Fast track surgery for knee replacement surgery: a lean six sigma approach

PurposeThe reduction of costs has a more and more relevant role in the healthcare context, therefore, a large effort is done by health providers to this aim, for example, by reducing the length of hospital stay (LOS) of patients undergoing surgery. Fast track surgery fits perfectly this issue and was applied to patients undergoing knee replacement surgery due to Osteoarthritis, one of the most common diseases of aged population. The paper aims to discuss these issues.Design/methodology/approachLean six sigma was applied to analyze the implementation of fast track surgery through the define, measure, analyze, improve, control roadmap, used as a typical problem-solving approach. It is characterized by five operational phases, which make possible the achievement of fixed goals through a rigorous process of defining, measuring, analyzing, improving and controlling business problems.FindingsThe corrective action, consisting in the application of fast track surgery, improved both effectiveness and efficiency of the process of care. The average length of hospital stay (LOS) was reduced from 8.34 to 6.68 days (–19.9 percent) and its standard deviation from 2.41 to 1.99 days (–17.1 percent). The statistical significance of this decrease was verified by means of proper tests. Moreover, some variables influencing the LOS were identified.Research limitations/implicationsThe follow up and the satisfaction of patients were not analyzed and could be a future development of this study.Practical implicationsPatients will experience a faster recovery while the hospital will benefit from a rise of available beds. The effect is a general improvement of hospital management.Originality/valueThe introduction of fast track surgery for patients undergoing knee replacement surgery made significantly reduce LOS and, consequently, costs' with a money saving of more than 50,000 euro per year

Achilles tendon pathologies: How to choose the best treatment

The Achilles tendon is the thickest and strongest tendon of the human body and it gets frequently injured during sports activity. The incidence of Achilles tendon pathologies has increased over the last decades, especially in the last few years, as a result of the increased sports participation among general population and for the diffusion of competitive sports at a high level. Although the increased interest and number of studies about Achilles tendon pathologies, at the moment there is not a consensual point of view on which is the best treatment for Achilles tendon injuries, and its management is still controversial. Treatment options mainly include conservative treatment and surgical repair. The decision for treatment in patients with an Achilles tendon pathology should be tailored on patient’s needs and level of activity, since patients with high activity levels may accept the risk of a higher complication rate to rapidly return to previous activity, while less active patients or those who cannot undergo surgery due to comorbidities may choose the non-operative option to decrease the risk of infection and other complications. The aim of this article is to give an insight about the most used and recent treatment options for Achilles tendon pathologies

Achilles tendon pathologies: How to choose the best treatment

The Achilles tendon is the thickest and strongest tendon of the human body and it gets frequently injured during sports activity. The incidence of Achilles tendon pathologies has increased over the last decades, especially in the last few years, as a result of the increased sports participation among general population and for the diffusion of competitive sports at a high level. Although the increased interest and number of studies about Achilles tendon pathologies, at the moment there is not a consensual point of view on which is the best treatment for Achilles tendon injuries, and its management is still controversial. Treatment options mainly include conservative treatment and surgical repair. The decision for treatment in patients with an Achilles tendon pathology should be tailored on patient’s needs and level of activity, since patients with high activity levels may accept the risk of a higher complication rate to rapidly return to previous activity, while less active patients or those who cannot undergo surgery due to comorbidities may choose the non-operative option to decrease the risk of infection and other complications. The aim of this article is to give an insight about the most used and recent treatment options for Achilles tendon pathologies

Lean Six Sigma: A new approach to the management of patients undergoing prosthetic hip replacement surgery

Rationale, aims and objectives In 2012, health care spending in Italy reached €114.5 billion, accounting for 7.2% of the Gross Domestic Product (GDP) and 14.2% of total public spending. Therefore, reducing waste in health facilities could generate substantial cost savings. The objective of this study is to show that Lean Six Sigma represents an appropriate methodology for the development of a clinical pathway which allows to improve quality and to reduce costs in prosthetic hip replacement surgery. Methods The methodology used for the development of a new clinical pathway was Lean Six Sigma. Problem solving in Lean Six Sigma is the DMAIC (Define, Measure, Analyse, Improve, Control) roadmap, characterized by five operational phases which make possible to reach fixed goals through a rigorous process of defining, measuring, analysing, improving and controlling business problems. Results The following project indicated several variables influencing the inappropriate prolongation of the length of stay for inpatient treatment and corrective actions were performed to improve the effectiveness and efficiency of the process of care. The average length of stay was reduced from 18.9 to 10.6 days (-44%). Conclusion This article shows there is no trade-off between quality and costs: Lean Six Sigma improves quality and, at the same time, reduces costs

Sonication of antibiotic-loaded cement spacers in a two-stage revision protocol for infected joint arthroplasty

Background. Culturing of the sonication fluid of removed implants has proven to be more sensitive than conventional periprosthetic tissue culture for the microbiological diagnosis of prosthetic joint infection. Since bacteria surviving on antibiotic-loaded cement spacers used in a two-stage exchange protocol for infected arthroplasties may cause the persistence of infection, in this study we asked whether the sonication also could be used to identify bacteria on antibiotic-loaded cement spacers removed at the second surgical stage during a two-stage exchange procedure to confirm whether or not the prosthetic joint infection had been eradicated. Methods. We cultured the sonication fluid of cement spacers that had been originally implanted in a two-stage exchange protocol in 21 patients (mean age, 66 years) affected by prosthetic joint infection (16 total knee prostheses and 5 hip prostheses). The cement spacers were vortexed for 30 seconds and then subjected to sonication (frequency 35–40 KHz). The resulting sonicate fluid was cultured for aerobic and anaerobic bacteria. Results. The sonication fluid culture of the removed spacer was positive in six patients (29%), with isolation of methicillin-sensible Staphylococcus Aureus (MSSA) in three cases, methicillin-resistant Staphylococcus Aureus (MRSA) in one case and Pseudomonas Aeruginosa in two cases. In three of these positive cases, the traditional culture of periprosthetic tissue was negative. Two patients with positive sonication culture of the spacer were successfully treated by early debridement of the revision prosthesis and systemic antibiotic therapy. In three patients a knee arthrodesis was planned and performed as the second surgical stage. In two of them the infection was caused by highly resistant Pseudomonas Aeruginosa. The other patient with a MSSA infection had been poorly compliant with the systemic antibiotic therapy due to her mental impairment. The patient originally affected by MRSA infection of his primary hip arthroplasty developed recurrent infection of his revision prosthesis and eventually underwent Girdlestone arthroplasty. Conclusions. The sonication culture can be used to discover any bacteria on the antibiotic-loaded cement spacer during a two-stage exchange protocol, thus permitting the adoption of timely treatment options, such as the early prosthetic debridment

Effectiveness of endoscopic trans-tendineous repair for partial-thickness tears of medius gluteus: A systematic review of literature

Tears of the gluteus medius can result in chronic hip pain over time. Pathological onsets involving the gluteus medius cause pain and weakness of abductor strength. Endoscopic repair is a suitable, effective and safe surgical alternative to traditional open techniques and give satisfactory results over time restoring the footprint of gluteus medius. The purpose of this systematic review is to analyse the effectiveness of endoscopic trans-tendinous technique for partial-thickness tears, analysing the subjective and functional outcome over the time. A search of literature (PubMed, Scopus, WebOfKnowledge) was performed. The PRISMA method was used to screen the articles. A total of 4 articles was screened and included for qualitative analysis. For data extraction patient characteristics, pre-clinical examination, imaging, timing from symptoms to surgery, technique performed, subjective scales, functional outcomes, post-operative clinical assessment were analysed. Subjective scores at mean follow-up of 18 months show a significative improvement in all the scales reported, in relief of pain (VAS score) and in terms of strength of abductor. Trans-tendinous technique represents the gold standard to treat endoscopically these injuries. Furthermore, other studies with larger number of patients and longer follow-up are required to validate the best surgical approach for these injuries

Cell Toxicity Study of Antiseptic Solutions Containing Povidone-Iodine and Hydrogen Peroxide

The increasing incidence of periprosthetic joint infections (PJIs) has led to a growing interest in developing strategies to prevent and treat this severe complication. The surgical site's application of antiseptic solutions to eliminate contaminating bacteria and eradicate the bacterial biofilm has been increasing over time. Even though it has been proven that combining antimicrobials could enhance their activities and help overcome acquired microbial resistance related to the topical use of antibiotics, the toxicity of integrated solutions is not well described. This study aimed to evaluate the cytotoxicity of solutions containing povidone-iodine (PI) and hydrogen peroxide (H2O2), alone or in combination, after 1.3 and 5 min of exposure. Chondrocytes, tenocytes, and fibroblast-like synoviocytes were used for cytotoxicity analysis. Trypan blue stain (0.4% in PBS) was applied to evaluate the dead cells. All solutions tested showed a progressive increase in toxicity as exposure time increased except for PI at 0.3%, which exhibited the lowest toxicity. The combined solutions reported a reduced cellular killing at 3 and 5 min than H2O2 at equal concentrations, similar results to PI solutions

Nutrition: a key environmental dietary factor in clinical severity and cardio-metabolic risk in psoriatic male patients evaluated by 7-day food-frequency questionnaire

Western dietary pattern is included among the environmental dietary factors involved in the pathogenesis of psoriasis. Nutritional data collection methods and gender differences might affect the association between diet and psoriasis. The 7-day food records is considered the "gold standard" of self-administered food frequency questionnaires. In this study, we evaluated the differences in the dietary intake, anthropometric measurements and cardio-metabolic risk profile in a group of psoriatic patients compared with an age and Body Mass Index (BMI)-matched control group. In addition, in the group of psoriatic patients we investigated the association between the dietary intake and clinical severity of psoriasis

CLINICAL RESULTS OF COLLAGENASE TREATMENT FOR DUPUYTREN’S DISEASE: A CASE SERIES STUDY WITH 2-YEARS FOLLOW-UP

ABSTRACT Objectives: This study aims to report our experience with Clostridium Histolyticum collagenase (CCH) to support the importance of its clinical use and assess its clinical efficacy, complications, and recurrences. Methods: This prospective observational study of 66 patients with a 2-year follow-up. Patients with an extension lag major of 20° at the metacarpophalangeal joint (MPJ) and/or proximal interphalangeal joint (PIPJ) were included. We collected data on demographic and anamnestic details, MPJ and PIPJ contracture degrees, DASH score, complications, and recurrences. Results: The mean pre-injection contracture was 34° for MPJ and 31° for PIPJ. At the 2-year follow-up, the mean contracture for the MPJ and PIPJ were respectively 3° and 14.5°. The mean DASH score decreased from 21.8 before injection to 10,4 after 2 years. The disease recurrence occurred in 34.8% of the patients, all with PIPJ contracture. The main complication was skin breakage (25.7%). Conclusion: The CCH injections remain a consistent option in treating DD; withdrawal from the European market deprives surgeons and patients of low invasiveness and safe tool for treating DD. Level of evidence IV, Therapeutic study investigating treatment results, Case series

Clinical usefulness of automated cellular analysis of synovial fluids: a paradigmatic case report for diagnosing peri-prosthetic infections

We describe here the case of an 18 years old male patient who underwent osteosynthesis surgery with a plate and screws for multi-fragment fracture of his right femur, in December 2000. The patient developed a series of complications up to May 2017, when he was readmitted with severe functional impairment and inability to walk without crutches. Physical examination revealed erythema, swelling at surgical site and leakage of pus from sinus-tract. An arthrocentesis was hence performed, followed by white blood cell count and differential in synovial fluid with Sysmex XN 2000 body fluid mode. The final leukocyte count was 38 7109/L, with 95% polymorphonuclear leukocytes (PMN), thus compatible with peri-prosthetic infection. The patient underwent additional surgery to remove the knee replacement, accurate debridement and antibiotic impregnated static cement spacer implantation. Three months after surgery, the patient was readmitted for removing the spacer, replaced by a new static device. In May 2018, surgical debridement and removal of the spacer was scheduled with resection arthroplasty. In November 2018 the patient presented again a sinus tract, and underwent another arthrocentesis for physical and microbiological examination of synovial fluid. The leukocyte count in the synovial fluid was again performed with Sysmex XN 2000 body fluid mode, and revealed the presence of 44.5 7109/L cells, with 90% PMN. The synovial fluid was positive for Van-A Enterococcus faecalis, so that right hip disarticulation was urgently planned. In conclusions, this case provides clear evidence that automated leukocyte count and differential in synovial fluid shall now be considered an unavoidable part of the diagnostic approach to patients with suspected peri-prosthetic infections