John M. Siliski

Impact of Relational Coordination on Quality of Care, Postoperative Pain and Functioning, and Length of Stay: A Nine-hospital Study of Surgical Patients

BACKGROUND Health care organizations face pressures from patients to improve the quality of care and clinical outcomes, as well as pressures from managed care to do so more efficiently. Coordination, the management of task interdependencies, is one way that health care organizations have attempted to meet these conflicting demands. OBJECTIVES The objectives of this study were to introduce the concept of relational coordination and to determine its impact on the quality of care, postoperative pain and functioning, and the length of stay for patients undergoing an elective surgical procedure. Relational coordination comprises frequent, timely, accurate communication, as well as problem-solving, shared goals, shared knowledge, and mutual respect among health care providers. RESEARCH DESIGN Relational coordination was measured by a cross-sectional questionnaire of health care providers. Quality of care was measured by a cross-sectional postoperative questionnaire of total hip and knee arthroplasty patients. On the same questionnaire, postoperative pain and functioning were measured by the WOMAC osteoarthritis instrument. Length of stay was measured from individual patient hospital records. SUBJECTS The subjects for this study were 338 care providers and 878 patients who completed questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX, between July and December 1997. MEASURES Quality of care, postoperative pain and functioning, and length of acute hospital stay. RESULTS Relational coordination varied significantly between sites, ranging from 3.86 to 4.22 (P <0.001). Quality of care was significantly improved by relational coordination (P <0.001) and each of its dimensions. Postoperative pain was significantly reduced by relational coordination (P = 0.041), whereas postoperative functioning was significantly improved by several dimensions of relational coordination, including the frequency of communication (P = 0.044), the strength of shared goals (P = 0.035), and the degree of mutual respect (P = 0.030) among care providers. Length of stay was significantly shortened (53.77%, P <0.001) by relational coordination and each of its dimensions. CONCLUSIONS Relational coordination across health care providers is associated with improved quality of care, reduced postoperative pain, and decreased lengths of hospital stay for patients undergoing total joint arthroplasty. These findings support the design of formal practices to strengthen communication and relationships among key caregivers on surgical units.

Operative treatment of distal femoral fractures proximal to total knee replacements

Twenty fractures of the distal part of the femur proximal to a total knee replacement were treated operatively by members of the New England Trauma Study Group. Notching of the anterior aspect of the femoral cortex was associated with only two of these fractures, and none of the knee prostheses was loose at the time of the fracture. All twenty fractures were treated with open reduction and stable internal fixation, and the operation on fifteen fractures was supplemented with bone grafts. Every fracture healed, and eighteen healed after a mean of sixteen weeks (range, six to forty weeks). Union of the other two fractures was delayed, but repeat open reduction and internal fixation combined with autogenous bone-grafting resulted in union. After operative treatment, the patients returned to the level of activity that they had had before the fracture. The pre-existing tibiofemoral alignment and range of motion of the knee were also restored. At the time of follow-up, the average clinical rating of the Knee Society for all twenty knees had not decreased compared with the score before the fracture.

The Use of a Modified V-Y Quadricepsplasty During Total Knee Replacement to Gain Exposure and Improve Flexion in the Ankylosed Knee

A modified V-Y quadricepsplasty technique is described that facilitates exposure for prosthetic replacement in the knee with limited preoperative motion. The technique allows increased postoperative flexion without increasing the final postoperative extension lag. Seven patients have undergone knee arthroplasty using this method. The average increase in flexion was 49 degrees. The average ultimate extension lag was 8 degrees.

Supracondylar-intercondylar fractures of the femur. Treatment by internal fixation.

The records on fifty-two supracondylar-intercondylar fractures of the femur were reviewed twenty to 120 months after injury. More than one-third of the fractures had been open. All of the fractures were treated in a single trauma center, using: (1) a single lateral incision, (2) internal fixation with ASIF interfragmentary screws and plates, (3) bone-grafting of comminuted metaphyseal segments, (4) impaction of comminuted metaphyseal segments in osteoporotic elderly patients, and (5) repair of any associated torn ligaments and patellar fractures. Postoperatively, early active motion of the knee was encouraged, and for selected patients a brace was used only to protect the repair of associated disruptions of ligaments or of the extensor mechanism. The fractures were classified by the ASIF system, with C1 being a simple Y pattern, C2 having additional supracondylar comminution, and C3 having intra-articular comminution. The final results were rated using the system that was described by Neer et al. for fractures of the distal end of the femur. The average time between the operation and full weight-bearing (healing) was 13.6 weeks and ranged from 12.3 weeks for C1 fractures (as graded using the ASIF classification) to 15.4 weeks for C3 fractures. The average final arc of motion of the knee was 107 degrees, ranging from 113 degrees for C1 fractures to 99 degrees for C3 fractures. C1 fractures had a better outcome (92 per cent excellent and good results) than did C2 and C3 fractures (77 per cent excellent and good results). Two amputations and one arthrodesis were done to treat infection, and infection accounted for three of the four poor results. Age did not influence the final results, although elderly patients had a longer period of hospitalization. Supracondylar-intercondylar fractures of the femur should be analyzed separately from other fractures of the distal end of the femur because of their intra-articular involvement and associated ligamentous injuries and patellar fractures. Rigid internal fixation permits early functional rehabilitation of the patient and decreases the incidence of malunion, non-union, and loss of fixation.

Prodromes of failure in total knee arthroplasty

A total of 102 revision total knee arthroplasties (TKAs) were reviewed to determine the prodromal symptoms and radiographic findings associated with failure. Presenting symptoms included pain (84%); swelling (76%); progressive varus or valgus deformity (19%); instability (17%); stiffness (17%); clicking or grinding (7%); catching (4%); and patellar pain, subluxation, or clicking (4%). Radiographs were diagnostic in 91% of cases, demonstrating complete radiolucencies (80%), polyethylene wear (43%), component breakage (5%), metallic debris (3%), patellar subluxation or dislocation (4%), and osteolysis (4%). Gross intraoperative findings included polyethylene wear (72%), osteolysis (22%), metal-wear synovitis (9%), component breakage (6%), patellar wear and dissociation (4%), and occult sepsis (5%). The average duration of symptoms was 13 months; the interval between orthopedic evaluations averaged 23 months. Based on this information, we recommend that an annual questionnaire and weight-bearing radiographs be used to ensure adequate surveillance of TKA patients and avoid complications associated with delay in diagnosis of polyethylene wear or implant loosening.

Blood-gas and circulatory changes during total knee replacement. Role of the intramedullary alignment rod.

The use of an intramedullary alignment rod in the distal part of the femur is an important step in performing total knee-replacement arthroplasty. On the basis of our observation of a sudden decrease in oxygen saturation in some patients after insertion of the rod, a prospective study was done of the circulatory and blood-gas changes that were associated with insertion in thirty-five patients. We examined the effects of the use of an eight-millimeter solid alignment rod, with and without venting; an eight-millimeter fluted alignment rod, with venting; and an eight-millimeter fluted or solid alignment rod, inserted through a 12.7-millimeter drill-hole, but without other venting. A statistically significant reduction in oxygen saturation, arterial oxygen tension (PaO2), and end-tidal carbon-dioxide tension (PETCO2) occurred after insertion of both solid and fluted eight-millimeter alignment rods through an eight-millimeter hold in both vented and unvented femoral canals, in association with a significant increase (p less than 0.01) in intramedullary pressure. Bone-marrow contents and fat were retrieved from samples of blood from the right atrium, indicating that embolization of marrow contents had occurred during insertion of the alignment rod. A small decrease in systemic blood pressure and heart rate also occurred. These changes were completely eliminated by the use of a 12.7-millimeter drill-hole as the entry site of the eight-millimeter fluted rod. We concluded that insertion of an intramedullary alignment rod in the femur causes embolization of marrow contents, which decreases arterial oxygen tension, oxygen saturation, end-tidal carbon-dioxide tension, arterial blood pressure, and heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Total knee arthroplasty for post-traumatic arthrosis

The outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 31 knees. The average age at arthroplasty was 60 years old (range, 36-78 years). The interval from fracture to total knee arthroplasty averaged 13 years. Simultaneous corrective osteotomy was necessary in 4 patients to correct axial alignment and preserve ligamentous integrity. Follow-up averaged 46 months. Mean arc of motion increased significantly, from 94 degrees to 100 degrees (P = .027). Average function score improved from 44 to 72 points. This change was statistically significant (P<.0001). Knee Society knee scores also improved significantly, from 36 to 78 points (P<.0001). At most recent follow-up, the functional scores were considered excellent or good in 58%; knee scores were considered excellent or good in 71% of cases. All periarticular osteotomies and tibial tubercle osteotomies healed uneventfully within 16 weeks. Complications occurred in 57% of cases, including aseptic failure (26%), septic failure (10%), patellar tendon rupture (3%), patellar subluxation (6%), thromboembolism (6%), and wound breakdown requiring debridement and muscle flap coverage (6%). Despite significant improvements in motion and function, patients with post-traumatic arthrosis are susceptible to high rates of complications. Adverse outcomes can be minimized by restoring limb alignment, soft tissue balance, and component alignment and by preserving vascularity of the skin and subcutaneous tissues.

Obturator-nerve palsy resulting from intrapelvic extrusion of cement during total hip replacement. Report of four cases.

Obturator neuropathy is an infrequently identified complication of total hip replacement that may cause debilitating pain. There have been isolated reports of this complication in the literature, but only one case has been published in which intrapelvic cement was the causative agent. We are describing the cases of four patients with obturator neuropathy after total hip replacement, documented by electromyography and attributed to intrapelvic extension of cement. In each patient the source of the symptoms was not initially apparent. In three of the patients the extruded cement and obturator nerve were explored surgically. One of the three patients was improved by obturator neurectomy. Of the other two patients, both treated by excision of cement, only one was improved. The fourth patient was not treated. Persistent pain in the groin and thigh, intrapelvic cement visible on plain roentgenograms, and adductor weakness after total hip replacement suggest that this complication has occurred. Electromyography can confirm the presence of obturator neuropathy. Based on this limited series, excision of the extruded cement and preservation of the nerve should be attempted only when the nerve is grossly normal and functional as determined by electrical stimulation at the time of surgical exploration; otherwise, obturator neurectomy should be considered.

Comparison of magnetic resonance imaging with operative findings in acute traumatic dislocations of the adult knee.

OBJECTIVES To compare magnetic resonance imaging (MRI) with examination under anesthesia and with surgical findings in evaluating soft tissue injuries in acute traumatic knee dislocations in adults. DESIGN Retrospective analysis. SETTING Level I trauma center. PATIENTS For a single surgeon, all patients who underwent MRI before surgical treatment for knee dislocations (ten individuals). INTERVENTION Incompetent ligaments were repaired or reconstructed. MAIN OUTCOME MEASUREMENTS MRI of knee dislocations was compared with clinical examination under anesthesia and with intraoperative findings at arthrotomy in ten cases. Pertinent positive and negative findings were recorded, and accuracy, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS Two mid-grade sprains of the anterior cruciate ligament were erroneously read as complete tears. One rupture or avulsion of each the biceps tendon, the lateral collateral ligament, and the posterolateral and posteromedial corners were considered intact on MRI. The MRI studies erroneously identified tears of the lateral collateral ligament and medial meniscus in one case each. Otherwise, the study was highly accurate. CONCLUSIONS MRI is useful for defining the presence of ligamentous injuries in knee dislocations; however, clinical examination under anesthesia is more accurate.

The management of femoral diaphyseal nonunions

OBJECTIVE To assess the efficacy of treatment and develop an algorithm for management of nonunions of the femoral diaphysis. STUDY DESIGN Retrospective. SETTING University hospital. METHODS Forty-four patients treated at one institution for nonunion of the femoral diaphysis were studied. Thirteen of these patients had a history of infection. After debridement (where appropriate) and repair of the femoral nonunion, follow-up averaged twenty-eight months (range, 24 to 108 months). All patients were examined at final follow-up. RESULTS Thirty-three patients achieved union after one procedure, and eight patients achieved union after additional procedures. One patient underwent above-knee amputation, and two patients remained ununited at the time of their final follow-up. Time to union averaged 11.8 months. Seventeen patients healed with more than two centimeters of shortening, and ten patients lost more than 30 degrees of knee flexion. CONCLUSION Established femoral diaphyseal nonunions can be treated effectively, even in the presence of chronic sepsis. Selective use of a vascularized fibula transfer has proven beneficial in addressing intercalary defects. Plate fixation, with or without a vascularized fibula transfer, has been the predominant mode of skeletal stabilization in more complex reconstructions.