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The Comparison of Fixation Devices and Provider Technique, Resulting in Post-Surgical Hardware Removal, Following ACL-Hamstring Reconstruction; A 5-Year Retrospective Chart Review Study

1 August 2004


Context: Multiple high-volume specialty clinics exist across the nation, many of which are orthopedic specialty groups. Often times, the shear volume of surgical cases make the monitoring of post-surgical outcomes difficult to accomplish. However, without such data, it is difficult to evaluate and apply evidence-based medicine in these settings. By monitoring surgical outcomes data, for specific procedures and providers, these groups might better evaluate their actual outcomes. The usefulness of an internal quality assessment analysis becomes important when considering the variability between clinics and their respective populations. There is substantial literature about graft type, surgical procedure, graft incorporation and efficacy of ACL reconstruction but little about specific fixation devices. However, there are varying techniques and types of fixation hardware used among providers and surgical groups. Therefore, cross-application of study results is difficult. Currently, no official analysis ofretum to operating room (RTOR) cases, following Anterior Cruciate Ligament (ACL) hamstring reconstruction, secondary to hardware complications, has been performed by Rebound Sports Medicine. Rebound Sports Medicine Surgeons and Associates have a vested interest in knowing their actual time spent in the OR for such complications. ACL reconstruction is the standard, nonconservative treatment for ACL rupture. Multiple types of hardware, and techniques using them, exist for Tibial fixation of Hamstring grafts.

Objective: To determine if there are significant differences in the rates ofRTOR for a particular type of hardware and/or technique, among all ACL reconstruction cases during the specified 5 year period. Secondly, identify possible associations of increased removal for provider and or technique. Thirdly, estimate the financial implications for the group and patients based in RTOR time and billing amount. The intent of this quality assessment, pilot study, will ultimately be to provide evidence supporting the benefit of future prospective cohort studies evaluating surgical outcomes for various procedures.

Design: This study was a 5-year retrograde chart review study looking at all ACL reconstructions using hamstring grafts and subsequent hardware removal (HWR) cases. Study population, hardware type (HWT) and technique was identified using an Electronic Medical Records system (EMR.)

Setting: This study was conducted at Southwest Washington Medical Center and specifically assessed the Rebound Sports Medicine group.

Subjects: All ACLHamstring reconstruction cases, performed by Rebound Sports Medicine, between 1998 and 2002.

Results: A strong association between specific hardware types/techniques and subsequent HWR was identified. Certain providers were also associated with higher rates of removal. Overall removal rates (16.2 %, 1 HWRl6.l8 cases) for the group, were higher than rates identified in previous literature. Infection and cysts were also associated with primarily one technique and type of fixation device (screw and post, Mitek screws.)

Conclusions: This pilot study identified strong associations between particular HWT and providers with HWR rates. Although associations were apparent from this pilot-study, it did not have the ability to assign probability, increased risk or actual statistical analysis. This study does support the need for a controlled prospective or case-matched study. Regardless of study design, an overwhelming association of increased cost to patients and lost time in RTOR was found with specific hardware types.


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