Empirical study of an team-based incentive model in the Day Surgical Department at Huddinge University Hospital

The study shows that a team-based incentive model changed personnel attitude and behaviour and increased the productivity in the Day Surgical Department at Huddinge University Hospital. The aims by introducing a team-based incentive model were to increase the productivity, to recruit personnel, to strengthen the team feeling and to commit the staff to work on continuous improvement. A bonus wage system based on production, financial and patient satisfaction in a balanced scorecard was implemented in October 2000. The results shown in the study cover the first year. Quantitative data on production, personnel administration and financial was collected. A questionnaire on patient satisfaction was given to patients. Qualitative data was collected by focused interviews with all personnel in the department and with key persons outside the department. The productivity measured as the surgical procedures/surgical-room hours increased by 7 per cent and the surgical hours/surgical-room hours also increased by 7 per cent. Net income was positive. Financial measured as total costs/surgical hour decreased despite of increased salaries and bonus. The patient satisfaction index was rated high. More employees were recruited than finished their employment. The qualitative analysis demonstrates that the employees had changed attitude with increased responsibility and teamwork resulting in an increased productivity. The reward system achieved a broad acceptance within as well as outside the department. Knowledge about the financial goals and the incentive model and information about related matters are fields for improvement. The results of increased productivity and the net recruitment of personnel in the study is encouraging. However, the results have to be evaluated over a longer period of time. The future development of the model may include rewards when achieving goals in the work on continuous improvement.Health care; management control; compensation systems; incentive; incentive model; productivity

Aspects of aetiology, pathoanatomy and diagnostic methods in chronic mid-portion achillodynia

The objectives of this thesis are to study aetiology and pathoanatomy, and toevaluate diagnostic methods in patients with long-standing pain and tenderness localisedto the mid portion of the Achilles tendon. Treatment had failed to relieve symptomsprior to referral to our clinic, where some of these patients underwent surgicaltreatment. Fifty eight patients, derived from 60 consecutive operations, were analysed regardinghistory, clinical assessment, ultrasound, histopathology and outcome of surgery.One third of the patients were not used to any form of vigorous physical activity.Ultrasonographic pathology was observed in 54 out of 59 examinations. Macroscopicallydiseased tendon tissue showed marked histopathological changes. At the follow-upto surgery, after in median 25 months (range 12-50), there was an overall satisfactoryresult in 75% of the patients. Topical applications of ketoprofen, a hydrophilic non-steroidal anti-inflammatorydrug, in patients in surgery for chronic tendon disorders revealed high concentrationsof ketoprofen in fat, paratenon and tendon, while plasma levels were found to below. The results indicated a direct penetration and that tissues act as a reservoirfor ketoprofen. No attempt was made to study clinical effects. Tendon biopsies from 40 surgically treated patients revealed abnormal fibre structureand arrangement, focal variations in cellularity, rounded nuclei, decreased collagenstainability and increased non-collagenous matrix. Increased vascularity was seenin 26 out of the 40 subjects. Inflammatory cell infiltration was not found. A semi-quantitativegrading, using a total tendon score, had a median of 21 (6-24) compared to 0 (0-13)in control biopsies (p<0.001). The volume-density estimation of glycosaminoglycan-richareas had a median of 0.47 (0-0.86) in patients and 0 (0-0.07) in controls (p<0.001). A percutaneous core biopsy technique, guided by ultrasound and performed underlocal anaesthesia, turned out to be a reliable and valid tool, which can be usedin clinical and experimental in vivo studies of Achilles tendon disorders. Gadolinium contrast enhancement improved the imaging of intra-tendinous signalabnormality on Tl-weighted magnetic resonance images. The increased amount of extracellular glycosaminoglycans, highly fixed negativly charged macromolecules with waterretaining capacity, may contribute to explain this finding. Intra-tendinous alterations were imaged with contrast medium enhanced magneticresonance and with ultrasound in 20 patients with achillodynia. Core biopsies wereobtained from ultrasound hypoechoic and normoechoic regions. The increased signalabnormality in gadolinium contrast enhanced Tl-weighted images revealed a largervolume of the lesion compared with ultrasound. Hypoechoic areas showed a markedlyabnormal tendon structure. However, moderate pathology was found also in the neighbouringnormoechogenous areas within the same tendon, indicating a more generalised disorderthan imaged by echogenic properties. In conclusion, the data and the new tools presented in this thesis encourage furtherstudies including treatment on the Achilles and other tendon disorders. Key words: Achilles tendon, achillodynia, pathology, MR-imaging, ultrasonography,gadolinium, contrast enhancement, glycosaminoglycan, aetiology, core biopsy. ISBN 91-628-2817-

Dynamic contrast enhanced magnetic resonance imaging in chronic Achilles tendinosis

Background: Chronic Achilles tendinosis is a common problem. When evaluating and comparing different therapies there is a need for reliable imaging methods. Our aim was to evaluate if chronic Achilles tendinosis affects the dynamic contrast-enhancement in the tendon and its surroundings and if short-term eccentric calf-muscle training normalizes the dynamic contrast-enhancement. Methods: 20 patients with chronic Achilles tendinopathy were included. Median duration of symptoms was 31 months (range 6 to 120 months). Both Achilles tendons were examined with dynamic contrast enhanced MRI before and after a 12-week exercise programme of eccentric calf-muscle training. The dynamic MRI was evaluated in tendon, vessel and in fat ventrally of tendon. Area under the curve (AUC), time to peak of signal, signal increase per second (SI/s) and increase in signal between start and peak as a percentage (SI%) was calculated. Pain and performance were evaluated using a questionnaire. Results: In the fat ventrally of the tendon, dynamic contrast enhancement was significantly higher in the symptomatic leg compared to the contralateral non-symptomatic leg before but not after treatment. Despite decreased pain and improved performance there was no significant change of dynamic contrast enhancement in symptomatic tendons after treatment. Conclusion: In Achilles tendinosis there is an increased contrast enhancement in the fat ventrally of the tendon. The lack of correlation with symptoms and the lack of significant changes in tendon contrast enhancement parameters do however indicate that dynamic enhanced MRI is currently not a useful method to evaluate chronic Achilles tendinosis

Histological and ultrastructural degenerative findings in the gluteus medius tendon after hip arthroplasty

Background - Despite gluteus medius (GMED) tendinosis being relatively common, its presence in association with hip osteoarthritis (OA) or total hip arthroplasty (THA) is not well studied. It was hypothesized that more tendon degeneration would be found in patients with OA of the hip and in those that had undergone THA than that in a control group. Methods - One hundred patients were included between 2016 and 2019 and were included into 4 groups; the patients were undergoing revision surgery in two groups and primary THA in the other two groups; 22 patients had previously undergone primary THA through a direct lateral approach (involving sectioning of the GMED tendon), 24 patients had previously undergone primary THA through a posterior approach (leaving the GMED tendon intact), 29 patients had primary hip OA, and 25 patients who suffered a femoral neck fracture served as controls. Biopsies from the GMED tendon were obtained at the time of the primary THA or the hip revision surgery. The tendon biopsies were examined ultrastructurally and histologically. Results - Ultrastructurally, the direct lateral and posterior revision groups had statistically significantly more collagen fibrils with smaller diameters compared with the fracture and primary THA groups. Moreover, the direct lateral revision group had more collagen fibrils with smaller diameters compared with the posterior revision group. Histologically, the direct lateral revision group had a higher total degeneration score (TDS) compared with the primary hip OA group. Conclusions - The GMED tendon shows more ultrastructural degeneration in patients who undergo hip revision arthroplasty than in patients with primary OA of the hip and control patients, who had suffered a femoral neck fracture. Furthermore, patients who had previously undergone primary THA through a direct lateral approach revealed more histological GMED tendon degeneration than patients who suffer primary hip OA

Periprosthetic joint infection after total hip arthroplasty induces histological degeneration of the gluteus medius tendon

Aims: A revision for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) has a major effect on the patient’s quality of life, including walking capacity. The objective of this case control study was to investigate the histological and ultrastructural changes to the gluteus medius tendon (GMED) in patients revised due to a PJI, and to compare it with revision THAs without infection performed using the same lateral approach. Methods: A group of eight patients revised due to a PJI with a previous lateral approach was compared with a group of 21 revised THAs without infection, performed using the same approach. The primary variables of the study were the fibril diameter, as seen in transmission electron microscopy (TEM), and the total degeneration score (TDS), as seen under the light microscope. An analysis of bacteriology, classification of infection, and antibiotic treatment was also performed. Results: Biopsy samples from the GMED from infected patients revealed a larger fibril diameter than control patients, as seen in the TEM (p < 0.001). Uninfected patients were slightly older and had their revisions performed significantly later than the infected patients. Histologically, samples from infected patients revealed significantly more vascularity (p < 0.001), the presence of glycosaminoglycans (p < 0.001), and a higher TDS (p = 0.003) than the control patients. The majority of patients had staphylococcal infections of various species. Conclusion: More histological degeneration in the GMED was found in patients undergoing THA revision surgery due to PJI than in patients undergoing THA revision surgery due to other reasons. Cite this article: Bone Jt Open 2023;4(8):628–635

More histologic and ultrastructural degenerative signs in the subscapularis tendon and the joint capsule in male patients with shoulder impingement

Purpose: The purpose of the present study was to analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with shoulder impingement syndrome (SAIS) and compare them with samples from male patients with post-traumatic recurrent shoulder instability. The hypothesis of the study was that patients with SAIS would have more histologic and ultrastructural degenerative changes in their subscapularis tendon and joint capsule than patients with post-traumatic recurrent shoulder instability. Methods: Male patients scheduled for surgery, with either subacromial decompression or Bankart reconstruction, were included. Four biopsies from each patient were obtained from the capsule and four from the subscapularis tendon during arthroscopic surgery. The histologic characteristics and the presence of glycosaminoglycans were assessed using the light microscope, and the ultrastructure was assessed using a transmission electron microscope. Results: Eight patients, median age 53 (45–74) years (p  Conclusion: Male patients with subacromial impingement have more histologic and ultrastructural degenerative changes in their shoulder compared with patients with post-traumatic recurrent shoulder instability. Clinical relevance: It appears that in patients with subacromial impingement, the whole shoulder joint is affected and not only the subacromial space. It is the opinion of the authors that intra-articular therapeutic injections could be tried more often in these patients. Level of evidence: III

The temporal responses of protein synthesis, gene expression and cell signalling in human quadriceps muscle and patellar tendon to disuse

We hypothesized that rates of myofibrillar and patellar tendon collagen synthesis would fall over time during disuse, the changes being accompanied in muscle by decreases in focal adhesion kinase (FAK) phosphorylation and in gene expression for proteolytic enzymes. We studied nine men (22 ± 4 years, BMI 24 ± 3 kg m−2 (means ± s.d.) who underwent unilateral lower leg suspension for 23 days; five were studied between 0 and 10 days and four between 10 and 21 days. Muscle and tendon biopsies were taken in the postabsorptive state at days 0, 10 and 21 for measurement of protein synthesis, gene expression and protein phosphorylation. Muscle cross-sectional area decreased by 5.2% at 14 days and 10.0% (both P < 0.001), at 23 days, i.e. 0.5% day−1, whereas tendon dimensions were constant. Rates of myofibrillar protein synthesis fell (P < 0.01) from 0.047% h−1 at day 0 to 0.022% h−1 at 10 days without further changes. Tendon collagen synthetic rates also fell (P < 0.01), from 0.052 to 0.023% h−1 at 10 days and then to 0.010% h−1 at 21 days. FAK phosphorylation decreased 30% (P < 0.01) at 10 days. No changes occurred in the amounts/phosphorylation of PKB–P70s6k–mTOR pathway components. Expression of mRNA for MuRF-1 increased ∼3-fold at 10 days without changes in MAFbx or tripeptidyl peptidase II mRNA, but all decreased between 10 and 21 days. Thus, both myofibrillar and tendon protein synthetic rates show progressive decreases during 21 days of disuse; in muscle, this is accompanied by decreased phosphorylation of FAK, with no marked increases in genes for proteolytic enzymes

Altered patterns of displacement within the Achilles tendon following surgical repair

Ultrasound speckle tracking was used to compare tendon deformation patterns between uninjured and surgically repaired Achilles tendons at 14-27-month follow-up. The hypothesis was that the non-homogenous displacement pattern previously described in uninjured tendons, where displacement within deep layers of the tendons exceeds that of superficial layers, is altered following tendon rupture and subsequent surgical repair. In the first part of this study, an in-house-developed block-matching speckle tracking algorithm was evaluated for assessment of displacement on porcine flexor digitorum tendons. Displacement data from speckle tracking were compared to displacement data from manual tracking. In the second part of the study, eleven patients with previous unilateral surgically treated Achilles tendon rupture were investigated using ultrasound speckle tracking. The difference in superficial and deep tendon displacement was assessed. Displacement patterns in the surgically repaired and uninjured tendons were compared during passive motion (Thompson's squeeze test) and during active ankle dorsiflexion. The difference in peak displacement between superficial and deep layers was significantly (p &lt; 0.01) larger in the uninjured tendons as compared to the surgically repaired tendons both during Thompson's test (-0.7 +/- 0.2 mm compared to -0.1 +/- 0.1 mm) and active dorsiflexion (3.3 +/- 1.1 mm compared to 0.3 +/- 0.2 mm). The evaluation of the speckle tracking algorithm showed correlations of r ae&lt;yen&gt; 0.89 between displacement data acquired from speckle tracking and the reference displacement acquired from manual tracking. Speckle tracking systematically underestimated the magnitude of displacement with coefficients of variation of less than 11.7%. Uninjured Achilles tendons display a non-uniform displacement pattern thought to reflect gliding between fascicles. This pattern was altered after a mean duration of 19 +/- 4 months following surgical repair of the tendon indicating that fascicle sliding is impaired. This may affect modulation of the action between different components of the triceps surae, which in turn may affect force transmission and tendon elasticity resulting in impaired function and risk of re-rupture