92 results found
Bhattacharyya R, Al-Obaidi B, Sugand K, et al., 2021, Evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool in a real-time simulation setting (Distributed Interactive Simulation): a randomized controlled trial, INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED, Vol: 52, Pages: 3420-3426, ISSN: 0020-1383
Karamchandani U, Bhattacharyya R, Patel R, et al., 2021, Training Surgeons to Perform Arthroscopic All-Inside Meniscal Repair: A Randomized Controlled Trial Evaluating the Effectiveness of a Novel Cognitive Task Analysis Teaching Tool, Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA), AMERICAN JOURNAL OF SPORTS MEDICINE, Vol: 49, Pages: 2341-2350, ISSN: 0363-5465
Edwards TC, Naqvi AZ, Dela Cruz N, et al., 2021, Predictors of Pediatric Anterior Cruciate Ligament Injury: The Influence of Steep Lateral Posterior Tibial Slope and Its Relationship to the Lateral Meniscus, ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY, Vol: 37, Pages: 1599-1609, ISSN: 0749-8063
Jaggard MKJ, Boulange CL, Graca G, et al., 2021, The influence of sample collection, handling and low temperature storage upon NMR metabolic profiling analysis in human synovial fluid, JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL ANALYSIS, Vol: 197, ISSN: 0731-7085
Bogomolova K, Sam AH, Misky AT, et al., 2021, Development of a Virtual Three-Dimensional Assessment Scenario for Anatomical Education, ANATOMICAL SCIENCES EDUCATION, Vol: 14, Pages: 385-393, ISSN: 1935-9772
Akhbari P, Jaggard MK, Boulange CL, et al., 2021, Differences between infected and noninfected synovial fluid, BONE & JOINT RESEARCH, Vol: 10, Pages: 85-95, ISSN: 2046-3758
Jaggard MKJ, Boulange CL, Graca G, et al., 2020, Can metabolic profiling provide a new description of osteoarthritis and enable a personalised medicine approach?, CLINICAL RHEUMATOLOGY, Vol: 39, Pages: 3875-3882, ISSN: 0770-3198
Akhbari P, Karamchandani U, Jaggard MKJ, et al., 2020, Can joint fluid metabolic profiling (or "metabonomics") reveal biomarkers for osteoarthritis and inflammatory joint disease? A SYSTEMATIC REVIEW, BONE & JOINT RESEARCH, Vol: 9, Pages: 108-119, ISSN: 2046-3758
Akhbari P, Jaggard MK, Boulange CL, et al., 2019, Differences in the composition of hip and knee synovial fluid in osteoarthritis: a nuclear magnetic resonance (NMR) spectroscopy study of metabolic profiles, OSTEOARTHRITIS AND CARTILAGE, Vol: 27, Pages: 1768-1777, ISSN: 1063-4584
Logishetty K, Gofton WT, Rudran B, et al., 2019, A Multicenter Randomized Controlled Trial Evaluating the Effectiveness of Cognitive Training for Anterior Approach Total Hip Arthroplasty., J Bone Joint Surg Am
BACKGROUND: For total hip arthroplasty (THA), cognitive training prior to performing real surgery may be an effective adjunct alongside simulation to shorten the learning curve. This study sought to create a cognitive training tool (CTT) to perform anterior approach (AA)-THA, which was validated by expert surgeons, and test its use as a training tool compared with conventional material. METHODS: We employed a modified Delphi method with 4 expert surgeons from 3 international centers of excellence. Surgeons were independently observed performing THA before undergoing semistructured cognitive task analysis (CTA) and before completing successive rounds of surveys until a consensus was reached. Thirty-six surgical residents (postgraduate year [PGY]-1 through PGY-4) were randomized to cognitive training or training with a standard operation manual with surgical videos before performing a simulated AA-THA. RESULTS: The consensus CTA defined THA in 11 phases, in which were embedded 46 basic steps, 36 decision points, and 42 critical errors and linked strategies. This CTA was mapped onto an open-access web-based CTT. Surgeons who prepared with the CTT performed a simulated THA 35% more quickly (time, mean 28 versus 38 minutes) with 69% fewer errors in instrument selection (mean 29 versus 49 instances), and required 92% fewer prompts (mean 13 versus 25 instances). They were more accurate in acetabular cup orientation (inclination error, mean 8° versus 10°; anteversion error, mean 14° versus 22°). CONCLUSIONS: This validated CTT for arthroplasty provides structure for competency-based learning. It is more effective at preparing orthopaedic trainees for a complex procedure than conventional materials, as well as for learning sequence, instrumentation utilization, and motor skills. CLINICAL RELEVANCE: Cognitive training combines education on decision-making, knowledge, and technical skill. It is an inexpensive technique to teach surgeons to perform hip arthropla
Sugand K, Malik HH, Newman S, et al., 2019, Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial, SURGEON-JOURNAL OF THE ROYAL COLLEGES OF SURGEONS OF EDINBURGH AND IRELAND, Vol: 17, Pages: 146-155, ISSN: 1479-666X
Sabharwal S, Archer S, Cadoux-Hudson D, et al., 2019, Exploring elderly patients' experiences of recovery following complex proximal humerus fracture: A qualitative study., J Health Psychol, Pages: 1359105319850883-1359105319850883
This study explores the experiences and perceptions of recovery in elderly patients who had sustained a proximal humerus fracture. In-depth semi-structured interviews were conducted with 15 patients over the age of 65. Thematic analysis identified aspects of care that impacted upon patient experience and quality of life. Seven main patient-reported themes were identified, including pain, sleep, shoulder function, emotional state, social support, relationship with their professional and experience of healthcare institution. These themes offer insight into the experiences of adults receiving care for proximal humerus fracture and highlight that existing quantitative measures of quality of life do not measure domains that are important to patients.
Jaggard MKJ, Boulange CL, Akhbari P, et al., 2019, A systematic review of the small molecule studies of osteoarthritis using nuclear magnetic resonance and mass spectroscopy, OSTEOARTHRITIS AND CARTILAGE, Vol: 27, Pages: 560-570, ISSN: 1063-4584
Stevenson H, Jaggard M, Akhbari P, et al., 2019, The role of denatured synovial fluid proteins in the lubrication of artificial joints, Biotribology, Vol: 17, Pages: 49-63, ISSN: 2352-5738
CoCrMo ball-on-flat wear tests were carried out with 25 wt% bovine calf serum (25BCS) and human synovial fluid (HSF) to investigate artificial joint lubricating mechanisms. Post-test the wear scar on the disc was measured and surface deposits in and around the rubbed region were analysed by Micro InfraRed Reflection Absorption Spectroscopy (Micro-IRRAS). In most tests the HSF samples gave higher wear than the 25BCS solution; in some cases, up to 77%. After rinsing a similar pattern of surface deposits was observed in and around the wear scar for both the model and HSF. Micro-IRRAS showed the deposits were primarily denatured proteins with an increased β-sheet content. In some cases, trans-alkyl chain/carbonyl components were also present and these were assigned to lipids. Thioflavin T fluorescent imaging also indicated aggregated non-native β-sheet fibrils were present in the deposits and their presence was associated with lower wear. The formation of insoluble, denatured protein films is thought to be the primary lubrication mechanism contributing to surface protection during rubbing. From this and earlier work we suggest inlet shear induces denaturing of proteins resulting in the formation of non-native β-sheet aggregates. This material is entrained into the contact region where it forms the lubricating film. Patient synovial fluid chemistry appears to influence wear, at least in the bench test, and thus could contributes to increased risk of failure, or success, with metal-metal hips. Finally using 25BCS as a reference screening fluid gives an overly optimistic view of wear in these systems.
Bhattacharyya R, Davidson DJ, Sugand K, et al., 2018, Knee Arthroscopy: A Simulation Demonstrating the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool., JBJS Essent Surg Tech, Vol: 8, Pages: e32-e32, ISSN: 2160-2204
Background: Virtual reality and cadaveric simulations are expensive and not readily accessible1. Innovative and accessible training adjuncts are required to help meet training needs. Cognitive task analysis (CTA) has been used extensively to train pilots and surgeons in other surgical specialties2-6. However, the use of CTA tools within orthopaedics is in its infancy. Arthroscopic procedures are minimally invasive and require a different skill set compared with open surgery. Residents often feel poorly prepared to perform this in the operating room because of the steep learning curve associated with acquiring basic arthroscopic skills. We designed the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) tool, which is, to our knowledge, the first CTA tool described in the orthopaedic literature, demonstrating significant objective benefits in training novices to perform diagnostic knee arthroscopy. Description: The IKACTA tool, which is the combination of the written description of the phases below and the videos (with superimposed audio recordings) of each phase, utilizes simultaneous written and audiovisual modalities to teach diagnostic knee arthroscopy. The procedure was divided into 7 phases: (1) operating room and patient setup, (2) preparation and draping, (3) anterolateral portal placement, (4) examination of the patellofemoral joint and the lateral gutter, (5) examination of the medial compartment and anteromedial portal placement, (6) examination of the intercondylar notch and the lateral compartment, and (7) postoperative care and rehabilitation.For each phase, there are sections on the technical steps, cognitive decision-making behind each technical step, and potential errors and solutions. Video clips recorded by an expert surgeon in the operating room specific to each phase and audio voice recordings explaining each phase superimposed on the video clips were combined with the written information to design the IKACTA tool. Alternatives: Not applic
Bhattacharyya R, Sugand K, Al-Obaidi B, et al., 2018, Trauma simulation training: a randomized controlled trial -evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool, Acta Orthopaedica, Vol: 89, Pages: 689-695, ISSN: 1745-3674
Background and purpose - Cognitive task analysis (CTA) has been used extensively to train pilots and in other surgical specialties. However, the use of CTA within orthopedics is in its infancy. We evaluated the effectiveness of a novel CTA tool to improve understanding of the procedural steps in antegrade femoral intramedullary nailing. Material and methods - Design: A modified Delphi technique was used to generate a CTA from 3 expert orthopedic trauma surgeons for antegrade femoral intramedullary nailing. The written and audiovisual information was combined to describe the technical steps, decision points, and errors for each phase of this procedure Validation: A randomized double-blind controlled trial was undertaken with 22 medical students (novices) randomized into 2 equal groups. The intervention group were given the CTA tool and the control group were given a standard operative technique manual. They were assessed using the validated "Touch Surgery™" application assessment tool on femoral intramedullary nailing. Results - The pre-test scores between the two groups were similar. However, the post-test scores were statistically significantly better in the intervention group compared with the control group. The improvement (post-test median scores) in the intervention group compared with the control group was 20% for patient positioning and preparation, 21% for femoral preparation, 10% for proximal locking, and 19% for distal locking respectively (p < 0.001 for all comparisons). Interpretation - This is the first multimedia CTA tool in femoral intramedullary nailing that is easily accessible, user-friendly, and has demonstrated significant benefits in training novices over the traditional use of operative technique manuals.
Sugand K, Gupte CM, 2018, ABC of Orthopaedics and Trauma, Publisher: John Wiley & Sons, ISBN: 9781118561218
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Lord BR, Colaco HB, Gupte CM, et al., 2018, ACL graft compression: a method to allow reduced tunnel sizes in ACL reconstruction, Knee Surgery, Sports Traumatology, Arthroscopy, Vol: 26, Pages: 2430-2437, ISSN: 0942-2056
PURPOSE: A common problem during ACL reconstruction is asymmetry of proximal-distal graft diameter leading to tunnel upsizing and graft-tunnel mismatch. Compression downsizing provides a graft of uniform size, allowing easy passage into a smaller tunnel. The purpose of this study was to quantify the graft compression technique and its effects on graft biomechanics and stability. It was hypothesised that compression downsizing would significantly reduce cross-sectional area (CSA); that no significant changes in graft biomechanics would occur; graft fixation stability would be improved. METHOD: Sixty-eight non-irradiated peroneus longus (PL) tendons were investigated. Twenty were halved and paired into ten four-strand grafts, 20 strands were compressed by 0.5-1 mm diameter and changes in CSA recorded using an alginate mould technique. The following properties were compared with 20 control strands: cyclic strain when loaded 70-220 N for 1000 cycles; stiffness; ultimate tensile load and stress; Young's modulus. 24 PL tendons were quadrupled into grafts, 12 were compressed and all 24 were submerged in Ringer's solution at 37 °C and the CSA recorded over 12 h. Twelve compressed and 12 control quadrupled grafts were mounted in porcine femurs, placed in Ringer's solution for 12 h at 37 °C and graft displacement at the bone tunnel aperture recorded under cyclic loading. RESULTS: Mean decreases in CSA of 31% under a stress of 471 kPa and 21% under a stress of 447 kPa were observed for doubled and quadrupled grafts, respectively. Compressed grafts re-expanded by 19% over 12 h compared to 2% for controls. No significant differences were observed between compressed and control grafts in the biomechanical properties and graft stability; mean cyclic displacements were 0.3 mm for both groups. CONCLUSIONS: No detrimental biomechanical effects of graft compression on allograft PL tendons were observed. Following compression, t
Stevenson H, Parkes M, Austin L, et al., 2018, The development of a small-scale wear test for CoCrMo specimens with human synovial fluid, Biotribology, Vol: 14, Pages: 1-10, ISSN: 2352-5738
A new test was developed to measure friction and wear of hip implant materials under reciprocating sliding conditions. The method requires a very small amount of lubricant (<3 ml) which allows testing of human synovial fluid. Friction and wear of Cobalt Chromium Molybdenum (CoCrMo) material pairs were measured for a range of model and human synovial fluid samples. The initial development of the test assessed the effect of fluid volume and bovine calf serum (BCS) concentration on friction and wear. In a second series of tests human synovial fluid (HSF) was used. The wear scar size (depth and volume) on the disc was dependent on protein content and reduced significantly for increasing BCS concentration. The results showed that fluid volumes of <1.5 ml were affected by evaporative loss effectively increasing the protein concentration resulting in anomalously lower wear. At the end of the test thick deposits were observed in and around the wear scars on the disc and ball; these were analysed by Infrared Reflection-Absorption Spectroscopy. The deposits were composed primarily of denatured proteins and similar IR spectra were obtained from the BCS and HSF tests. The analysis confirmed the importance of SF proteins in determining wear of CoCrMo couples.
Gupte CM, 2017, Knee Arthroscopy SimulationA Randomized Controlled Trial Evaluating the Effectiveness of the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool, Journal of Bone and Joint Surgery, American Volume, ISSN: 0021-9355
Lord BR, El-Daou H, Sabnis BM, et al., 2016, Erratum to: Biomechanical comparison of graft structures in anterior cruciate ligament reconstruction (vol 25, pg 559, 2017), Knee Surgery, Sports Traumatology, Arthroscopy, Vol: 25, Pages: 988-988, ISSN: 0942-2056
Purpose: Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction may offer kinematic restoration superior to anatomic single bundle (SB), but it remains technically challenging. The femoral attachment site has the most effect on ACL graft isometry, so a simplified three-socket (3S) construct which still uses two sockets to cover the femoral ACL attachment is attractive. It was hypothesised that ACL reconstruction using three- and four-socket techniques would more closely restore native knee kinematics compared to anatomic two-socket (SB) surgery.Methods: Nine cadaveric knees were used to evaluate the kinematics of ACL-intact, ACL-deficient, anatomic SB, three-socket, and DB arthroscopic ACL reconstructions. Suspensory fixation was used, and grafts were tensioned to match the anterior draw of the intact knee at 20°. A six-degree-of-freedom robotic system measured knee laxity under 90 N anterior tibial force and rotational laxity under 5 N-m torque. Combined moments were applied to simulate the pivot-shift subluxation: 4 N-m internal rotation and 8 N-m valgus.Results: Significant differences between reconstructions were not found during anterior tibial loading, apart from SB being more lax than DB at 60° flexion. All reconstructions produced comparable laxity to the intact state, apart from SB at 60°. Significant differences between reconstructions were not found at any flexion angle during tibial internal/external applied torques. Under combined loading, DB produced significantly less laxity than SB constructs apart from anterior tibial translation at 0° and internal rotation at 45°. 3S and DB were comparable to the native knee throughout.Conclusion: Although 3S restored laxities to a similar extent to DB, significant superiority over SB surgery was not observed. Although statistically significant differences were found between SB and DB surgery during anterior tibial and simulated pivot-shift loading, both remained similar to the nativ
Sabharwal S, Patel NK, Griffiths D, et al., 2016, Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus, Bone & Joint Research, Vol: 5, Pages: 470-480, ISSN: 2046-3758
Objectives The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes.Methods A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed.Results Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009).Conclusion This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria.
Fanous R, Sabharwal S, Altaie A, et al., 2016, Hip fracture litigation: A 10-year review of NHS Litigation Authority data and the effect of national guidelines., Annals of the Royal College of Surgeons of England, ISSN: 1478-7083
We present a review evaluating all litigation claims relating to hip fractures made in a 10-year period between 2005 and 2015. Data was obtained from the NHS Litigation Authority through a freedom of information request. All claims relating to hip fractures were reviewed. During the period analysed, 216 claims were made, of which 148 were successful (69%). The total cost of settling these claims was in excess of £5 million. The introduction of a best-practice tariff by the Department of Health in 2010 was designed to improve the quality of care for hip fracture patients. This was followed by guidance from the National Institute for Health and Clinical Excellence in 2011 and the British Orthopaedic Association in 2012. We analysed claims submitted before and after these guidelines were introduced and no significant difference in the number of claims was noted. The most common cause for litigation was a delay in diagnosis, which accounted for 86 claims in total (40%). Despite the presence of these guidelines and targets, there has not been a significant reduction in the number of claims or an improvement in diagnostic accuracy. This may be due to an increasing level of litigation in the UK but we must also question whether we are indeed providing best-practice care to our hip fracture patients and whether these guidelines need further review.
Lord BR, El-Daou H, Sabnis BM, et al., 2016, Biomechanical comparison of graft structures in anterior cruciate ligament reconstruction, Knee Surgery Sports Traumatology Arthroscopy, Vol: 25, Pages: 559-568, ISSN: 1433-7347
PURPOSE: Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction may offer kinematic restoration superior to anatomic single bundle (SB), but it remains technically challenging. The femoral attachment site has the most effect on ACL graft isometry, so a simplified three-socket (3S) construct which still uses two sockets to cover the femoral ACL attachment is attractive. It was hypothesised that ACL reconstruction using three- and four-socket techniques would more closely restore native knee kinematics compared to anatomic two-socket (SB) surgery. METHODS: Nine cadaveric knees were used to evaluate the kinematics of ACL-intact, ACL-deficient, anatomic SB, three-socket, and DB arthroscopic ACL reconstructions. Suspensory fixation was used, and grafts were tensioned to match the anterior draw of the intact knee at 20°. A six-degree-of-freedom robotic system measured knee laxity under 90 N anterior tibial force and rotational laxity under 5 N-m torque. Combined moments were applied to simulate the pivot-shift subluxation: 4 N-m internal rotation and 8 N-m valgus. RESULTS: Significant differences between reconstructions were not found during anterior tibial loading, apart from SB being more lax than DB at 60° flexion. All reconstructions produced comparable laxity to the intact state, apart from SB at 60°. Significant differences between reconstructions were not found at any flexion angle during tibial internal/external applied torques. Under combined loading, DB produced significantly less laxity than SB constructs apart from anterior tibial translation at 0° and internal rotation at 45°. 3S and DB were comparable to the native knee throughout. CONCLUSION: Although 3S restored laxities to a similar extent to DB, significant superiority over SB surgery was not observed. Although statistically significant differences were found between SB and DB surgery during anterior tibial and simulated pivot-shift loading, both remain
Gulati V, Simpson AI, Uzoigwe C, et al., 2016, Surgical care practitioners in orthopaedics: a current concepts review., Journal of the Royal Society of Medicine, ISSN: 1758-1095
Kittl C, El-Daou H, Athwal KK, et al., 2016, The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee: Response., American Journal of Sports Medicine, Vol: 44, Pages: NP15-NP18, ISSN: 1552-3365
Ang WW, Sabharwal S, Johannsson H, et al., 2016, The cost of trauma operating theatre inefficiency., Annals of Medicine and Surgery, Vol: 7, Pages: 24-29, ISSN: 2049-0801
The National Health Service (NHS) is currently facing a financial crisis with a projected deficit of £2billion by the end of financial year 2015/16. As operating rooms (OR) are one of the costliest components in secondary care, improving theatre efficiency should be at the forefront of efforts to improve health service efficiency. The objectives of this study were to characterize the causes of trauma OR delays and to estimate the cost of this inefficiency. A 1-month prospective single-centre study in St. Mary's Hospital. Turnaround time (TT) was used as the surrogate parameter to measure theatre efficiency. Factors including patient age, ASA score and presence of surgical and anaesthetic consultant were evaluated to identify positive or negative associations with theatre delays. Inefficiency cost was calculated by multiplying the time wasted with staff capacity costs and opportunity costs, found to be £24.77/minute. The commonest causes for increased TT were delays in sending for patients (50%) and problems with patient transport to the OR (31%). 461 min of delay was observed in 12 days, equivalent to loss of £951.58/theatre/day. Non-statistically significant trends were seen between length of delays and advancing patient age, ASA score and absence of either a senior clinician or an anaesthetic consultant. Interestingly, the trend was not as strong for absence of an anaesthetic consultant. This study found delays in operating TT to represent a sizable cost, with potential efficiency savings based on TT of £347,327/theatre/year. Further study of a larger sample is warranted to better evaluate the identified trends.
Akhtar K, Sugand K, Wijendra A, et al., 2016, The Transferability of Generic Minimally Invasive Surgical Skills: Is There Crossover of Core Skills Between Laparoscopy and Arthroscopy?, JOURNAL OF SURGICAL EDUCATION, Vol: 73, Pages: 329-338, ISSN: 1931-7204
Sabharwal S, Carter AW, Rashid A, et al., 2016, Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff, Bone & Joint Journal, Vol: 98B, Pages: 249-259, ISSN: 2049-4394
Aims The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost.Methods A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of costResults The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of incomeDiscussion Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs.Take home message: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned.
Kittl C, El-Daou H, Athwal KK, et al., 2016, The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee, AMERICAN JOURNAL OF SPORTS MEDICINE, Vol: 44, Pages: 345-354, ISSN: 0363-5465
Background:Anterolateral rotatory instability (ALRI) may result from combined anterior cruciate ligament (ACL) and lateral extra-articular lesions, but the roles of the anterolateral structures remain controversial.Purpose:To determine the contribution of each anterolateral structure and the ACL in restraining simulated clinical laxity in both the intact and ACL-deficient knee.Study Design:Controlled laboratory study.Methods:A total of 16 knees were tested using a 6 degrees of freedom robot with a universal force-moment sensor. The system automatically defined the path of unloaded flexion/extension. At different flexion angles, anterior-posterior, internal-external, and internal rotational laxity in response to a simulated pivot shift were tested. Eight ACL-intact and 8 ACL-deficient knees were tested. The kinematics of the intact/deficient knee was replayed after transecting/resecting each structure of interest; therefore, the decrease in force/torque reflected the contribution of the transected/resected structure in restraining laxity. Data were analyzed using repeated-measures analyses of variance and paired t tests.Results:For anterior translation, the intact ACL was clearly the primary restraint. The iliotibial tract (ITT) resisted 31% ± 6% of the drawer force with the ACL cut at 30° of flexion; the anterolateral ligament (ALL) and anterolateral capsule resisted 4%. For internal rotation, the superficial layer of the ITT significantly restrained internal rotation at higher flexion angles: 56% ± 20% and 56% ± 16% at 90° for the ACL-intact and ACL-deficient groups, respectively. The deep layer of the ITT restrained internal rotation at lower flexion angles, with 26% ± 9% and 33% ± 12% at 30° for the ACL-intact and ACL-deficient groups, respectively. The other anterolateral structures provided no significant contribution. During the pivot-shift test, the ITT provided 72% ± 14% of the restraint at 45° for th
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