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Pennestrì F, Lega F, Banfi G. From volume to value: Improving peri-operative elective pathways through a roadmap from fast-track orthopedic surgery. Health Serv Manage Res 2023; 36:284-290. [PMID: 36444939 PMCID: PMC10552341 DOI: 10.1177/09514848221127623] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Healthcare institutions face the pressure generated by modern medicine and society, in terms of increasing expectations and financial constraints. Chronic patients need multidisciplinary care pathways to preserve their wellbeing across the entire journey.The orthopaedic community has been particularly receptive in testing solutions to align good clinical outcomes and financial sustainability, given the increase in elective procedures provided among aging populations to alleviate pain and reduce disability. Fast-track (FT) total joint arthroplasty (TJA) and bundled payments (BPs) offer relevant examples both from the clinical and the financial perspective; however, they have not been evaluated in combination yet.The aim of this manuscript is to provide a road map to improve the value of high-volume, multidisciplinary elective procedures, with potential applications in a vast number of surgical specialties, (1) based on an integrated financial budget per episode of care (the BP), (2) building on lessons from a review of the literature on FT TJA.Although clinical outcomes vary from procedure to procedure, the coordination between the single treatments and providers involved across the patient journey; the commitment of patients and relatives; and the systematic adoption of patient-reported outcomes; can add further value for the benefit of patients, healthcare funders and providers, once essential clinical, financial and administrative conditions are guaranteed.
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Affiliation(s)
| | - Federico Lega
- Research Center on Health Administration, University of Milan, Italy
| | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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2
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Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
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Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
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Detecting total hip arthroplasty dislocations using deep learning: clinical and Internet validation. Emerg Radiol 2022; 29:801-808. [PMID: 35608786 DOI: 10.1007/s10140-022-02060-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Periprosthetic dislocations of total hip arthroplasty (THA) are time-sensitive injuries, as the longer diagnosis and treatment are delayed, the more difficult they are to reduce. Automated triage of radiographs with dislocations could help reduce these delays. We trained convolutional neural networks (CNNs) for the detection of THA dislocations, and evaluated their generalizability by evaluating them on external datasets. METHODS We used 357 THA radiographs from a single hospital (185 with dislocation [51.8%]) to develop and internally test a variety of CNNs to identify THA dislocation. We performed external testing of these CNNs on two datasets to evaluate generalizability. CNN performance was evaluated using area under the receiving operating characteristic curve (AUROC). Class activation mapping (CAM) was used to create heatmaps of test images for visualization of regions emphasized by the CNNs. RESULTS Multiple CNNs achieved AUCs of 1 for both internal and external test sets, indicating good generalizability. Heatmaps showed that CNNs consistently emphasized the THA for both dislocated and located THAs. CONCLUSION CNNs can be trained to recognize THA dislocation with high diagnostic performance, which supports their potential use for triage in the emergency department. Importantly, our CNNs generalized well to external data from two sources, further supporting their potential clinical utility.
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Keppler AM, Holzschuh J, Pfeufer D, Gleich J, Neuerburg C, Kammerlander C, Böcker W, Fürmetz J. Mobility improvement in the first 6 postoperative weeks in orthogeriatric fracture patients. Eur J Trauma Emerg Surg 2021; 48:2867-2872. [PMID: 34932124 PMCID: PMC9360084 DOI: 10.1007/s00068-021-01856-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/04/2021] [Indexed: 11/29/2022]
Abstract
Background Physical activity is a relevant outcome parameter in orthopedic surgery, that can be objectively assessed. Until now, there is little information regarding objective gait parameters in the orthogeriatric population. This study focuses on the first 6 weeks of postoperative rehabilitation, and delivers objective data about gait speed and step length in typical orthogeriatric fracture patterns. Methods Thirty-one orthogeriatric fracture patients [pertrochanteric femur fractures (PFF), femoral neck (FN), and proximal humerus fractures (PHF)] were consecutively enrolled in a maximum care hospital in a prospective study design. All patients wore an accelerometer placed at the waist during the postoperative stay (24 h/d) and at 6-week follow-up, to measure real gait speed and step length. In addition, self-assessment of mobility (Parker mobility score) and activities of daily living (Barthel index) were collected at baseline, during the inpatient stay, and at 6-week follow-up. Results During postoperative hospitalization, significantly higher gait speed (m/s) was observed in the PHF group (0.52 ± 0.27) compared with the FN group (0.36 ± 0.28) and PFF group (0.19 ± 0.28) (p < 0.05). Six weeks postoperatively, gait speed improved significantly in all groups (PHF 0.90 ± 0.41; FN 0.72 ± 0.13; PFF 0.60 ± 0.23). Similarly, step length (m) differed between groups postoperatively [FN 0.16 ± 0.13; PFF 0.12 ± 0.15; PHF 0.31 ± 0.05 (p < 0.005)] and improved over time significantly (FN 0.47 ± 0.01; 0.39 ± 0.19; 0.50 ± 0.18). Self-assessment scores indicate that the majority of the patients had minor restrictions in mobility before the fracture. These values decreased immediately postoperatively and improved in the first 6 weeks, but did not reach the initial level. Conclusions Gait speed, step length, and self-assessment in terms of mobility and activities of daily living improve significantly in the first 6 postoperative weeks in orthogeriatric fracture patients. As very low postoperative mobility during hospitalization was observed, this collective shows great potential in postoperative rehabilitation regardless of their fracture pattern. For this reason, specific aftercare concepts similar to the “fast track” concepts in primary arthroplasty are crucial for orthogeriatric patients in clinical practice. Level of evidence Prospective cohort study, 2.
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Affiliation(s)
- Alexander M Keppler
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Jenny Holzschuh
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Daniel Pfeufer
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Johannes Gleich
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Carl Neuerburg
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Christian Kammerlander
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,AUVA Trauma Hospital Styria, Graz, Austria
| | - Wolfgang Böcker
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Julian Fürmetz
- Department for Orthopaedics and Trauma Surgery, Muscuoskeletal University Center Munich (MUM), University Hospital LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,Department of Trauma Surgery, BG Trauma Center Murnau, Murnau, Germany
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Wang Z, Chen M, Luo X, Xiong X, Ma F. Effectiveness of optimised care chain for hip fractures in elderly Chinese. Int J Health Plann Manage 2021; 36:1445-1464. [PMID: 34519092 DOI: 10.1002/hpm.3261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Studies have found that optimised care chain (OCC) can promote the recovery of hip fracture patients. Fast track (FT) has been widely proven to play a good role, but there is no systematic review report. METHODS We conducted a comprehensive search and obtained search data as of April 2020. These included randomised controlled trials (RCTs) and cohort trials (CTs). We applied the research input Review Manager 5.3 for data synthesis, and used Stata 12.0 for meta- regression analysis. RESULTS This review reported 2200 hip fractures. Our analysis showed that OCC can reduce complications and 1-year mortality, and shorten the length of stay (LOS). After dividing the complications into bed-related complications and other complications, OCC has advantages in reducing bed-related complications, but has no significant effect on other complications. For the conventional care group, the secondary outcome of the OCC group showed there was no significant difference in duration of surgery, and the rest were significantly improved. Subgroup analysis between green channel (GC) and FT showed a shorter LOS for GC. CONCLUSIONS This meta-analysis suggests that the use of OCC in China promotes rehabilitation in elderly patients with hip fractures, that FT and GC are similar in effect in China, and that GC shows a greater advantage in reducing LOS.
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Affiliation(s)
- Zhaofu Wang
- School of Surgery, Ningxia Medical University, Yinchuan, China
| | - Meixue Chen
- School of Nursing, Jinan University, Guangzhou, China
| | - Xiaohai Luo
- School of Surgery, Ningxia Medical University, Yinchuan, China
| | - Xianghua Xiong
- School of Surgery, Ningxia Medical University, Yinchuan, China
| | - Feng Ma
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
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Caesar U, Karlsson L, Hamrin Senorski E, Karlsson J, Hansson-Olofsson E. Delayed and cancelled orthopaedic surgery; are there solutions to reduce the complex set of problems? A systematic literature review. Int J Clin Pract 2021; 75:e14092. [PMID: 33590942 DOI: 10.1111/ijcp.14092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 02/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Unexpected cancellations of, and delays to, orthopaedic surgery have adverse effects, with a negative impact on hospital performance and undesirable patient outcomes. As cancellations and delays are common, finding measures to prevent them is a matter of urgency. METHODS The present systematic review conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and the Cochrane Handbook. Peer-reviewed studies reporting on cancellations or delays in patients requiring emergency orthopaedic or planned orthopaedic surgery that compared care action/intervention with no action or traditional care were included. The Grading of Recommendations Assessment, Development and Evaluation used to assess the quality of evidence of the results from the included studies. The objective of the present study was systematically to search and review the literature for qualitative evidence of factors that might reduce cancellations of and delays to orthopaedic surgical procedures. RESULTS The electronic search yielded 1209 studies and eight articles were included in the performed quality assessment. The heterogeneity of the studies and the lack of calculations and statistics in the studies resulted in no meta-analysis. The result of the quality assessment indicated that the evidence ranked from low to very low across the different outcomes. The main limiting factor, which was the reason for a decrease in quality in some outcomes, was the study designs, which were non-randomised control or retrospective approach. The interventions in the included studies could help to support a reduction in the risk of cancelled and delayed orthopaedic procedures. CONCLUSION This systematic literature review has revealed important evidence to help reduce the risk of cancelled and delayed orthopaedic procedures associated with a variety of care action exposures. They include a fast-track pathway, pre-operative guidelines and telephone contact with patients prior to surgery, as well as careful consideration of additional pre-operative tests.
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Affiliation(s)
- Ulla Caesar
- Department of Orthopaedics, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Faculty of Caring Sciences Work Life & Social Welfare, Boras University, Boras, Sweden
| | - Louise Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Hansson-Olofsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
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Deng QF, Gu HY, Peng WY, Zhang Q, Huang ZD, Zhang C, Yu YX. Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: results from a systematic review and meta-analysis. Postgrad Med J 2018; 94:678-693. [PMID: 30665908 DOI: 10.1136/postgradmedj-2018-136166] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/07/2018] [Accepted: 12/01/2018] [Indexed: 12/22/2022]
Abstract
STUDY DESIGN Systematic review with meta-analysis. OBJECTIVES To evaluate the effects of enhanced recovery after surgery (ERAS) on the postoperative recovery of patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS The PubMed, Embase, Cochrane and ISI Web of Science databases were searched to identify literature including randomised controlled trials (RCTs), cohort studies and case-control studies through 2 May 2018. The analysed outcomes were mortality rate, transfusion rate, range of motion (ROM), 30-day readmission rate, postoperative complication rate and in-hospital length of stay (LOS). RESULTS A total of 25 studies involving 16 699 patients met the inclusion criteria and were included in the meta-analysis. Compared with conventional care, ERAS was associated with a significant decrease in mortality rate (relative risk (RR) 0.48, 95% CI 0.27 to 0.85), transfusion rate (RR 0.43, 95% CI 0.37 to 0.51), complication rate (RR 0.74, 95% CI 0.62 to 0.87) and LOS (mean difference (MD) -2.03, 95% CI -2.64 to -1.42) among all included trials. However, no significant difference was found in ROM (MD 7.53, 95% CI -2.16 to 17.23) and 30-day readmission rate (RR 0.86, 95% CI 0.56 to 1.30). There was no significant difference in complications of TKA (RR 0.84, 95% CI 0.34 to 2.06) and transfusion rate in RCTs (RR 0.66, 95% CI 0.15 to 2.88) between the ERAS group and the control group. CONCLUSIONS This meta-analysis showed that ERAS significantly reduced the mortality rate, transfusion rate, incidence of complications and LOS of patients undergoing TKA or THA. However, ERAS did not show a significant impact on ROM and 30-day readmission rate. Complications after hip replacement are less than those of knee replacement, and the young patients recover better. LEVEL OF EVIDENCE Level 1.
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Affiliation(s)
- Qi-Feng Deng
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hui-Yun Gu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Wu-Ya Peng
- Department of Orthopedics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Qiong Zhang
- Department of Orthopedics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Zheng-Dong Huang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yun-Xiang Yu
- Department of Orthopedics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Closed reduction of dislocated hip arthroplasty: a teaching institution’s experience. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Li D, Xie X, Kang P, Shen B, Pei F, Wang C. Percutaneously drilling through femoral head and neck fenestration combining with compacted autograft for early femoral head necrosis: A retrospective study. J Orthop Sci 2017; 22:1060-1065. [PMID: 28539248 DOI: 10.1016/j.jos.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 05/03/2017] [Accepted: 05/07/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical results, survivorship and quick rehabilitation effects of modified surgery of percutaneously drilling and decompression through femoral head and neck fenestration combined with compacted autograft for early femoral head necrosis. METHODS We conducted a retrospective cohort study with 83 hips performed percutaneous decompression through femoral head and neck fenestration (Modified group) combined with autogenous bone grafting for early ONFH. For comparison, another 90 hips treated with conventional core decompression with bone grafting (Control group). RESULTS Median follow-up was 36 months (32-44 months). The length of incision, blood loss in operation, incision drainage, operation time and hospital stays in Modified group had better results than those in control group (P < 0.001). There were four cases in Modified group and five cases in control group had complications (P = 0.9). The VAS score and range of hip motion were better in Modified group during hospital stays summarily (P < 0.05). The average Harris score in modified group was higher than the control group at the first month (P = 0.005), while at other time of follow-up the two groups were with similar Harris scores (P > 0.05). There were 22 hips progressed to stage III in Modified group, while 23 hips progressed to stage III in control group (P = 0.89). The clinical success rate in Modified group were 86.7%, compared with that in control group (87.8%) ( P= 0.84). CONCLUSION Percutaneous drilling and decompression through femoral head and neck fenestration combined with compacted autograft we reported showed an good surgical effect with a quick rehabilitation and had similar short-term effects compared with the conventional core decompression in treatment of early ONFH.
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Affiliation(s)
- Donghai Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, Sichuan 610041, PR China.
| | - Xiaowei Xie
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, Sichuan 610041, PR China.
| | - Pengde Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, Sichuan 610041, PR China.
| | - Bin Shen
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, Sichuan 610041, PR China.
| | - Fuxing Pei
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, Sichuan 610041, PR China.
| | - Changde Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, Sichuan 610041, PR China.
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