevant information about demographics, co-morbidity, type of implant, microbiology data, surgical treatment, and outcome were recorded. Comparison of proportions was made using χ(2) test or Fisher exact test when necessary. The Kaplan-Meier survival method was used to estimate the cumulative probability of treatment failure from open débridement to the last visit. RESULTS: Seventy-nine patients were included. There were no differences between the main characteristics between both groups (p > 0.05). Mean (SD) age of the whole cohort was 70.2 (11.9) years. There were 46 infections on knee prosthesis, 17 on hip prosthesis, 7 on hip hemiarthroplasties and 9 on osteosynthesis devices. There were 69 acute post-surgical infections, 8 acute haematogenous infections and 2 chronic infections. The most common microorganisms isolated were coagulase-negative Staphylococci in 34 cases, Staphylococcus aureus in 26 and Escherichia coli in 19 cases. There were 30 polymicrobial infections. A total of 42 and 37 patients were randomized to a high-pressure pulsatile or a low-pressure lavage, respectively. There was no difference in the success rate between both arms (80.9 vs. 86.5%, p = 0.56). CONCLUSION: The use of a high-pressure pulsatile lavage during open débridement of implant infections had a similar success rate as a low-pressure lavage.

Secondary patellar resurfacing in the treatment of patellofemoral pain after total knee arthroplasty.

PURPOSE: This paper reports a prospective review of patients who, between 2004 and 2007, underwent secondary patellar resurfacing (SPR) due to anterior knee pain after a primary total knee arthroplasty (TKA). The aim was to evaluate the clinical outcomes obtained with the SPR and to compare them with radiological findings. METHODS: A total of twenty-seven consecutive patients met the inclusion criteria. There were twenty-three (85%) women and four (15%) men with a median age of 70 years. The patients were evaluated before and after the surgery with the same functional scores and radiological parameters. Bone scintigraphy was also used in the assessment, and a CT-scan was performed in order to evaluate the femoral component rotation. The median time between TKA and SPR was 18 months. RESULTS: With a median follow-up of 23 months, seventeen patients (63%) reported a clear subjective improvement after SPR, and patellofemoral scores (primary outcome measure), KSS and WOMAC (secondary outcome measures) showed a statistically significant improvement following the procedure. There were no significant changes after SPR in the Insall-Salvati ratio, the lateral patellar displacement or the lateral patellar tilt. The mean time between TKA and SPR had no statistically significant effect on outcome. The bone scintigraphy revealed increased patellar uptake in seven cases, but this was not related to subsequent improvement after SPR. Rotational computed tomography showed a median internal rotation of the femoral component of 1º. The complications observed were a patellar component loosening and an acute post-infection. CONCLUSION: No clinical or radiological parameter was found to be related to the final outcome after SPR. There was a discrepancy between functional scale scores and the patient's subjective satisfaction.

Acute disassembly of a bipolar radial head arthroplasty.

The GUEPAR(®) implant is a metallic bipolar radial head prosthesis designed to treat comminuted radial head fractures when anatomic realignment of the articular surface of the radiocapitellar joint is not possible. We report herein the rare case of an acute complete disassembly of this implant, discuss the reason for this occurrence and review the literature. In the presented case, the complete removal of the prosthesis provided a satisfactory outcome with an excellent Mayo Elbow Performance Score at 12months follow-up.

[Evaluation of the results of the treatment of Vancouver B1 periprosthetic fractures and proposed indications for the use of cortical allograft as part of the fixation]. / Evaluación de resultados en el tratamiento de fracturas periprotésicas Vancouver B1 y propuesta de indicaciones del uso de aloinjerto cortical como parte de la fijación.

Currently there is limited information on the indications for the use of cortical allograft for the treatment of periprosthetic fractures on a stable stem. The purpose of this study was to retrospectively evaluate the treatment and the results obtained in this type of fractures and propose a series of criteria for the use of cortical allograft. Between 2003 and 2008 a total of 31 periprosthetic femur fractures were treated at our institution. Twelve of them were classified as B1: 6 were treated with a Dall-Miles (Stryker) system plate and 6 with the same plate supplemented with a structural cortical allograft over the medial cortex of the femur (DM and DM-Allo groups, respectively). An evaluation of the clinical and radiologic results was performed in the latest follow-up available. A patient in the DM-Allo group had rupture of a screw and 10 degrees varization; the fracture healed despite this and the patient had a satisfactory clinical course. The Oxford Hip Score was 9 points lower in the DM group compared with the DM-Allo group, and the EQ-5D health scale was 0.10 better for the DM group. The DM-Allo group had a longer hospital stay and more transfusion-related requirements. We think that the patients with clinical or radiologic criteria of osteoporotic bone may benefit from the use of a cortical allograft to favor healing and increase the bone stock. However, those advantages should be weighed considering the higher risk of surgical-related morbidity associated with the surgical insult.

Results of treatment of subtrochanteric femoral fractures with the AO/ASIF Long Trochanteric Fixation Nail (LTFN).

PURPOSE OF THE STUDY: This retrospective study reports on the clinical results of a group of 23 patients with subtrochanteric femoral fractures using the Long Trochanteric Fixation Nail (LTFN). MATERIAL: Between January 2005 and January 2008, 23 patients (20 women, 3 men; average age: 64.8 years old) with subtrochanteric femoral fractures were treated surgically. According to the AO/ASIF Classification, the most frequent fracture type was an 32-A1. They were also classified regarding the Seinsheimer Classification, in which the commonest type was the IIB. Of the 23 fractures, 14 of them had been the result of an unexpected fall, 2 were the result of a high-energy trauma and 7 consisted of pathologic fractures. METHODS: All the patients were treated using the LTFN device and they all received clinical and radiological follow-ups at least until their fractures were consolidated. The average surgery time, average decrease in haemoglobin in the first 24 hours post- surgery, average need for red blood cell transfusion, postoperative mortality at a 6th month follow-up, time to autonomous deambulation, most frequent destination at the time of discharge, average time for consolidation of the fracture and average follow-up time were reported. Intraoperative and postoperative complications were also recorded. RESULTS: The average surgery time from cut to stitch was 97.45 minutes with the decrease in haemoglobin averaging 26.45 g/L and, on average, the need for red blood cell transfusion was 1.12 concentrates. In the first postoperative week, 57.1% of the total number patients were capable of deambulation. The time to hospital discharge was 12.9 days. After an average follow-up of 13.9 months, total weightbearing was achieved in the 64.7% of the patients. The average consolidation time was 21.6 weeks and none of the patients developed pseudoarthrosis. Technical failures were seen in 4.3% of the cases: 1 patient suffered a migration of the distal locking screw. There were no cases of deep infection, cut-out, bending/breaking of the implant, malrotation or fracture of the femoral shaft at the tip of the implant. DISCUSSION: From a mechanical point of view the use of a long intramedullary nail in combination with a blade or a screw seems to be the most appropriate treatment for subtrochanteric fractures of the femur. Despite the improvement of implants and surgical techniques, failures due to complications are still considerable. The low distal shaft diameter of the LTFN, in combination with an extremely precise positioning of the blade in the middle of the femoral head, can prevent mechanical complications. Open reduction and cerclage cabling may be required so as to obtain a correct alignment of the fracture. CONCLUSION: We conclude that the LTFN is a safe and reliable intramedullary device for the treatment of subtrochanteric fractures of the femur. Deambulation within the first postoperative surgery is possible when positioned properly. Its implantation requires more surgical time than the standard nails.