In patients with hand sepsis does bedside debridement compared to operating theatre debridement have similar clinical outcomes, hospital cost and time to discharge in a District Hospital setting in South Africa?. A case series of 130 adult patients presenting to a district level orthopaedic unit over 1 year with hand sepsis requiring debridement. All included patients were debrided at the bedside (i.e. the emergency room, ward, OPD) under wrist or digital block. Patients excluded from the study included patients with necrotising soft tissue infections that required debridement in theatre. A cost analysis was done based on operating theatre (OT) costs saved as defined by Samuel1 et al. If an average theatre time of 45 min is taken then the cost saved per patient is approximately R1500 and approximately R300000 for the patients included in the case series. This excludes ward and other hospital costs related to a longer hospital admission. The mean time to discharge for the included patients was 24 hours. This study suggests that bedside debridement can be a viable and cost effective option for selected cases of hand sepsis that can avoid the high cost and time associated with operating theatre debridement with similar outcomes. This has implications for the future treatment of hand sepsis in resource constrained settings were operating theatre time is not only very expensive but also very scarce

C-reactive protein (CRP) level is used at our tertiary paediatric hospital in the diagnosis, management, and discharge evaluation of paediatric septic arthritis patients. The purpose of this study was to evaluate the efficacy of a discharge criterion of CRP less than 2 mg/dL for patients with septic arthritis in preventing reoperation and readmission. We also aimed to identify other risk factors of treatment failure. Patients diagnosed with septic arthritis between January 1, 2007 and December 31, 2017 were reviewed retrospectively. The diagnosis of septic arthritis was made based on clinical presentation, laboratory results and the finding of purulent material on joint aspiration or the isolation of a bacterial pathogen from joint fluid or tissue. Bivariate tests of associations between patient or infection factors and readmission and reoperation were performed. Quantitative variables were analyzed using Mann-Whitney tests and categorical variables were analyzed using Chi-square tests. One hundred eighty-three children were included in the study. Seven (3.8%) were readmitted after hospital discharge for further management, including additional advanced imaging, and IV antibiotics. Six (85.7%) of the readmitted patients underwent reoperation. Mean CRP values on presentation were similar between the two groups: 8.26 mg/dL (± 7.87) in the single-admission group and 7.94 mg/dL (± 11.26) in the readmission group (p = 0.430). Mean CRP on discharge for single-admission patients was 1.71 mg/dL (± 1.07), while it was 1.96 mg/dL (± 1.19) for the readmission group (p = 0.664), with a range of < 0 .8 to 6.5 mg/dL and a median of 1.5 mg/dL for the two groups combined. A total of 48 children (25.9%) had CRP values greater than the recommended 2 mg/dL at discharge, though only three of these patients (6.2%) were later readmitted. The only common variable in the readmitted children was either a negative culture result at time of discharge or atypical causative bacteria. CRP values are useful in monitoring treatment efficacy but not as reliable as a discharge criterion to prevent readmission or reoperation in children with septic arthritis. We recommend determining discharge readiness on the basis of clinical improvement and downtrending CRP values. There was a higher risk of readmission in children with an atypical causative bacteria and when culture results were negative at discharge. Close monitoring of these patients after discharge is suggested to identify signs of persistent infection

Nationwide, proximal femoral fractures contribute a significant workload for the NHS and are the commonest trauma admission. Timely discharge from the acute hospital setting is beneficial to both patient and orthopaedic team.

The Community Care Act 2003 formed part of Governmental strategy to reduce ‘bed blocking’. Introduced on 5 January 2004, the scheme enabled Trusts to charge Local Authorities £100 a day where there was delayed transfer of care due to lack of Social Service [SS] provision. The Act brought with it a £250 million package of funding over three years.

We looked at patients admitted to Weston Area Healthcare Trust [WAHT] sustaining fractured neck of femur. These were pre-scheme group A, admitted 08/09/2003-06/10/2003 and post scheme group B, 08/03/2004 – 05/04/2003. Patient numbers, group ‘A’ 33 patients, group ‘B’ 28 patients. Average length of stay, ‘A’ 22.3 days, ‘B’ 16.1 days. The average time spent in hospital after being declared ‘medically fit’, ‘A’ 6.6 days, ‘B’ 2.3 days. Only 13 patients were referred to SS post scheme, with combined delayed discharge of 116 days.

The impact of the scheme in reducing length of stay has not been proven. Few patients were referred to SS even after the implementation of the scheme; however, the delay in discharge for these patients would have amounted to £11600 of funding. To date, WAHT have not received any funds for patients in whom discharge was delayed.

The Act states that lack of SS input must be the ‘sole reason’ for delay in discharge. The scheme is not applicable if delay is due to family choice, lack of equipment or lack of intermediate care package and for these reasons transfer of funds from SS to Trusts has become a multidisciplinary minefield. The impact of the reimbursement scheme will only become apparent if the Act is enforced.

The drive in contemporary medicine is improved utilisation of scarce resources and a faster turn around of patients, with patients seeking faster recovery from surgery. Delaying factors in discharge from hospital following total knee replacement surgery include the time taken to get active extension and a straight leg raise following surgery. A retrospective case matched study of 20 patients shows that reducing the length of incision into the quadriceps tendon, therefore sparing the quadriceps mechanism speeds the post operative recovery significantly. Reducing the average time to discharge from 9.6 days in the control group to 3.2 days in the quadriceps-sparing group. All but one patient had an ASA grade of 2 with no significant co-morbidity in either group. No patient in either group suffered a post-operative medical event precipitating a delayed discharge. The criteria for discharge were the same in both groups

Abstract. Introduction. Adverse reactions to pain medication and pain can delay discharge after outpatient knee arthroplasty (TKA). Pharmacogenomics is an emerging tool that might help reduce adverse events by tailoring medication use based on known genetic variations in the CYP genes determining drug metabolism. This study was undertaken to evaluate whether pre-operative pharmacogenomic testing could optimize peri-operative pain management in patients undergoing total knee arthroplasty (TKA). Methods. This prospective, randomized study was performed in adults undergoing primary TKA. Patients in the experimental group underwent pre-operative pharmacogenomic evaluation and medication adjustments. Medications were not optimized for control patients. The Overall Benefit of Analgesic Score (OBAS) at 24 hours post-op was the primary outcome. Postoperative pain scores (VAS scale), total opioid use, time in recovery, and time to discharge were also compared. Results. 76 patients enrolled. 93% of patients had a poor-intermediate phenotype for at least one of four CYP genes. OBAS did not differ significantly between the two groups (4.2 control vs. 4.7 experimental; 95% CI −1.1 to 2.1) and was below the minimum clinically important difference of 2.0 points. Furthermore, there were no differences in any OBAS subscale including pain, satisfaction, or nausea. There were no differences in time in the recovery area or to discharge from hospital, or narcotic use. Conclusions. Despite many patients having a poor-intermediate phenotype for a CYP gene, pharmacogenomic testing prior to TKA and medication adjustment did not improve anesthesia or pain management outcomes, time to discharge or mean total opioid use after surgery

Aims. The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures. Methods. A total of 120 PLWH with limb fractures, between January 2015 and December 2023, were included in this study. We established a multidisciplinary team to design and implement a standardized ERAS protocol. The demographic, surgical, clinical, and follow-up information of the patients were collected and analyzed retrospectively. Results. Compared with the control group, the ERAS group had a shorter operating time, hospital stay, preoperative waiting time, postoperative discharge time, less intraoperative blood loss, and higher albumin and haemoglobin on the first postoperative day. The time to removal of the urinary catheter/drainage tube was shortened, and the drainage volume was also significantly reduced in the ERAS group. There was no significant difference in the visual analogue scale (VAS) scores on postoperative return to the ward, but the ERAS group had lower scores on the first, second, and third postoperative days. There were no significant differences in the incidence of complications, other than 10% more nausea and vomiting in the control group. The limb function scores at one-year follow-up were similar between the two groups, but time to radiological fracture union and time to return to physical work and sports were significantly reduced in the ERAS group. Conclusion. The implementation of a series of perioperative nursing measures based on the concept of ERAS in PLWH with limb fracture can significantly reduce the operating time and intraoperative blood loss, reduce the occurrence of postoperative pain and complications, and accelerate the improvement of the functional status of the affected limb in the early stage, which is worthy of applying in more medical institutions. Cite this article: Bone Joint Res 2024;13(11):647–658

As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction. Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning. We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance. Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension. Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital

The primary purpose of this longitudinal study was to examine the impact of physical and mental well-being on a successful return to work after cartilage or ligament knee injury. A secondary purpose was to examine the effectiveness of our program regarding ordering imaging (plain X-rays, US, MRI, CT scan), and the impact that costly investigations made in clinical management. Workers who had sustained a work-related knee injury and were assessed at the lower extremity specialty clinic of our hospital program were followed up until they were discharged. All patients completed the numeric pain rating scale (NPRS), the Lower Extremity Functional Scale (LEFS), and the Hospital Anxiety and Depression Scale (HADS) on the initial assessment and at final follow-up. We included 30 patients, mean age, 50(9), 11(37%) females, 19(63%) males. The most common mechanisms of injury were twisting (13, 45%) and falls (12, 41%). The knee injuries included 10 anterior collateral ligament (ACL), 3 posterior collateral ligament (PCL), 19 medical and lateral ligament injuries, and 22 meniscus injuries with some injuries overlapping. Ten patients (30%) underwent surgery (8 meniscectomy, two ligamentous repairs). Patients showed improvement in pain scores (p<0.0001) and the LEFS scores (p=0.004). Seventeen patients (57%) returned to full-time work and 11 (37%) were not working at the time of discharge with one patient performing part-time work, and one on re-training. Higher levels of pre (p=0.02) and post-treatment (p=0.03) depression and post-treatment anxiety (p=0.02) had a negative impact on a successful return to work. Most clients had proper investigations ordered by their family physicians in the community (24 plain x-rays, 11 US, and 21 MRI). Our team ordered only 6 plain x-rays and 6 new MRI. We found significant improvement in pain and disability in injured workers who received an expedited multidisciplinary care. Anxiety and depression were the most important predictors of poorer recovery and a less successful work status. The judicious use of costly imaging is expected to reduce the overall health care cost of an injury, while providing new important information such as adding a new diagnosis or changing the management

Abstract. Objectives. High tibial osteotomy for knee realignment is effective at relieving symptoms of knee osteoarthritis but the operation is surgically challenging. A new personalised treatment with simpler surgery using pre-operatively planned measurements from computed tomography (CT) imaging and 3D-printed implants and instrumentation has been designed and is undergoing clinical trial. The aim of this study was to evaluate the early clinical results of a preliminary pilot study evaluating the safety of this new personalised treatment. Methods. The single-centre prospective clinical trial is ongoing (IRCCS Istituto Ortopedico Rizzoli; IRB-0013355; ClinicalTrials.gov NCT04574570), with recruitment completed and all patients having received the novel custom surgical treatment. To preserve the completeness of the trial reporting, only surgical aspects were evaluated in the present study. Specifically, the length of the implanted osteosynthesis screws was considered, being determined pre-operatively eliminating intraoperative measurements, and examined post-operatively (n=7) using CT image processing (ScanIP, Synopsys) and surface distance mapping. The surgical time, patient discharge date and ease of wound closure were recorded for all patients (n=25). Results. Over the study period the average surgical time (skin incision to suture) reduced from 54 to 31 minutes (range: 17–62, n=25). It was noted that wound closure was easier than the conventional surgery due to the lower profile of the implant. Over seventy percent of patients were discharged day 2 post-op. The position, orientation and length of all screws matched the pre-operative configuration to within approximately 1mm. Conclusions. The early trial results are promising from a clinical perspective. It was evident that surgical time was saved because no intraoperative screw length measurements were required, and the use of custom instrumentation significantly reduced the surgical inventory. The reduced invasiveness and ease of surgery may contribute to faster patient recovery compared to conventional techniques. The full trial results will be reported later this year. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

Introduction. Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have focused on payer type and have not controlled for the surgeon's practice or patient care setting. This study aims to evaluate whether patient point of entry plays a role in quality outcomes and discharge disposition following THA. Methods. The electronic medical record at our institution was retrospectively reviewed for all primary, elective, unilateral THA between January 2016 and June 2018. THA recipients were categorized as either Hospital Ambulatory Clinic Centers (HACC) with Medicaid as the primary payer or private office patients with a non-Medicaid primary payer based on a previous visit to our institution's HACC within the 6-months prior to surgery. Only patients who had been operated on by a surgeon with at least 10 HACC and 10 private office patients were included. Results. A total of 426 patients were included in this study, with 114 HACC and 312 private office patients. HACC patients were significantly younger (p<0.01), more likely to be black or “other” race (p<0.01), and more likely to be a current smoker (p<0.01). In the unadjusted model, length of stay (p=0.15) and surgical time (p=0.03) were greater in HACC patients. There was no difference in discharge disposition (p=1). After adjusting for patient risk factors, LOS was greater for HACC patients, whereas surgical time and facility discharge were lower. Conclusion. There was a significant difference in surgical time between HACC and private clinic patients. After controlling for patient risk factors, LOS, surgical time, and facility discharge were similar between the two groups. These results indicate that similar outcomes can be achieved for Medicaid patients as compared to non-Medicaid patients as long as the surgeon and patient care setting are similar. For any tables or figures, please contact the authors directly

Background: The aim of this study was to analyse mid-shaft clavicle fractures in children and adults to find out the factors that would influence the healing time and the necessity of surgical intervention. Methods: We identified all the midshaft clavicle fractures treated at Chesterfield Hospital between January 2003 and January 2006. We studied the case notes and radiographs of these patients. We grouped the midshaft fractures into those in children and those in adults. Each group was further subdivided into two part and three part fractures. It was also noted whether a vertical butterfly fragment was present in the three or more part fractures. The fractures were analysed for their incidence, presence of comminution, degree of displacement, type of treatment and the follow-up time before discharge. Results: – Over the 3 year period, 242 middle 1/3 clavicle shaft fractures were treated. Among the mid shaft fractures there were one hundred and eight (44.6%) children and one hundred and thirty four (55.3%) adults. There were one hundred and three children with two part clavicle fracture (95.3%) and one required surgical fixation (1%). There were only five children with three or more fracture fragments (4.7%) and one required surgical fixation (20%). All five children who had three or more fracture fragments were found to have vertical fragment on x-ray. The average time for discharge was 27.48 days for two part fractures and 49 days for three part fractures. There were seventy-five (55.5%) adults with two part fractures and ten of them required surgical fixation (13.3%). There were fifty-nine (44.0%) with three or more fragments and eleven of them required surgical fixation (18.6%). Out of the fifty-nine fractures, which had three or more fragments, forty-eight had vertical fragment on x-ray (81.3%). Among the three part fractures, there were ten fractures with vertical fragment that required surgical fixation (20.8%). The average time for discharge was 52.07 days for two part fractures and 93.56 days for fractures with three or more fragments. There was no difference in the discharge time for non operated three part fractures with or without vertical fragment. Conclusion: The incidence of clavicle fractures in children is nearly as high as in adults. In children the number of days for discharge is nearly double for three part fractures when compared to two part fractures. The presence of vertical fragment predicts higher rate of surgical intervention required due to either delayed/non union or localised skin tenting. We recommend that we should have a lower threshold to fix the 3 or more part clavicle fractures with vertical fragment

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Since November 2003 there have been 62 Metacarpophalangeal Joint (MCPJ) replacements carried out on 16 patients at Macclesfield District general hospital. 11 of the patients were female and 5 were male. The mean patient age at procedure was 64.9 years, with an age range of 28 to 80. Of the 62 MCPJ replacements carried out, 58 (93.5%) were as a result of rheumatoid arthritis, with only 4 (6.5%) as a result of osteo-arthritis. The primary objective of this study is to assess their outcomes to date. Data was collected retrospectively by means of case note review. Outcomes measured were patient rating of pain and function at post operative review and post operative complications. All operations were carried out by a single surgeon, using his standard operative technique, and all replacements used the Neuflex Finger Joint Implant System. All 16 patients attended for post operative review. At the time of discharge 13 patients rated their outcome as excellent to good, 1 patient was deceased and 2 patients are currently under follow up with no reported complications. Mean time to discharge was 19 months (2–68). Of the total 62 joints replaced, 10 revisions were carried out. Of these, 3 were as a result of dislocation, 6 were for subluxation and 1 as a result of failure of the prosthesis. There were 3 other post operative complications; 1 was for superficial wound infection, 1 resulting from a prominent prosthesis and 1 hypertrophic scar. Results showed that 81.3% of patients rated their range of movement as good to excellent and 87.5% reported an improvement in pain. Overall, 81% of patients rated their outcome at discharge as good to excellent. From the data available we conclude that the Neuflex system is an effective treatment method with a low complication rate

The management of closed ankle fractures requiring open reduction and internal fixation is dependent upon soft tissue swelling to determine the timing of the surgery. At Exeter in 2001 one third of all trauma cases were operated on “out of hours”, in 2007 less than ten percent were principally because of the lack of anaesthetic staff. The senior author has developed a technique of percutaneous ankle fixation that may be undertaken at an early stage despite the presence of swelling. A retrospective study of four years focusing on time to surgery, time to discharge and complications was compared with a cohort selected at random that had undergone open fixation from the same period. Patients undergoing percutaneous fixation were extracted using the Plato database and all patients were included. Admission documentation, operation notes and subsequent clinic letters were used to ascertain the outcomes. Pre and post-operative imaging was evaluated. Over a four year period two consultants and four specialist registrars performed the technique on a total of 22 patients. The mean time to surgery was 2.04 days for the percutaneous cohort (range 0–5 days) compared with 4.04 for the open cohort (range 1–10). Time to discharge was 4.6 days to 5.8 in favour of percutaneous. No complications were experienced in the percutaneous cohort compared with 6 patients in the open. Preliminary results demonstrate a reduced waiting time for surgery and a quicker discharge. Percutaneous fixation is an option when swelling precludes open fixation

Aims

Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

Aims

Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design.

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

The timing of surgery in treating closed ankle fractures requiring open reduction and internal fixation is dependent upon soft tissue swelling. At Exeter in 2001 one third of all trauma cases were operated on “out of hours,” in 2007 this was less than 10%, principally as a result of the lack of anaesthetic staff. The senior author has developed a technique of minimally invasive percutaneous plate osteosynthesis for ankle fracture fixation that may be undertaken at an early stage, despite the presence of swelling. In a retrospective study 25 patients fixed with percutaneous osteosynthesis over four years were compared with a cohort of 25 patients selected at random who had undergone standard open reduction and internal fixation in the same time period. Particular attention was paid to time to surgery, time to discharge and complications. Patients undergoing percutaneous fixation were found from the hospital database. One patient was excluded because of a delay to surgery whilst being treated on the intensive care unit. Admission documentation, operation notes and clinic letters were used to ascertain the outcome. Pre and post-operative imaging was evaluated. Over a four-year period the senior author performed minimally invasive percutaneous plate osteosynthesis on a total of 25 patients. The mean time to surgery was two days for the percutaneous cohort (range 0–5 days) compared with 4.1 days for the open cohort (range 1–11). Time to discharge was 4.2 days as opposed to 6.2 in the percutaneous group. There were no complications in the percutaneous cohort, as opposed to three in the standard cohort. Preliminary results demonstrate a reduced waiting time for surgery and a quicker discharge when using minimally invasive percutaneous plate osteosynthesis technique for ankle fracture fixation. We believe that our institution is the first to develop this technique. Percutaneous fixation is an option when swelling precludes open surgery

Aims

This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification.