“Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign.Objectives
Methods
40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67. 3 years, (range 48 to 87 years) and the mean follow up 50 months (range 8 to 134 months). Each patient had undergone at least 1 operation prior to the index arthroplasty (range 1 to 10). 27 elbows were flail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2. A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a snap-fit Souter Strath-clyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. At review 38 elbows had no or mild pain, 2 moderate, and no patient had severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant. Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in one and curettage and bone grafting of a cement granuloma in one. One patient with a Charcot joint developed a non-union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition six had delayed wound healing, two ulnar nerve symptoms and two triceps weakness. In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a flail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.
