Background

Internet delivered interventions may provide a route to rapid support for behavioural self-management for low back pain (LBP) that could be widely applied within primary care. Although evidence is emerging that more complex technologies (mobile apps linked to digital wristbands) can have some impact on LBP-related disability, there is a need to determine the effectiveness of highly accessible, web-based support for self-management for LBP.

Fewer delays in starting a trauma list can reduce cancellations. A novel system has been previously described where a patient is identified the day before and optimised for theatre. The patient is listed first and designated “Golden Patient”. This project aimed to assess the impact of introducing a “Golden Patient” system on trauma list start times in a district general hospital.

Two months of first case sending and anaesthetic start times were recorded retrospectively (43 cases). The “Golden Patient” system was introduced with a multi-disciplinary implementation group. Target send time of 0830 hours (hrs) and anaesthetic start time of 0900hrs was agreed. First patients on trauma lists were noted in two cycles, two months apart (Cycle 1: 46, Cycle 2: 38).

Prior to implementation: Mean Send Time (MST) of 0855hrs, Mean Anaesthetic Start Time (AST) of 0921hrs.

Cycle 1: MST fell by 9 minutes (p = 0.03) and AST by 11 minutes (p = 0.023). Lists labelled with a “Golden Patient” (47.8%) were sent 14 minutes earlier (p = 0.004) and started 12 minutes earlier (p = 0.02) than those not labelled “Golden”.

Cycle 2: Implementation produced a 13-minute reduction in send times (p = o.oo3) and start times (p = 0.008) overall. “Golden Patient” cases (42.1%) showed an improved MST of 0836hrs and AST of 0902hrs, 10 minutes earlier than those not designated “Golden”.

Implementation of the “Golden Patient” produced a significant improvement in trauma list starts overall. Specifically, “Golden Patients” help to improve efficiency in sending and anaesthetic start times, by up to 19 minutes on average.

An enhanced recovery programme for knee arthroplasty was introduced two years ago to our orthopaedic department. It involved the setting up of an educational programme for patients along with an extensive rehabilitation programme. The main aim of the programme is to provide an efficient and personalised service that results in an improved patient experience and fewer bed days following surgery.

We carried out a retrospective study, randomly selecting 100 patients over a period of a year who were enrolled in the enhanced recovery programme. We analysed three main areas involving the pre-, peri- and post-operative period. We looked for any key factors that led to an increase or decrease in bed days. The re-admissions were analysed and the cost benefit was calculated.

99 patients were randomly selected and satisfied the inclusion criteria. We found that with the enhanced recovery programme the average length of stay for a knee arthroplasty was four days. There were no re-admissions within the population.

We would like to share our enhanced recovery programme model as we feel it is a robust and effective way of providing a high level of care and decreasing the length of stay post-operatively.

Fascia iliaca compartment block (FIB), performed in the Emergency Department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether FIB significantly reduced the requirement for systemic opiates in the pre-operative setting. Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a four month period were gathered prospectively. 33% patients had received FIB at diagnosis in ED, dependant on the expertise of the attending physician. Morphine requirements on arrival on the ward between groups were analysed. Over a four month period 144 patients were admitted with fractured neck of femur. Over this time period, introduction of an informal educational programme in A&E increased the incidence of FIB provision at diagnosis and reduced the average amount of morphine administered. Administration of FIB reduced the average morphine requirement in A&E by 56%, when compared with those who received systemic analgesia alone (CI 0.4–3.5, p=0.014). No adverse effects were reported with FIB. Fascia Iliaca Compartment Block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement.

Introduction

The muscles of the leg collectively comprise the calf pump, however the action of each muscle group on calf pump function is not known. Patients with foot or ankle injury or surgery are often advised to perform foot and ankle movements to help prevent deep venous thrombosis. Our aim was to determine which foot and ankle movements were most effective in stimulating the calf pump. Method: Nine healthy participants were enrolled in this research and ethics approved prospective study. Participants with a previous history of peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Each participant followed a standardized protocol of foot and ankle movements, starting with foot in neutral position and the baseline and movement peak systolic velocity within the popliteal vein was measured during each movement. The movements tested were toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion.

Introduction

The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function.

Background

Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery.

Independent sector treatment centres (ISTCs) were introduced in October 2003 in the United Kingdom in order to reduce waiting times for elective operations and to improve patient choice and experience. Many concerns have been voiced from several authorities over a number of issues related to these centres. One of these concerns was regarding the practice of ‘cherry-picking’. Trusts are paid according to ‘payment by results’ at national tariffs. The national tariff is an average of costs occurring in an average mix of patients. The assumption is that the higher the co-morbidities of the patients the more likely they are to consume a higher amount of resource and to require a longer length of stay. Cherry-picking may also affect the quality of training available to trainees.

This audit was aimed at identifying if, and how much this practice occurs. It also identifies what affect this has on the case-load of patients left for the NHS hospitals.

We looked at the number of co-morbidities amongst 198 consecutive patients undergoing hip and knee primary total arthroplasty at an ISTC, a district general hospital whose PCTs provide patient to the ISTC (Doncaster Royal Infirmary - DRI), and a district general hospital in the same area whose PCT did not provide choice at that time and who therefore did not send patients to the ISTC (Bassetlaw District General Hospital - BDGH). We found a statistically significant difference in the number of co-morbidities per patient at the ISTC compared with the DRI (1.23 vs. 2.05) and the ISTC compared with the BDGH (1.23 vs. 1.76). We were unable to show a statistically significant difference between the DRI and the BDGH. We conclude that cherry-picking does take place, and further work should be done to assess the impact on training and finance.

Aim To assess whether prosthetic femoral stem centralisers have a detrimental effect on the maroporosity of the cement mantle, and if so, whether this is independent of their design and the rate of implantation.

Methods 30 identical moulded prosthetic femora were divided into 3 groups. Group 1; no centraliser (control), Group 2; centraliser A, Group 3 centraliser B. Using third generation cementation techniques and pressure monitoring, Charnley C-stems +/− the appropriate centraliser were implanted to a constant depth. Half in each group were implanted as rapidly as possible and the other half over 90 seconds. The stems were removed and the cement mantle then underwent a preliminary arthroscopic examination prior to being sectioned transversely at 3 constant levels. Each level was then photographed and digitally enlarged to a known scale to allow examination and determination of any cement voids (macropores) surface area.

Results There were no significant pressure fluctuations between the groups. Preliminary arthroscopic examination revealed that cement voids appeared more common when a centraliser was used. This difference was statistically confirmed (p=0.002) following sectioning of the specimens with cement voids found in 85% of femora when a centraliser was used and only 20% in the control group. Centraliser B performed worst with cement voids of a larger volume and more frequent occurrence (p=0.002). The macroporosity of the cement mantle was independent of the rate of implantation (p=0.39).

Conclusion The use of femoral stem centralisers is helpful in preventing malposition of the implant but results in increased macroporosity of the cement mantle. This may have implications regarding the longevity of an implant in terms of early loosening and therefore their design and use must always be carefully considered.

We set out to determine whether modification of ward facilities and working practices can prevent MRSA infection on an elective Orthopaedic ward, and whether these changes are cost effective.

Following a cluster of 3 cases of acute, deep MRSA infections in arthroplasty patients in early 1999, a review of elective orthopaedic facilities was carried out. The problems identified on the elective Orthopaedic ward were:

inadequate toilet/washing facilities

The following changes were made:

Ward

reduction of beds from 36 to original complement of 30

Staff

regular MRSA screening of all staff

Practices

all patients must have a negative MRSA screen before admission

There has been only one further case of MRSA wound infection in the 1300 major cases that have been through the ward in the last 3 years. This patient spent the first 48 hours post-operatively on the ITU, where MRSA colonisation was widespread.

We performed a cost analysis exercise on the request of our Microbiology department, as they felt that the routine swabbing of so many patients was not cost effective.

We analysed the year 2000 in which 1783 patients were screened for MRSA at a total cost of £24,962 (£14.00 per screen).

A literature search gave us the estimated cost of an MRSA infected arthroplasty being in the order of £31,568, which compares favourably with the total yearly cost of our screening program.

With appropriate facilities and modification of working practices, MRSA infection can be controlled on an elective Orthopaedic ward.

The total yearly cost of our screening programme is less than the potential cost of a single MRSA infected arthroplasty.

The changes made to our working practice and the introduction of our screening programme have been found to be both clinically and cost effective.

Aim: To determine the complication rate following fixation of olecranon fractures in the elderly.

Method: A retrospective review of clinical notes and x-rays over a 4 year period at 3 district general hospitals in South Wales was performed. Only patients with isolated, displaced olecranon fractures over 65 years were included.

Results: 80 patients who underwent olecranon fixation were identified and reviewed. It was found that 80% of these underwent tension band wiring and the operations were performed in the majority by training grade surgeons. The overall complication rate was 37%. This included an infection rate of 13%, of which the majority required re-operation.2 patients required multiple procedures including olecranon excision and triceps advancement. Prominence of metalwork was a significant problem with removal of metalwork performed in 24% of patients.

Conclusion: In what is commonly regarded as a straightforward procedure carried out by training grade surgeons we found an unacceptable re-operation rate of 37%. It is our belief that olecranon fixation in the elderly is not a benign procedure and caution should be exercised when dealing with these injuries. We propose an alternative method of surgical treatment for these injuries.

Of 41 consecutive patients with newly diagnosed osteogenic sarcoma admitted to the Children's Orthopedic Hospital and Medical Center in Seattle, Washington, between 1952 and 1977, 19 treated before 1973 did not receive adjunctive chemotherapy (histological group) whereas after 1972 22 have been so treated (chemotherapy group). Chemotherapy consisted primarily of high doses of methotrexate and adriamycin for 16 months after surgical treatment. Patients in the historical group have been observed for a minimum of nine years (six patients) or until death (13 patients). The 13 surviving patients in the chemotherapy group have been followed for a minimum of three years (median five years) and all 12 disease-free patients have been off therapy for between one and a half and five and a half years (median three years). Overall, the chemotherapy group has had a significant increase in both survival (p = 0.03) and disease-free survival (P = 0.02) compared to the historical group. In 35 patients with localised disease at diagnosis, the three-year disease-free survival and the three-year survival rates were 18 per cent and 41 per cent respectively in the historical group, and 67 per cent and 78 per cent (life table estimates) respectively in the chemotherapy group. With adjunctive chemotherapy only one of the seven patients developing pulmonary metastases did so later than nine months after diagnosis. The superior results in the chemotherapy group could not be accounted for by differences in age, sex, presence of metastases at diagnosis, histopathology, location of primary tumour, type of initial or subsequent surgical treatment, or the use of standard or computerised lung tomography. Although the use of historical controls in this study does not exclude other changes as contributing to the observed improvement in outcome, our data support the contention that adjunctive chemotherapy improves both the disease-free survival and the overall survival of patients with osteosarcoma and rarely delays the onset of recurrent or metastatic disease.