Adverse events in orthopedic care identified via the Global Trigger Tool in Sweden – implications on preventable prolonged hospitalizations

Background: The national incidence of adverse events (AEs) in Swedish orthopedic care has never been described. A new national database has made it possible to describe incidence, nature, preventability and consequences of AEs in Swedish orthopedic care. Methods: We used national data from a structured two-stage record review with a Swedish modification of the Global Trigger Tool. The sample was 4,994 randomly selected orthopedic admissions in 56 hospitals during 2013 and 2014. The AEs were classified according to the Swedish Patient Safety Act into preventable or non-preventable. Results: At least one AE occurred in 733 (15%, 95% CI 13.7-15.7) admissions. Of 950 identified AEs, 697 (73%) were judged preventable. More than half of the AEs (54%) were of temporary nature. The most common types of AE were healthcare-associated infections and distended urinary bladder. Patients ≥65years had more AEs (p<0.001), and were more often affected by pressure ulcer (p<0.001) and urinary tract infections (p<0.01). Distended urinary bladder was seen more frequently in patients aged 18-64 years (p=0.01). Length of stay was twice as long for patients with AEs (p<0.001). We estimate 232,000 extra hospital days due to AEs during these 2years. The pattern of AEs in orthopedic care was different compared to other hospital specialties. Conclusions: Using a national database, we found AEs in 15% of orthopedic admissions. The majority of the AEs was of temporary nature and judged preventable. Our results can be used to guide focused patient safety work

Timing of preoperative antibiotics for knee arthroplasties: Improving the routines in Sweden

<p>Abstract</p> <p>Background</p> <p>A slight increase in revisions for infected joint arthroplasties has been observed in the Nordic countries since 2000 for which the reasons are unclear. However, in 2007 a Swedish study of the timing for prophylactic antibiotics in a random sample of knee arthroplasties found that only 57% of the patients had received the antibiotic during the optimal time interval 45-15 minutes before surgery. The purpose of the report was to evaluate the effect of measures taken to improve the timing of prophylactic antibiotics.</p> <p>Findings</p> <p>Reporting this finding to surgeons at national meetings during 2008 the Swedish Knee Arthroplasty Register (SKAR) introduced a new report form from January 2009 including the time for administration of preoperative antibiotics. Furthermore, the WHO's surgical checklist was introduced during 2009 and a national project was started to reduce infections in arthroplasty surgery (PRISS). The effect of these measures was found to be positive showing that in 2009, 69% of the 12,707 primary knee arthroplasties were reported to have received the prophylaxis within the 45-15 min time interval and 79% of the first 7,000 knee arthroplasties in 2010. A survey concerning the use of the WHO checklist at Swedish hospitals showed that 73 of 75 clinics had introduced a surgical checklist.</p> <p>Conclusions</p> <p>By registration and bringing back information to surgeons on the state of infection prophylaxis in combination with the introduction of the WHO checklist and the preventive work done by the PRISS project, the timing of preoperative prophylactic antibiotics in knee arthroplasty surgery was clearly improved.</p

Should tumor depth be included in prognostication of soft tissue sarcoma?

BACKGROUND: Most staging systems for soft tissue sarcoma are based on histologic malignancy-grade, tumor size and tumor depth. These factors are generally dichotomized, size at 5 cm. We believe it is unlikely that tumor depth per se should influence a tumor's metastatic capability. Therefore we hypothesized that the unfavourable prognostic importance of depth could be explained by the close association between size and depth, deep-seated tumors on average being larger than the superficial ones. When tumor size is dichotomized, this effect should be most pronounced in the large size (>5 cm) group in which the size span is larger. METHODS: We analyzed the associations between tumor size and depth and the prognostic importance of grade, size and depth in a population-based series of 490 adult patients with soft tissue sarcoma of the extremity or trunk wall with complete, 4.5 years minimum, follow-up. RESULTS: Multivariate analysis showed no major prognostic effect of tumor depth when grade and size were taken into account. The mean size of small tumors was the same whether superficial or deep but the mean size of large and deep-seated tumors were one third larger than that of large but superficial tumors. Tumor depth influenced the prognosis in the subset of high-grade and large tumors. In this subset deep-seated tumors had poorer survival rate than superficial tumors, which could be explained by the larger mean size of the deep-seated tumors. CONCLUSION: Most of the prognostic value of tumor depth in soft tissue sarcomas of the extremity or trunk wall can be explained by the association between tumor size and depth

Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better

Background and purpose There are rising concerns about the frequency of infection after arthroplasty surgery. Prophylactic antibiotics are an important part of the preventive measures. As their effect is related to the timing of administration, it is important to follow how the routines with preoperative prophylactic antibiotics are working

Cytologic features of primary, recurrent, and metastatic dermatofibrosarcoma protuberans

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a low-grade spindle cell neoplasm involving both dermis and subcutis. Its diagnosis may be difficult to render from cytologic smears, as it shares some features with other spindle cell lesions occurring in the skin and soft tissue.METHODS: Fourteen aspiration smears from 12 patients with primary, recurrent, or metastatic DFSP, examined by fine-needle aspiration biopsy (FNAB), were reviewed and compared with corresponding surgical specimens (13 aspirates) and clinical data (one aspirate). The cytologic features of DFSP were evaluated. Other spindle cell lesions in the differential diagnoses were discussed.RESULTS: Unequivocal spindle cell sarcoma diagnoses were rendered in nine aspirates, six of which were labeled correctly as DFSP in the original reports. In three aspirates, the preoperative diagnoses were inconclusive with regard to whether the tumors were benign or malignant. Two aspirates were diagnosed erroneously as benign spindle cell lesions. Cytologic features included tight clusters of bland spindle cells embedded in a collagenous/fibrillar and, often, metachromatic matrix along with dissociated, uniform, or slightly atypical spindle cells or bare nuclei. Tissue fragments showing a storiform pattern and entrapped fat tissue, reported in previous series, were less characteristic, presenting in nine and seven aspirates, respectively.CONCLUSIONS: Correct subtyping of DFSP in fine-needle aspiration smears can be difficult, due to its morphologic overlapping with other spindle cell lesions. A combination of cytology with ancillary studies and appropriate clinical information is crucial to establishing a correct diagnosis

Surgery for metastatic lesions of the femur: Good outcome after 245 operations in 216 patients

We report our experience with surgery for femoral metastatic lesions, based on 216 patients who underwent a total of 245 operations for femoral metastatic lesions. The median age was 66 (30-94) years, and the most common diagnosis breast cancer, followed by prostate cancer. All patients had pain on weight bearing, 196 had pain at rest, 147 were unable to walk preoperatively, and 148 were confined to a health-care facility. The patients were operated with bipolar hip prosthesis (n=7), total hip replacement (THR) with Harrington reconstruction of the acetabulum (n=42), ordinary THR (n=108), intramedullary nailing (n=55), and other techniques (n=33). All patients improved as regards pain at rest, pain on weight bearing, walking ability and social independence. The median survival for the 216 patients was 6 (0-123) months. All in all, 47 operations were followed by complications of any kind, where dislocations of hip prostheses and implant breakdown were the commonest, but pulmonary embolism the most serious. Patients with femoral metastatic lesions can be operated safely and with acceptable complication rates. Furthermore, large and long-standing gains as regards pain control and mobility can be expected