Typical UK patients spend 5–7 days in hospital following total hip replacement (THR). Decreasing length of stay (LOS) increases throughput and reduces cost. We have developed a short stay THR programme (SSP), which has been used in all patients since May 2006; we present the first 100. Every patient undergoing THR is included in the dataset. All attend ‘bone school’ before admission, with talks and individual assessments by the senior sister, physiotherapist and occupational therapist. Medical concerns are discussed with an anaesthetist. Patients receive training with crutches; crutches are provided for home practice. All receive an uncemented Corail-Pinnacle THR via piriformis-sparing mini-posterior approach. ‘Low dose’ spinal plus light general anaesthesia provides sensory block whilst retaining motor function; painfree fully weightbearing mobilisation is predictably achieved within four hours. Following radiograph and haemoglobin check next morning, patients are discharged on meeting specific nursing/physiotherapy criteria. Those within 20 miles receive outreach follow-up. Follow-up assessment is undertaken using SF36, Visual Analogue, Merle d'Aubigné-Postel and Oxford Hip Scores.Introduction
Methods
Recent interest has focused on minimally invasive hip surgery, with less attention being directed to maximising the potential benefits of this type of surgery. We have developed a new multidisciplinary programme for patients undergoing total hip replacement in order to facilitate an overnight hip replacement service. The programme involves a pre-operative regimen of education and physiotherapy, a modified anaesthetic technique, a minimally invasive surgical approach and a portable local anaesthetic pump infusion for post-operative pain control. Strict inclusion and exclusion criteria were developed based on age, medical status and social circumstances. Patients were mobilised on the day of their operation and discharged home with an ‘outreach team’ support network. No patient complained that their discharge was early. Independent evaluation was performed using the Oxford Hip Questionnaire, the Merle d'Aubigné clinical rating system and Visual Analogue Pain Scores. Thirty seven patients underwent total hip replacement using the new protocol. The average length of stay was 1.2 days. The mean pain score on discharge was 1.3/10. The Oxford Hip Questionnaire and Merle d'Aubigné scores were comparable to patients who underwent surgery prior to the introduction of the new protocol. Minimising in-patient stay for total hip replacement benefits the patient by reducing exposure to nosocomial infection and expediting the return to a normal environment for faster rehabilitation. This new programme allows patients undergoing total hip replacement to be discharged after 1 night post-operatively without compromising safety or quality of care. Minimally invasive surgery with a suitable infrastructure can be used to dramatically reduce the length of stay in suitable patients. This can be achieved reliably, safely and with high patient satisfaction. In order to gain the benefit of Minimally Invasive Surgery we recommend introducing this type of comprehensive programme.
This study aims to assess prospectively whether measurement of perioperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur. All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. 108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T >0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p<0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p<0.012). There were 9 deaths in the raised Troponin group (21.4%), and 5 (7.6%) in the group with no rise (p<0.05). The principal causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.
The use of ultrasound-guided wire localisation of lesions is not well described in the orthopaedic literature. We describe a case of an impalpable schwannoma of the femoral nerve and another of sacroiliitis with an associated pelvic abscess. In both, surgical localisation was difficult. Peri-operative ultrasound-guided wire localisation was used to guide surgery and minimise tissue damage, thereby optimising the results and recovery of the patient.
