Ankle fractures are common injuries affecting all age groups and constitute a large proportion of the orthopaedic trauma case load. Patients are usually admitted directly to the ward from the emergency department and a large number of bed-days are spent waiting for the ankle swelling to subside prior to surgery. We audited current practice and then implemented a home therapy programme (HTP). The purpose of the study was to assess the pioneering HTP with respect to cost effectiveness, length of stay and patient satisfaction.
PATIENTS AND METHODS
If HTP criteria were met, patients with reduced, unstable ankle fractures were taught safe mobilisation by physiotherapists in the emergency department. They were then discharged home to ice and elevate their ankle in a plaster backslab. A provisional operation date was allocated on discharge. They were admitted to hospital the day of surgery and then discharged home when safe and comfortable.
Forty-three consecutive patients met our inclusion criteria and underwent surgical fixation of unstable ankle fractures over a 3-month period (February–April 2008). The average length of hospital stay was 8 days (range, 1–18 days), 4.5 days pre-operatively and 3.5 days postoperatively. Patients were frustrated and dissatisfied with the whole process. In total, 177 patients underwent surgical fixation of unstable ankle fractures over an 11-month period (November 2008 to October 2009) and, of these, 59 met the home therapy criteria. The average length of hospital stay was 2.4 days, 1 day pre-operatively (range, 0–4 days) and 1.4 days postoperatively (range, 0–5 days). All HTP patients expressed satisfaction with the process. Over the course of the HTP, 354 bed-days were saved which equates to a saving of £81,774. The annual estimated cost saving is £90,000.
The home therapy programme has proved effective in reducing hospital stay both pre- and postoperatively. It is cost-effective and well received by patients.
Ankle fractures; Cost; Satisfaction; Pathway
Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival.
PATIENTS AND METHODS
The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit.
A total of 883 patients were included in the audit (35–126 per hospital). Overall, 5–15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5–19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with > 10 lists per week (n = 6) and those with < 10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with > 10 lists (34.6% of patients versus 28.9%; P = 0.09).
Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.
Fracture; Neck of femur; Hip surgery; Trauma
Geriatric hip fracture is one of the commonest fractures in orthopaedic trauma. There is a trend of further increase in its incidence in the coming decades. Besides the development of techniques and implants to overcome the difficulties in fixation of osteoporosis bone, the general management of the hip fracture is also very challenging in terms of the preparation of the generally poorer pre-morbid state and complicate social problems associated with this group of patients. In order to cope with the increasing demand, our hospital started a geriatric hip fracture clinical pathway in 2007. The aim of this pathway is to provide better care for this group of patients through multidisciplinary approach. From year 2007 to 2009, we had managed 964 hip fracture patients. After the implementation of the pathway, the pre-operative and the total length of stay in acute hospital were shortened by over 5 days. Other clinical outcomes including surgical site infection, 30 days mortality and also incidence of pressure sore improved when compared to the data before the pathway. The rate of surgical site infection was 0.98%, and the 30 days mortality was 1.67% in 2009. The active participation of physiotherapists, occupational therapists as well as medical social workers also helped to formulate the discharge plan as early as the patient is admitted. In conclusion, a well-planned and executed clinical pathway for hip fracture can improve the clinical outcomes of the geriatric hip fractures.
Clinical outcomes; Clinical pathway; Geriatric hip fracture; Multidisciplinary
Reducing hospital stay optimizes bed capacity. Shortage of operating time can cause some patients to have their treatment and discharge home delayed. Extra operating sessions could help in reducing such a delay. We performed a feasibility study for a simulated model of trauma lists, implemented ad- hoc to reduce time to surgery.
Materials and methods
Two hundred thirty-five consecutive trauma admissions were audited. The time required to deliver surgical treatment was recorded. Patients waiting for their operation more than 48 h from admission were allocated into a simulated system of ad hoc trauma lists, using a realistic decision-making process. The potential to reduce time-to-operation was assessed and the number of saved bed occupancy days was calculated. A cost analysis was also performed.
Surgical treatment was delivered within 48 h in 193 (85%) patients, while 32 (15%) patients waited a mean of 3.8 days (3–7), because of insufficient time. To operate on these patients earlier, additional lists would have cost £38, 703, reducing the time to surgery to 1 day (0–2). This would have saved 86 days of bed occupancy, representing a savings of £17,200. Restricting the use of extra lists to the elderly patients in the cohort would have required only 11 extra lists and reduced waiting from 3 (3–4) to 1 days (0–2), for a cost of £22,407. Elderly patients’ lists would have had space left to treat additional seven younger patients, with a total saving of 51 bed occupancy days, corresponding to £10,200.
The system of ad hoc trauma lists is easy to organize and it appears to impact significantly on patients’ discharge and bed capacity. Direct costs to the health service are contained, as they are partially compensated by the improvement in beds availability.
Cost analysis; Audit; Trauma; Fracture neck of femur; Bed management
Musculoskeletal trauma represents a considerable global health burden, however reliable population-based incidence data are scarce. A fracture and dislocation registry was established within a well-defined population. An audit of the establishment process, feasibility of the registry work and report of the collected data is given.
Demographic data, fracture type and location, mode of treatment, and the reasons for the secondary procedures were collected and scored using recognized systems, such as the AO/OTA classification and the Gustilo-Anderson classification for open fractures. The reporting was done in the operation planning program by the involved orthopaedic surgeon. Both inpatient and day-case procedures were collected. Data were collected prospectively from 2006 until 2010. Compliance among the surgeons and completeness and accuracy of the data was continuously assured by an orthopaedic surgeon.
During the study period, 39 orthopaedic surgeons were involved in the recording of a total of 8,188 procedures, consisting of primary treatment of 4,986 long bone fractures, 467 non long bone fractures, 123 dislocations and 2,612 secondary treatments. In the study period 532 fractures or dislocations were treated at least once for one or more serious complications. For the index year of 2009, a total of 5710 fractures or dislocations were treated in the emergency department or hospitalized, of which the 1594 (28%) were treated at the inpatient or day-case operation rooms, thus registered in the FDR. Quality assurance, educational incentives and continuous feedback between coders and controller in the integrated electronic system are available and used through the features of the electronic database.
Implementing an integrated registry of fractures and dislocations with the electronic hospital system has been possible despite several users involved. The electronic system and the data controller provide for completeness and validity. The FDR has become an indispensable tool for the department for planning and education and will serve as a prerequisite for the conduct and execution of future prospective trials within the department. Further, other departments with similar electronic patient files may fairly easily adopt this system for implementation.
Despite dedicated emergency theatre, emergency surgery can be often delayed due to competing urgencies, suggesting a need for innovative theatre time management.
To investigate if a change in the emergency theatre prioritisation affects outcomes for a common urgent operation such as appendicectomy.
We prospectively recorded data from 67 patients undergoing appendicectomy, for two cohorts of patients: before and after change in theatre prioritisation: Group 1 (Jan-Mar) and 2 (Aug-Oct) respectively. Demographic and peri-operative data, time from admission to surgery, postoperative length of stay and total length of stay and complications were compared.
The two groups were comparable with regards to gender, age, time of admission and histological confirmation of appendicitis. No differences between the two groups were found regarding time from admission to surgery (24.4 (95% CI 11.2;27.6) hours versus 16.1 (95% CI 10.4;21.7) hours, Mann-Whitney U test, p = 0.35), postoperative length of stay (90.8 (95% CI 61.4;120.1) hours versus 70 (95% CI 48.3;91.6) hours, Mann-Whitney U test, p = 0.25) and total length of stay (115.2 (95% CI 84.6;145.7) hours versus 86 (95% CI 61.6;110.4) hours, Mann-Whitney U test, p = 0.07) as well as complication or re-admission rates.
A change in the emergency theatre prioritisation does not affect outcome for appendicectomy. Provision of a second emergency theatre could be a solution to reduce the delays in acute surgical operations.
BACKGROUND: Published guidelines recommend early surgical treatment of hip fractures in elderly patients. Understanding the factors that delay surgical intervention is essential in order to introduce changes that will facilitate early treatment. AIM: To determine the factors delaying surgical treatment of hip fractures in elderly patients for more than 24 h. PATIENTS AND METHODS: Assessment of 163 consecutive patients undergoing surgery for hip fractures at the trauma unit of Manchester Royal Infirmary. RESULTS: Only 72/163 (44.2%) patients had their operation within 24 h of presenting to hospital. The remaining 91 patients had a total of 239 days delay (in excess of the initial 24 h) for surgical treatment. Active medical problems (56.5%) and a wait for medical investigations (19.7%) caused most delays. Lack of operating theatre time and Sunday trauma lists caused 23.8% of delays. CONCLUSIONS: Medical problems account for most delays of surgical treatment of hip fractures. A multidisciplinary approach, with early input by medical and anaesthetic teams, is essential in managing such patients. Established protocols may reduce waiting times for essential investigations.
Traumatic cervical spinal cord injury with subaxial fracture and dislocation not only indicates a highly unstable spine but can also induce life-threatening complications. This makes first aid critically important before any definitive operative procedure is undertaken. The present study analyzes the various first aid measures and operative procedures for such injury.
Materials and Methods:
Two hundred and ninety-five patients suffered from cervical spinal cord injury with fracture and dislocation. The average period between injury and admission was 4.5 days (range 5 h-12 weeks). The injury includes burst fractures (n = 90), compression fractures with herniated discs (n = 50), fractures and dislocation (n = 88) and pure dislocation (n = 36). Other injuries including developmental spinal canal stenosis and/or multi-segment spinal cord compression associated with trauma (n = 12), lamina fractures compressing the spinal cord (n = 6), ligament injuries (n = 7) and hematoma (n = 6) were observed in the present study. The injury level was C4 (n = 17), C5 (n = 29), C6 (n = 39), C7 (n = 35), C4-5 (n = 38), C5-6 (n = 58), C6-7 (n = 49), C4-6 (n = 16) and C5-7 (n = 14). According to the Frankel grading system, grade A was observed in 20 cases, grade B in 91, grade C in 124 and grade D in 60. One hundred and eighteen (40%) patients had a high fever and difficulty in breathing on presentation. First aid measures included early reduction and immobilization of the injured cervical spine, controlling the temperature, breathing support, and administration of high-dose methylprednisolone within eight hours of the injury (n = 12) and administration of dehydration and neurotrophy medicine. Oxygen support was given and tracheotomy was performed for patients with serious difficulty in breathing. Measures were taken to prevent bedsores and infections of the respiratory and urological systems. Two hundred and thirty six patients were treated with anterior decompression, 31 patients were treated by posterior approach surgery and combined anterior and posterior approach surgery was performed in a single sitting on 28 patients.
All patients were followed for 0.5-18 years (mean 11.8 years). At least one Frankel grade improvement was observed in 178 (60.3%) patients. In the anterior surgery group, the best results were observed in the cases with slight compressive fracture with disc herniation (44/50 patients, 88.0%). In the posterior surgery group, one Frankel grade improvement was observed in the cases with developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries and hematoma (27/31, 87.1%). Most of the patients in the Frankel D group recovered normal neurological function after surgery. The majority of the patients with Frankel C neurological deficit (102/124) had the ability to walk postoperatively, while most of the seriously injured patients (Frankel A and B) had no improvement in their neurological function. Radiolographic fusion of the operated segments occurred in most patients within three months. Loss of intervertebral height and cervical physiological curvature was observed to varying degrees in 30.1% (71/236) of the cases in the anterior surgery group.
First aid measures of early closed reduction or realignment and immobilization of the cervical spine, breathing support and high-dose methylprednisolone were most important in the treatment for traumatic spinal cord injury. Surgery should be performed as soon as the indications of spinal injury appear. The choice of the approach—anterior, posterior or both, should be based on the type of the injury and the surgeon's experience. Any complications should be actively prevented and treated.
Cervical spine; first aid; spinal cord injury; surgical treatment
Background and purpose
There is some clinical evidence that fracture healing is impaired in multiply injured patients. Nothing is known, however, about the effects of various types of injuries and their contribution to a possible disturbance of the fracture-healing process. We investigated the effect of a thoracic trauma and an additional soft-tissue trauma on fracture healing in a rat tibia model.
3 groups of rats were operated: group A with a simple fracture of the tibia and fibula, group B with a fracture and an additional thoracic trauma, and group C with a fracture, thoracic trauma, and an additional soft-tissue trauma. The fracture and the soft-tissue injury were produced by a special guillotine-like device and the thoracic trauma by a blast wave generator.
After one day, the serum level of IL-6 was quantified, and at the end of the study (28 days) the mechanical properties and the callus volume of the healed tibia were determined.
Increasing the severity of the injury caused IL-6 levels to more than double 1 day after injury. It halved the load to failure in mechanical tests and led to reduced callus volume after 28 days of healing.
Fracture healing is impaired when additional thoracic trauma and soft tissue trauma occurs.
Problem: The first East Anglian audit of hip fracture was conducted in eight hospitals during 1992. There were significant differences between hospitals in 90-day mortality, development of pressure sores, median lengths of hospital stay, and in most other process measures. Only about half the survivors recovered their pre-fracture physical function. A marked decrease in physical function (for 31%) was associated with postoperative complications.
Design: A re-audit was conducted in 1997 as part of a process of continuing quality improvement. This was an interview and record based prospective audit of process and outcome of care with 3 month follow up. Seven hospitals with trauma orthopaedic departments took part in both audits. Results from the 1992 audit and indicator standards for re-audit were circulated to all orthopaedic consultants, care of the elderly consultants, and lead audit facilitators at each hospital.
Key measures for improvement: Processes likely to reduce postoperative complications and improve patient outcomes at 90 days.
Strategy for change: As this was a multi-site audit, the project group had no direct power to bring about changes within individual NHS hospital trusts.
Results: Significant increases were seen in pharmaceutical thromboembolic prophylaxis (from 45% to 81%) and early mobilisation (from 56% to 70%) between 1992 and 1997. There were reduced levels of pneumonia, wound infection, pressure sores, and fatal pulmonary embolism, but no change was recorded in 3 month functional outcomes or mortality.
Lessons learnt: While some hospitals had made improvements in care by 1997, others were failing to maintain their level of good practice. This highlights the need for continuous quality improvement by repeating the audit cycle in order to reach and then improve standards. Rehabilitation and long term support to improve functional outcomes are key areas for future audit and research.
We prospectively studied the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonisation and infection, the patterns and types of operation associated with MRSA acquisition in an orthopaedic and trauma unit in London, UK. Over the 12-month study period from January to December 2000, we found that 1.6% of the total admission was diagnosed to be either MRSA infected or colonised, with an average of three new MRSA cases detected per month. A significant proportion of patients (23%) were diagnosed within the first 48h of admission. Both hip joint surgery, especially emergency procedures for femoral neck fractures, and the presence of a wound presented higher risk of infection. The Intensive Care Unit (ICU) did not appear to be a significant source for intra-hospital dissemination among the orthopaedic patients. MRSA infection or colonisation contributed to an increased length of hospital stay; 88 days compared to 11 days on average for non-MRSA patients; 41% of the positive patients still carried MRSA on discharge. Our data show the importance of diagnosing MRSA in orthopaedic surgery and emphasises that understanding its epidemiology will be crucial to secure a decrease in the incidence of MRSA. Hand hygiene, patient screening, careful surveillance of infections and the prompt implementation of isolation policies, are essential components of control.
Most health services in the United Kingdom provide unacceptable in-hospital care for hip fracture patients. We describe the impact on surgical delay following the introduction of an orthogeriatrician and the addition of one extra trauma list per week at our centre. Prospective data were collected on 101 consecutive patients followed by a second cohort of 105 patients. Mean time to surgery in cohorts 1 and 2 was 4.08 and 4.05 days, respectively (p = 0.71). Diagnosis of medical comorbidity increased with input from the orthogeriatrician from 69.7% to 74.2% (p = 0.24). Length of stay and mortality were comparable in the two groups. A full trauma list accounted for the most frequent orthopaedic delay, which decreased from 18.1% to 12.9% (p = 0.09). Increased recognition of medical comorbidity has financial implications for hospital remuneration. However, lack of orthopaedic provisions accounts for significant avoidable surgical delay requiring further investment if national standards are to be achieved.
Ankle fractures and fracture dislocations are common injuries in orthopaedic practice however pure ankle dislocation without an associated fracture is extremely rare. There are a few cases reporting such a lesion in the literature. Also this injuries are generally open high energy trauma injuries. Closed treatments are reported to be effective and ligament injuries are generally not reported. In this study, we report a closed pure posteromedial ankle dislocation with anterior talofibular ligament rupture and its treatment and outcome in a 12 year-old boy. We think that this is an extremely rare lesion.
High-energy trauma may result in uncommon open injuries around the elbow joint. The management of these injuries can be difficult.
Fourteen patients were treated between 1999 and 2003 and their injuries consisted of Monteggia fracture-dislocations combined with segmental fractures of the ulna or fractures of the forearm bones and/or various more complex trauma such as neural injuries, bone comminution and severe soft tissue injuries around the elbow. Eight of them (57%) were multiply injured with severe additional injuries. All patients underwent surgery within first 4–6 hours. Internal fixation, external fixation or a combination of both methods were used to stabilize fractures while open wounds had secondary closure.
Additional operations were required in 6 patients. The functional results according to the Mayo Elbow Performance Index were excellent or good in eleven patients, and fair or poor in the remaining three. The patients with fair and poor results had suffered from severe neural and soft tissue trauma and/or multiple fractures of the upper extremity.
These injuries should be treated as an emergency. The surgeon should apply any available method that can provide stability to the bone fragments and safe handling of the soft tissues giving priority to internal fixation of the fractures. Severe osseous, soft tissue and neural trauma affect the functional results of the elbow region.
The patterns, management and outcome of non-fatal orthopaedic injury in childhood was audited over a 1 year period in Southampton. A computer-based audit (1 September 1993 to 31 August 1994) was conducted of all children aged under 15 years who were admitted to the orthopaedic unit after accidental injury. Management was audited by studying the primary conservative and operative treatment methods employed. Treatment outcome was evaluated in terms of need for secondary operative treatment, salvage internal fixation, length of hospital stay and unplanned readmission. In all, 398 children, representing 50/10,000 of the local paediatric population, were admitted with a traumatic injury. There was a significant (P < 0.001, Kolmogorov-Smirnov) seasonal variation in admission rate. There were 87.3% admissions required for fractures, 8.5% after soft tissue injury and 2.2% after joint injury. The following areas were identified where management and outcome could be improved: 1 A 12.1% readmission rate (47/346) in children with fractures owing to a 16% incidence of loss of position after closed reduction of distal radial, forearm shaft and distal humeral fractures. 2 In all, 24% of internal fixation procedures were performed as 'salvage' after failure of conservative treatment, entailing either reoperation during the initial admission or a further unplanned readmission. 3 A prolonged inpatient stay for patients with femoral fractures owing to a wide variation in treatment method. The outcome of non-fatal orthopaedic injury can be improved through the selective use of primary internal fixation of distal radial and humeral fractures and the close adherence to a management algorithm in femoral fractures. There may be a role for more specialised supervision of primary treatment of these particular fractures.
Displaced talar neck and body fractures are rare and serious injuries with important outcomes. The aim of our study was to evaluate the long-term outcomes of these fractures after operative treatment in our centre between 1993 and 2005. Displaced talar fractures have a high rate of long-term complications. This was a retrospective study concerning 20 patients with an average follow-up of 7.5 years. The final follow-up examination included determination of the AHS score (ankle–hindfoot scale) from the American Orthopaedic Foot and Ankle Society (AOFAS), range of motion evaluation and radiological analysis. Mean age at the time of trauma was 38.8 years. This study comprised ten talar neck fractures and ten talar body fractures. We always used a single surgical approach and obtained anatomical reduction in 30% of the whole series of both groups. Four early complications were noted in four patients (20%). We noted no skin complications and the rate of consolidation was 100%. Four patients (20%) developed avascular necrosis of the talus, and at final follow-up seven patients (35%) had undergone secondary surgery. Radiographic analysis showed an osteoarthritis rate of 94% and a malunion rate of 59%. The mean AOFAS score was 66.9/100 and range of motion was systematically decreased. Contrary to undisplaced talar fractures, displaced talar fractures are a therapeutic challenge with many early or late complications. The outcome often revealed stiffness and osteoarthritis.
Though pedestrian versus motor vehicle (PVMV) accidents are a common cause of trauma admission and subsequent orthopaedic consult, the prevalence of upper extremity fracture (UEF) in such events and its association with lower extremity injury (LEI) is unknown. We sought to describe UEF in PVMV accident patients at the time of orthopaedic consult.
A retrospective chart review was conducted for all pedestrian hit by motor vehicle cases for which an orthopaedic consult was performed at Jackson Memorial Hospital between July 2006 and January 2008. Fractures were recorded by location along with relevant clinical information. Logistic regression was used to calculate odds ratios (O.R.) and 95% confidence intervals (C.I.) for variables associated with UEF.
336 cases were identified and reviewed. LEI was the most frequent injury type (67% of cases). UEF was also common, found in 25% of cases (humerus 11%, ulna 7%, radius 6%, hand 4%, and wrist 2%). Tibia or fibula fracture, femur fracture, and spine fracture were negatively associated with UEF in univariate analyses and after controlling for other associated factors.
In PVMV accident populations, UEF is a frequent injury often seen in the absence of any LEI. These findings emphasize the importance of carefully screening all PVMV accident patients for UEF and may call into question the usefulness of currently discussed injury pattern.
Ankylosing Spondylitis (AS) is a multifactorial
and polygenic rheumatic condition without a well-understood pathophysiology (Braun and Sieper (2007)). It results in
chronic pain, deformity, and fracture of the axial
skeleton. AS alters the biomechanical properties
of the spine through a chronic inflammatory
process, yielding a brittle, minimally compliant
spinal column. Consequently, this patient
population is highly susceptible to unstable spine
fractures and associated neurologic devastation
even with minimal trauma. Delay in diagnosis is
not uncommon, resulting in inappropriate
immobilization and treatment. Clinicians must
maintain a high index of suspicion for fracture
when evaluating this group to avoid morbidity and
mortality. Advanced imaging studies in the form of
multidetector CT and/or MRI should be employed to
confirm the diagnosis. Initial immobilization in
the patient's preinjury alignment is
mandatory to prevent iatrogenic neurologic injury.
Both nonoperative and operative treatments can be
employed depending on the patient's age,
comorbidities, and fracture stability. Operative
techniques must be individually tailored for this
patient population. A multidisciplinary team
approach is best with preoperative nutritional
assessment and pulmonary evaluation.
AIMS: To evaluate the efficacy of combined care between orthopaedic surgeons and geriatricians in the management of patients with fractured necks of femur. PATIENTS AND METHODS: A prospective study of the admissions to a district general hospital with hip fractures was carried out over a 5-year period. In the years 1992-1994, medical problems in this patient group were managed by a consultation-only service. At the end of 1994, a consultant geriatrician was appointed to manage these patients jointly with the orthopaedic surgeons, and the study was then carried through until the end of 1996. Information about the patients from admission to discharge or death was gathered prospectively using a proforma for the 3 years prior to orthogeriatric care, and the 2 years after. Main outcome measures were mortality, length of stay and discharge destination. These were compared for the two periods--pre- and post-orthogeriatric care. RESULTS: No significant differences were noted in mortality, length of stay or discharge destination. CONCLUSIONS: Combined orthogeriatric care according to our model did not have an impact on our chosen outcome measures.
Over the years, there has been a tremendous increase in the use of fluoroscopy in orthopaedics. The risk of contracting cancer is significantly higher for an orthopedic surgeon. Hip and spine surgeries account for 99% of the total radiation dose. The amount of radiation to patients and operating surgeon depends on the position of the patient and the type of protection used during the surgery. A retrospective study to assess the influence of the radiation exposure of the operating surgeon during fluoroscopically assisted fixation of fractures of neck of femur (dynamic hip screw) and ankle (Weber B) was performed at a district general hospital in the United Kingdom.
Materials and Methods:
Sixty patients with undisplaced intertrochanteric fracture were included in the hip group, and 60 patients with isolated fracture of lateral malleolus without communition were included in the ankle group. The hip and ankle groups were further divided into subgroups of 20 patients each depending on the operative experience of the operating surgeon. All patients had fluoroscopically assisted fixation of fracture by the same approach and technique. The radiation dose and screening time of each group were recorded and analyzed.
The radiation dose and screening time during fluoroscopically assisted fixation of fracture neck of femur were significantly high with surgeons and trainees with less than 3 years of surgical experience in comparison with surgeons with more than 10 years of experience. The radiation dose and screening time during fluoroscopically assisted fixation of Weber B fracture of ankle were relatively independent of operating surgeon's surgical experience.
The experience of operating surgeon is one of the important factors affecting screening time and radiation dose during fluoroscopically assisted fixation of fracture neck of femur. The use of snapshot pulsed fluoroscopy and involvement of senior surgeons could significantly reduce the radiation dose and screening time.
Experience; fixation; fracture; radiation; surgeon
OBJECTIVE: To establish whether increased waiting time to operation in elderly patients with hip fracture significantly affects postoperative time to discharge. METHODS: Combined prospective and retrospective analysis of theatre logbooks and in-patient data to determine the type, time and date of operation and subsequent in-patient stay. SETTING: A busy district general hospital in the South East Thames Valley area with changing availability of a dedicated trauma list. PATIENTS: 441 elderly patients undergoing hip surgery between May 1995 and March 1997. MAIN OUTCOME MEASURES: Waiting time from booking of operation to surgery and length of postoperative hospital stay. RESULTS: Increased pre-operative wait for emergency hip surgery in elderly patients significantly increases postoperative stay. Roughly doubling pre-operative wait increases postoperative stay by 19% (P < 0.01).
The objective of this prospective audit was to compare two methods of anticoagulation reversal in the pre-oper-ative period for hip fracture patients.
PATIENTS AND METHODS
In the first part of the audit, our current practice was analysed. Data relating to the number of days from admission to surgery and the reasons for delay to surgery were collected. Also, data concerning common reasons for which the patients were started on warfarin and the time required for INR to drop to 1.5 or below were collected. In the second part of the audit, 45 patients with INR above 1.5 were given a single dose of vitamin K (1 mg i.v.) in addition to stopping warfarin.
The mean difference in the time for INR < 1.5 in the two groups was 2 days (52 h; P < 0.05). The mean difference in wait for surgery since admission between the two groups was 4 days (91 h; P < 0.05). There was no significant difference between the two groups as regards the average number of co-morbidities in the patient groups.
A single 1 mg intravenous dose of vitamin K significantly reduces the time for the reversal of INR and the pre-operative delay to surgery, in patients on long-term warfarin. We conclude that 1 mg of intravenous vitamin K on admission is a safe and effective treatment to avoid delay in the treatment in this group of patients.
Hip fracture; Vitamin K; INR
Bilateral traumatic knee dislocations are a rarity. We report a case of bilateral traumatic knee dislocations with concomitant right hip dislocation and complete traumatic amputation of the left, nondominant upper extremity at the level of the proximal one-third of the humerus. Angiograms revealed no evidence of popliteal artery injury. Orthopedic treatment consisted of immediate reduction of the dislocations and urgent revision amputation of the upper extremity. Staged, bilateral knee ligamentous reconstructions were performed on hospital days 24 and 29, respectively. Despite this constellation of devastating injuries, the patient had a satisfactory outcome. In patients with high-energy hip or knee dislocations, the bilateral hips and knees should be carefully examined to check for associated fractures and/or dislocations.
knee dislocation; hip dislocation; traumatic amputation; multiligamentous knee reconstruction
The primary aim of this study was to provide an estimate of effect size for the functional outcome of operative versus non-operative treatment for patients with an acute rupture of the Achilles tendon using accelerated rehabilitation for both groups of patients. The secondary aim was to assess the use of a comprehensive cohort research design (i.e. a parallel patient-preference group alongside a randomised group) in improving the accuracy of this estimate within an orthopaedic trauma setting.
Pragmatic randomised controlled trial and comprehensive cohort study within a level 1 trauma centre. Twenty randomised participants (10 operative and 10 non-operative) and 29 preference participants (3 operative and 26 non-operative). The ge range was 22-72 years and 37 of the 52 patients were men. All participants had an acute rupture of their Achilles tendon and no other injuries. All of the patients in the operative group had a simple end-to-end repair of the tendon with no augmentation. Both groups then followed the same eight-week immediate weight-bearing rehabilitation programme using an off-the-shelf orthotic. The disability rating index (DRI; primary outcome), EQ-5D, Achilles Total Rupture Score and complications were assessed ed at two weeks, six weeks, three months, six months and nine months after initial injury.
At nine months, there was no significant difference in DRI between patients randomised to operative or non-operative management. There was no difference in DRI between the randomised group and the parallel patient preference group. The use of a comprehensive cohort of patients did not provide useful additional information as to the treatment effect size because the majority of patients chose non-operative management.
Recruitment to clinical trials that compare operative and non-operative interventions is notoriously difficult; especially within the trauma setting. Including a parallel patient preference group to create a comprehensive cohort of patients has been suggested as a way of increasing the power of such trials. In our study, the comprehensive cohort model doubled the number of patients involved in the study. However, a strong preference for non-operative treatment meant that the increased number of patients did not significantly increase the ability of the trial to detect a difference between the two interventions.
Published guidelines recommend early transfer of patients with hip fractures to hospital wards and avoidance of unnecessary delays in A&E. We describe a protocol whereby the liaison of an orthopaedic trauma co-ordinator with A&E reduced A&E-to-ward transfer times by 43%. Following introduction of the new protocol, 39% of hip fracture patients were in a ward bed within 3 h of admission to A&E compared to 4% previously. The new protocol also reduces administrative workload for the on-call orthopaedic SHOs.