Although day surgery has a good patient satisfaction and safety profile, accurate episode-of-care costs (EOCC) calculation for of this procedure compared to standard same-day admission (SDA), while considering functional outcomes, is not well known. This study assesses the EOCC for patients with a THA while comparing DS and Same Day Admission (SDA) (with a 1-day hospitalization) pathways. The episode-of-care cost (EOCC) of 50 consecutive day surgery and SDA patients who underwent a THA was evaluated. The episode-of-care cost was determined using a bottom-up Time Driven- Activity Based Funding method. Functional outcomes were measured using preoperative and postoperative Harris Hip Score (HHS). Overall, the SDA THA cost 11% more than a DS THA. The mean total EOCC of DS THA was 9 672 CAD compared to 10 911 CAD in the SDA THA group. Both groups showed an improvement in HHS score following the procedure but patients in the DS group had a significantly higher postoperative HHS score and a significantly greater improvement in their HHS score postoperatively. Day surgery THA is cost-effective, safe and associated with high patient satisfaction due to functional improvement. Providing policymakers the information to develop optimal financing methods is paramount for clinicians wishing to develop modern protocols, increase productivity while providing the optimal care for patients

In patients admitted to hospital with a hip fracture, urinary issues are common. Despite guidelines that recommend avoiding foley catheter usage when possible, it remains a common part of perioperative care. To date, there is no prospective data on the safety and satisfaction associated with catheter use in such cohort. The aim of this study was to evaluate the satisfaction of patients when using a foley catheter while they await surgery for their fractured hip and the safety associated with catheter use. In our prospectively collected database, 587 patients were admitted to our tertiary care center over a 1 year period. Most patients (328) were catheterized within the first 24h of admission, primarily inserted in ED. Of these patients, 119 patients (61 catheterized and 58 noncatheterized) completed a questionnaire about their perioperative management with foley catheter usage administered on day 1 of admission. This was used to determine satisfaction of catheter use (if catheterized) and pain levels (associated with catheterized or associated with transferring/voiding if not catheterized). Adverse effects related with catheter use included urinary tract infection (UTI) and post-operative urinary retention (POUR). Ninety-five percent of patients found the catheter to be convenient. Only 5% of patients reported any pain with catheter use. On the contrary, 47.5% of non-catheterized patients found it difficult to move to the bathroom and 30.4% found it difficult to urinate. Catheterized patients had significative less pain than uncatheterized patients (0.62/10 vs 2.45/10 respectively, p < 0 .001). The use of nerve block reduced pain levels amongst catheterized patients but was not associated with reduced pain levels or satisfaction amongst non-catheterized patients. The use of catheter was not associated with increased risk of UTI(17.5% in the catheterized vs 13.3% in the non-catheterized, p = 0.541) or POUR (6.8% in the catheterized vs 11.1% in the non-catheterized, p = 0.406). This study illustrates the benefits and safety associated with the use of urinary catheters in the pre-operative period amongst hip fractures. The use of catheters was associated with reduced pain and satisfaction without increasing post-operative UTI or POUR. These findings suggest that pre-operative catheter use is associated with less pain and more satisfaction for patients awaiting hip surgery and whom other measures, such as nerve blocks, are unlikely to reduce the discomfort associated with the mobility required to void. A prospective randomized control study could lead to a more evidence based approach for perioperative foley catheter usage in hip fracture patients

The treatment for Humeral Supracondylar fractures in children is percutaneous fixation with Kirschner wires using a unilateral or crossed wire configuration. Capitellar entry point with divergent wires is thought crucial in the lateral entry approach. Crossed wire configuration carries a risk of Ulnar nerve injury. Our department had recorded a number of failures and this required review. A search was conducted for children with this injury and surgical fixation. A two year time frame was allocated to allow for adequate numbers. The hospitals radiography viewing system and patient notes were utilized to gather required information. 30 patients from 2–14 years all underwent surgery on the day of admission or the following day. 18 had sustained Gartland grade 3 or 4 injuries. Unilateral configuration was used in 10 cases; a loss of reduction was noted in 5 of these with one case requiring reoperation. Crossed wires were used in 20 cases with a loss of reduction in 1. Crossed wire configuration provides a more reliable fixation with a lower chance or re-operation. Our DGH policy now advises the use of this configuration. A small “mini-open” ulnar approach is utilized with visualization and protection of the nerve

Aim. The objective of this study was to define hospital-related healthcare costs associated with infection after fracture fixation (IFF) of the tibia and identify the subset of clinical variables relevant in driving these costs within the Belgium's healthcare system. Method. Between January 1. st. 2009 and January 1. st. 2014, a total of 358 patients treated operatively for AO type 41, 42 and 43 tibial fractures, were included in this study. The calculated costs were related to the Belgium's healthcare financing context and limited to costs induced by hospital related care. Five main hospital-related cost categories were studied: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. In addition, a total of 19 clinical and process variables were defined. Results. The median total treatment cost for all tibial fractures was €6.962 euro (IQR €4932 – €10.972), with AO type 42 being the most expensive fracture type. In 12 (3.4%) patients the treatment was complicated by deep (implant-related) infection. Subsequently, the treatment costs for deep (implant-related) infection were almost 7-times higher compared to non-infected patients (€44.680 vs. €6.855 p<0.001) with hospitalization, length of stay (LOS), accounting for 50% of the total amount of the cost. The bivariate correlation between total treatment costs and LOS was close to 1. Multivariate analyses showed deep (implant-related) infection, non-union, age and ASA-3 as most important drivers (p<0.001) for both the total treatment costs and LOS. Moreover, the LOS was also driven by a delayed staged surgery protocol. Conclusions. One of the most challenging complications in trauma surgery is the development of IFF. Infections associated with fracture fixation devices result in significant patient morbidity and a prolonged treatment period. Currently, there is a lack of data regarding the definition, functional outcome and health care burden of this musculoskeletal complication. This study shows that treatment costs for deep (implant-related) infection were almost 7-times higher compared to non-infected patients. Furthermore, LOS accounted for 50% of the total amount of the cost. This study shows that future research needs to focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures. Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database. Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14). The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes

Trauma ward rounds (TWR) are usually preceded by trauma meetings where previous day admissions are discussed and management decisions made. Therefore, one would expect TWR to be relatively quick and efficient. We measured the distance walked during TWR over a one week period and examined effects of number of patients and their location on distance walked. We used a pedometer (after calibration) to measure the distance walked by a single consultant orthopaedic surgeon during his trauma week. The consultant conducted a daily TWR after the trauma meeting where previous day admissions and postoperative patients were reviewed. We initially measured the distance required to visit five wards where trauma patients could be found (trial distance) and used that for comparison. We recorded number of patients reviewed and wards visited daily. The distance walked daily during TWR was 1.37–2.4 times longer than trial distance. There was no correlation between number of patients reviewed or number of wards visited and distance walked. Despite the larger number of patients towards the end of the week (33 patients on 3 wards on last TWR), the distance walked remained shorter than on the first TWR (11 patients on 3 wards). The distance walked during the whole week was 30.8 miles!. We found no correlation between number of patients reviewed or their location and distance walked during TWR. The relatively shorter distances walked towards the end of the week could be explained by more familiarity and therefore, better organisation by the team as the week progressed

Aim. (1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN. Materials and Methods. 56 children presented with slipped upper femoral epiphysis (SUFE) from 1998 to 2008; 29 males, 27 females; mean age 12.8 years. The Loder & Southwick classifications were used. All slips were treated surgically. The mild and moderate groups were treated with a single pin-in-situ. The severe group had either surgical reduction [Fish femoral neck osteotomy], alternatively a single pin-in-situ, randomised by day of admission. Avascular necrosis of the femoral head (AVN) was the primary outcome measurement. Results. There were seven cases of AVN (12.5%). 2/41 in the stable group developed AVN compared to 5/15 in the unstable group, statistically significant [Chi-Square P=0.001]. No patient in the mild group, one out of seven in the moderate group, and six out of 22 in the severe group developed AVN. In the severe slip group, the AVN rate in the PIS group was 40%, after Fish osteotomy it was 23.5%. This is not statistically significant, but the trend favours surgical reduction. Conclusion and Significance. (1) Surgical reduction by Fish osteotomy is no riskier for AVN than pinning in situ for severe SUFE. Surgical reduction should therefore be performed to avoid gross deformity in these cases. (2) We have confirmed that the stability and the severity of the slip at presentation are the best indicators for predicting AVN

Aim. To determine if the location and pattern of knee pain as described by the patients using the knee pain map was comparable with the intra articular pathology found on arthroscopy as well as to facilitate diagnosis based on pain. Methods. There were fifty five consecutive patients with acute and chronic knee pain participating in the study and they subsequently underwent arthroscopy of the knee joint as therapeutic or diagnostic procedure in day surgery. Those patients with extra articular pathologies, referred pain hip, back and foot were excluded from the study. All the participants were consented for the study; subjective data was recorded on the standardised knee pain map that included visual analogue pain scale preoperatively on the day of admission for arthroscopy. The findings of the arthroscopy including EUA were recorded on the on standard arthroscopy forms used in our department by the operating surgeon. Results. Patients on the knee pain map most often recorded sharp/stabbing pain (72%), followed by diffuse dull pain (14.5%), mixed dull and sharp pain (10 %) and burning pain (3.5%). 82% of the localising pain pattern recorded on the knee pain map by the patients corresponded to the intra articular lesion found during knee arthroscopy. 18 % of the pain mapping location and pattern was not very specific to the intrarticular arthroscopic lesions. Conclusions. The results from our study indicate, majority of the patients could map the knee pain location and pattern correlating to the knee arthroscopic findings. Furthermore, the knee pain mapping can be used as a reliable tool to assist the clinician to determine the specific knee pain patterns correlating with intra-articular lesion

Background. Osteomyelitis can be difficult to diagnose. Unlike septic arthritis no defined diagnostic criteria exist as a guide. Inflammatory markers are frequently utilized at initial presentation, (in addition to white cell count). Methods. All radiologically confirmed cases of long bone osteomyelitis without septic arthritis, joint effusion or abscess, in paediatric patients, presenting to one hospital over an eighteen-month period were included. These patients were compared with all culture positive septic arthrides presenting to the same hospital within the same time period. Inflammatory markers taken on the day of admission were studied. Results. Thirty-seven patients with long bone osteomyelitis and thirteen with culture positive septic arthritis were identified. The two groups were comparable with regards to age and gender. At presentation 65% of the osteomyelitis patients had an ESR less than 40mm/hour, 48% below 20mm/hour and 19% within the normal range. 23% of the septic arthritis patients had an ESR below 40mm/hour, and none had an ESR below 20mm/hour or in the normal range. The CRP was in the normal range in 46% of the osteomyelitis patients and none of the septic arthritis patients. The average ESR and CRP in the osteomyelitis patients were 47mm/hour and 35mg/L respectively, while in the septic arthritis group these were 72mm/hour, (P< 0.021), and 107mg/L, (P< 0.028). Conclusions. The initial rise in inflammatory markers due to long bone osteomyelitis is significantly less than that in septic arthritis. A proportion of patients presenting with osteomyelitis have normal inflammatory markers at presentation. A high index of suspicion is required in diagnosing osteomyelitis, and inflammatory markers, while a useful adjunct to monitoring treatment, may offer false reassurance regarding the initial diagnosis

Patients with hip fractures should have surgery within 36 hours of admission to hospital. This reduces mortality and is required for hospitals to receive the NHS Best Practice Tariff. Many patients with hip fractures take Warfarin and reversing the effect of this frequently delays surgery. We report the results of a case-control study. The primary outcome measure was the number of patients with an INR of 1.7 or less on the day following admission to hospital. This is considered an acceptable INR for hip fracture surgery in our department. In the control group the dose of Vitamin K given was decided by the admitting doctor based on the patients' INR. In the intervention group all patients received 5mg of IV Vitamin K on admission. They had their INR rechecked at 6:00am the following morning and a further 2.5mg of Vitamin K was given if it was 1.8 to 2.0 and a further 5mg of Vitamin K was given if it was greater than 2.0. 350 patients with hip fractures were admitted to our department and 26 (7.4%) of these were taking Warfarin. The control group contained fourteen patients who had a mean INR of 3.3 on admission. The time taken to achieve an INR of 1.7 or less was one day for four patients; two days for nine patients and three days for one patient. The intervention group contained twelve patients who had a mean INR of 2.7 on admission. The time taken to achieve an INR of 1.7 or less was one day for eleven patients and two days for one patient. There were no complications caused by Warfarin reversal. A high proportion of patients with hip fractures take Warfarin. This can be reversed promptly and safely using our protocol

Introduction. Excessive soft tissue swelling will delay surgery for a proportion of patients admitted with ankle fractures. Surgical and anesthetic teams may waste time assessing patients destined to be cancelled due to swelling. The aim of this investigation was to determine factors associated with cancellation. Methods. Case notes of 87 patients (46 male, 41 female), mean age 43 years (range, 13 to 80) who underwent ankle fracture fixation were retrospectively analysed. 31 of 87 ankles (36%) were unsuitable for day after admission surgery due to swelling. Factors investigated included age, gender, mechanism of injury, fracture configuration and necessity for reduction on arrival in the emergency department due to dislocation; each factor was independently analysed for significance using Fisher's exact test. Results. Ankle fractures associated with a higher energy injury such as sports, falls from height and road traffic accidents were significantly more likely than simple slips to be cancelled due to excess swelling the following morning (p = 0.053). Tri- or bi-malleolar ankle injuries and fracture dislocations requiring manipulation in the emergency department were also significant risk factors for cancellation (p = 0.004 and p = 0.002 respectively). Patients presenting with at least two of these factors demonstrated a 71% probability of cancellation the following day (17 of 87 patients). Presence of three risk factors increased the probability of cancellation to 100% (3 of 87 patients). Conclusion. Cancellation on the day of surgery wastes time and causes patient distress. During busy on-call periods patients with all three risk criteria will almost certainly be too swollen for next day surgery. With the proviso that these fractures are immobilised in an acceptable position, patients could be rested with elevation and rebooked for surgery as opposed to being assessed and subsequently cancelled due to soft tissue swelling the day after injury

The straddle fractures represent a distinct anatomical pattern of pelvic trauma. Their specific clinical characteristics, associated injuries and clinical outcome remain mostly underreported and ambiguous. Over a 3-year period all straddle fractures were identified from a prospective database of a tertiary referral hospital. For all cases, excluding children < 16 years and pathologic fractures, demographic characteristics, associated trauma, ISS-2005, transfusion requirements, surgical procedures, post-operative course, complications and clinical outcome were recorded over a median follow-up of 19 months (7-36). All fractures were classified by the two senior authors separately. Of 280 pelvic fractures, 31(11%) straddle fractures were identified. The median age was 38 years (17-88) and the male/female ratio was 1.38. Half of them were classified as lateral-compression (51.6%), 19.4% as anteroposterior-compression, and 29% combined mechanism of injury. 9 cases had an intra-articular extension to one or both acetabula. Median ISS was 21 (9-57), while 71% had a serious (AIS>2) associated thoracic injury, 48.4% head injury, 38.7% abdominal injury, 51.6%- lower extremity fracture, and 38.7% significant urogenital injuries. Six underwent acute embolisation, and the mean transfusion rates over the initial 72hrs were 7.5 units-cRBC, 2.3 units-FFP, 0.5 units-PLTs. All cases were treated operatively, either with ORIF (14 cases), closed reduction and percutaneous screw fixation (10 cases), while an external fixator was used in 21 cases. The median length of stay was 21 days (1-106). The mortality rate was 6.5% (one on the day of admission and another after 15 days at the ICU). Eight superficial infections, 2 deep sepsis of pfannestiel wounds, as well as 1 asymptomatic nonunion of an inferior pubic rami were recorded. 5 cases underwent further surgery for late urogenital repair and 4 cases have chronic incontinence and sexual dysfunction symptoms. Straddle fractures represent a severe type of pelvic trauma, associated with severe mostly thoracic, head and extremity trauma, severe urogenital complications, and suggest pelvic ring instability that requires surgical stabilisation in the acute setting. They are easily identifiable at the initial radiological investigations and should alert the clinician for multidisciplinary assessment and early referral

Introduction

Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics.