The impact of digitisation of a virtual fracture clinic on referral quality, outcomes and assessment times.

BACKGROUND: Virtual fracture clinics (VFCs) have become widely adopted, aiming to improve efficiency, standardise patient care and reduce clinic appointments for injuries that can be managed conservatively. A variety of means exist to manage VFC referrals and assessment, including paper-based and digital methods. This study assesses VFC referral quality and outcomes before and after implementation of a digital VFC referral and management system. METHODS: A retrospective analysis was conducted of all VFC referrals and assessments from July 2017-March 2020 in a large UK district general hospital. All referrals and assessments were analysed for quality and completeness of referral information, grade of assessor, outcome of assessment, referral-to-assessment time, and assessment-to-surgery time (for those requiring operative management). RESULTS: 3038 paper and 9,228 digital referrals were analysed by 2 separate reviewers. Quality and completeness of referral information showed significant improvement in 11 predetermined key data points with the digital referral system (p < 0.001). Date and mechanism of injury were the most commonly missing data criteria (67.5% and 68.2%, respectively) with paper referrals. Significant improvements were noted in the proportion of Consultant delivered VFC assessments (84.2% vs 71.0%; p < 0.001), VFC discharge rate (20.8% vs 13.1%; p < 0.001) and patients recalled for urgent review (6.2% vs 0.8%; p < 0.001) with digital referrals. Mean referral-to-assessment (31.2 vs 49.9 h; p < 0.001) and assessment-to-surgery (9.2 vs 13.0 days; p = 0.01) times also reduced significantly with referral digitisation. CONCLUSION: Improvements in virtual referral quality and completeness directly lead to facilitation of more thorough, detailed and appropriate virtual assessments; improving timely decision-making, reducing unnecessary appointments, and permitting better prioritisation of workload and earlier surgery for patients requiring operative treatment. Purpose-built digital solutions are an excellent means of achieving these aims.

Improving the quality of trauma meetings by implementation of a modern trauma management platform.

Trauma meetings constitute the majority of clinical decision-making for new referrals and also act as a crucial tool to coordinate the trauma theatre list. Incorporation of electronic technology has been shown to improve the quality of patient handover. eTrauma is a recently developed cloud-based patient management platform which we planned to implement at our hospital. The aim of our project was to evaluate the quality of our current trauma meeting and subsequently the effect of implementing a modern trauma management platform. In order to identify the key concerns of staff members with the trauma meeting handover, a questionnaire was given to 20 members of the team. A review of effective handover guidelines published from the Royal College of Surgeons and the Royal College of Physicians was undertaken. We combined information from these guidelines to identify two key sets of data points for an effective trauma referral: patient demographics and referral details. Questionnaires were distributed at three separate time periods providing assessment of implementation of changes. The questionnaire results indicated progressive improvement in the morning trauma meeting with increased clarity for the anaesthetic team, better communication of operation to be performed, better documentation and clarity of management plans. A total of 150 referrals using the existing system (TIGER) were compared with 100 eTrauma referrals at two separate time intervals. Our analysis showed significant improvements in 12 (57%) of the 21 key data points indicating improved data entry for referrals using the new platform. Three PDSA (Plan, Do, Study, Act) cycles were completed with relevant adjustments within this process. Introduction of a new cloud-based trauma management platform has had a positive impact overall within our trust. Modern electronic trauma systems have the ability to improve our trauma management, this must go hand in hand, however, with a structured and effectively communicated trauma meeting.

Bile Gastritis Following Laparoscopic Single Anastomosis Gastric Bypass: Pilot Study to Assess Significance of Bilirubin Level in Gastric Aspirate.

INTRODUCTION: Laparoscopic single anastomosis gastric bypass (SAGB) is increasingly performed for morbidly obese patients. AIM OF WORK: This pilot study aims primarily at evaluating the incidence of bile gastritis after SAGB. The occurrence of reflux oesophagitis and reflux symptoms were also assessed. PATIENTS AND METHODS: This study included 20 patients having no reflux symptoms. All patients underwent a SAGB as a primary bariatric procedure by a single surgeon. Patients included consented to have an upper GI endoscopy done at 6 months postoperatively. Gastric aspirate was sent for bilirubin level assessment. Gastric and esophageal biopsies were submitted for histopathology and campylobacter-like organism (CLO) test. RESULTS: In our study, the rate of bile gastritis was 30%. In 18 patients, the level of bilirubin in gastric aspirate seems to be related to the degree of mucosal inflammation. The remaining two patients had microscopic moderate to severe gastritis with normal aspirate bilirubin level. Two patients with bilirubin level in aspirate more than 20 mg/dl had severe oesophagitis, gastritis with erosions, and metaplasia. Relationship between bilirubin level and histopathological findings of gastric biopsy examination was statistically significant with a P value of 0.001. CONCLUSION: The incidence of bile gastritis in this cohort is higher than reported in the literature, and this may be worrying. The correlation between endoscopic findings and patients' symptoms is poor. Bilirubin level and pH in aspirate might be useful tools to confirm alkaline reflux. Its level might help to choose candidates for revision surgery after SAGB. This needs further validation with larger sample size.

The Introduction of a Multidisciplinary Hip Fracture Pathway to Optimise Patient Care and Reduce Mortality: A Prospective Audit of 161 Patients.

INTRODUCTION: Hip fractures are a major cause of morbidity and mortality in the elderly. A new patient pathway was introduced in our institution to facilitate rapid preoperative assessment, acute physician involvement and early surgery for patients with hip fractures. We sought to assess its impact on patient care and outcomes. MATERIALS AND METHODS: Prospective audit of 161 patients admitted with a proximal femoral fracture in the six months before (92 patients) and after (69 patients) implementation of the pathway. Data included: time to orthogeriatric assessment (TtG); time to surgery (TtS); length of hospital stay (LOS); return to original accommodation; inpatient mortality rate. RESULTS: In the six months after introduction of the pathway, there was an increase in patients who received pre-operative medical assessment (85% after vs. 19% before, p=0.0001). Average TtG decreased (19 vs. 91 hours, p=0.0001), as did LOS (19.5 vs. 24.8 days, p=0.029) and mortality (4 vs. 14%, p=0.0336). There was an increase in patients returning to their original place of accommodation (80% vs. 57%, p=0.0069). There was a reduction in mean TtS (31 vs. 37 hours, p=0.0663), although this was not statistically significant. DISCUSSION AND CONCLUSIONS: Rapid medical optimisation and prompt surgery significantly improve outcomes in patients with hip fractures. By involving an acute medical team in patient care from the point of admission, we have significantly improved our inpatient mortality and increased the proportion of patients returning to their preoperative place of accommodation, thereby maintaining patient independence and reducing the financial and logistical burden on social care.

Successful Treatment of Painful Synchondrosis of Bipartite Patella after Direct Trauma by Operative Fixation: A Series of Six Cases.

INTRODUCTION: The patella is the largest sesamoid bone in the body and may have one (77%) or multiple (23%) ossification centres. Patellar and patellofemoral joint abnormalities are a common cause of anterior knee pain but symptomatic bipartite patella is an uncommon problem. CASE SERIES: We report a series of six cases of painful synchondrosis in bipartite patellae, all in keen athletes following a direct blow to the anterior aspect of the knee. A complete rupture of the synchondrosis with evidence of retropatellar chondral separation was seen on MRI scan in all cases. Successful surgical fixation was undertaken with complete resolution of symptoms in all patients at an average of three months post-operatively. CONCLUSION: Painful synchondrosis of a bipartite patella in young and active individuals following direct trauma is a relatively rare cause of anterior knee pain, but may be associated with significant morbidity. In cases refractory to non-operative management, successful symptomatic treatment can be achieved by operative fixation.

Patient functional outcomes with trapeziectomy alone versus trapeziectomy with TightRope(®).

PURPOSE OF THE STUDY: We assess whether patient functional outcomes with the use of a tightrope in conjunction with trapeziectomy are better than traditional trapeziectomy alone. METHODS: Retrospective study of 56 trapeziectomies in 53 patients; 26 trapeziectomies alone without additional procedures, and 30 trapeziectomies performed in conjunction with tightrope suspensionplasty. All patients were scored using Quick DASH, Patient-Rated Wrist Evaluation and Nelson base of thumb arthritis scores pre- and post-operatively. RESULTS: Significant improvements were seen with both operations using all three scoring systems. However, there was no statistically significant difference in post-operative scores between the two operations. STUDY DESIGN: Retrospective comparative study. LEVEL OF EVIDENCE: III.

Remnant prosthetic graft in revision or limb-salvage surgery: routine complete excision?

BACKGROUND: Prosthetic graft occlusion following vascular reconstruction is a major cause of morbidity commonly necessitating further limb-salvage revascularization or life-saving amputation. It is therefore surprising that there is scant data in the literature regarding the optimal management of any remnant prosthetic grafts left in situ. We present a case series of 3 patients with remnant prosthetic graft infection following revisional arterial reconstruction for limb salvage and a literature review on this topic. METHODS: Three patients presented to our institution with remnant prosthetic graft infection between March 2012 and January 2013. They had all undergone previous infrainguinal bypass surgery with polytetrafluorethylene (PTFE) grafts, which had subsequently thrombosed. Further limb salvage operations with autogenous long saphenous vein bypass in 2 cases and above-knee amputation in 1 case were performed. In all cases, the focus of infection was confirmed to have originated in the redundant remnant PTFE graft left in situ. These grafts were completely excised and the infected wounds were debrided. All patients made a full recovery. RESULTS AND CONCLUSIONS: Remnant prosthetic grafts left in situ are shown in this series to be a proven nidus for infection. Published data indicate that these infection rates are greatest in revision vascular surgery and when performing amputations. We propose that routine excision of any occluded remnant prosthetic grafts in revision surgery be considered at the time of revascularization to mitigate against the risk of subsequent infection.

Segmental arterial mediolysis: a systematic review of 85 cases.

BACKGROUND: Segmental arterial mediolysis (SAM) is a nonatherosclerotic, noninflammatory arteriopathy of unknown etiology with life-threatening manifestations. With advances in endovascular techniques, SAM is increasingly being managed without the need for major surgery. METHODS: A systematic review of the literature published on SAM between 1976 and 2012 was performed, focusing on arterial involvement, diagnostic imaging modalities, mortality and morbidity rates, and in particular treatment outcomes with open versus endovascular intervention. RESULTS: Sixty-two studies reporting on 85 cases of SAM were reviewed. Sixty-nine percent of cases were diagnosed histologically (24% on autopsy). Angiography was the most common form of diagnostic imaging modality (56% of cases). Arterial involvement was largely abdominal or cranial, with splenic arterial involvement being the most prevalent (29% of cases). There was a total SAM-related mortality of 26%. Endovascular intervention, most commonly in the form of coil embolization of aneurysmal vessel(s), was successful in 88% of cases where attempted, with no reported mortality. There was a mortality rate of 9% where open surgery was attempted. CONCLUSIONS: Catheter-based endovascular techniques can be a successful, minimally invasive treatment option in the management of this potentially life-threatening condition, and may also provide a temporary bailout measure in the acute phase before definitive surgical treatment at a later stage.

Fractured inferior pubic ramus with ipsilateral total hip replacement: a case report and review of the literature.

Pubic rami fractures are common. They are associated with significant morbidity and mortality. These fractures are usually classified as stable injuries and traditionally receive limited orthopaedic input. Management typically involves hospital admission and early input from physiotherapists and occupational therapists. Early mobilisation is advocated as a central part of managing these patients, with emphasis on secondary prevention. We report a case diagnosed as minimally displaced inferior pubic ramus fracture in a patient with an ipsilateral total hip replacement (THR). The patient was mobilised early and despite analgesia continued to complain of groin pain. Repeat radiographs showed a fracture of the acetabulum with displacement of the acetabular component of the hip replacement. We advocate early orthopaedic input for all pubic rami fractures, particularly in patients with hip arthroplasty, and thorough investigation including a CT scan of the pelvis to exclude acetabular extension prior to mobilisation.

Can patients really make an informed choice? An evaluation of the availability of online information about consultant surgeons in the United Kingdom.

OBJECTIVES: The National Health Service (NHS) 'Choose and Book' online scheme, which allows patients to select the location and time of hospital appointments, has now been extended to include the option for patients to select a specific consultant to carry out any necessary treatment. The aim of this study was to determine whether there is sufficient online information about consultants or consultant-led teams for patients to make an informed choice regarding a specific consultant. DESIGN: A web-based analysis of the availability of information. SETTING: North of England. PARTICIPANTS: Two hundred websites of orthopaedic surgeons. MAIN OUTCOME MEASURES: The websites were analysed using a bespoke template that took into account recommendations of the 2010 UK Government white paper. Each website was scored in relation to the availability of specific content relating to each surgeon. RESULTS: The majority of websites detailed authorship information (73.2%), level of professional qualification (98.5%) and area of general (73.7%) and specialist (93.3%) interest. However, approximately 50% of websites provided no information in relation to update cycle, involvement in teaching or research and patient satisfaction. Only five (2.6%) of the websites presented death rates, and none indicated morbidity rates. CONCLUSIONS: For patients to be able to make informed choices about their healthcare, surgeons need to ensure that sufficient information is available online, according to the identified limitations of the websites investigated in this study.

Meta-analysis: sacral nerve stimulation versus conservative therapy in the treatment of faecal incontinence.

AIM: Sacral nerve stimulation (SNS) has recently been used in the management of faecal incontinence (FI). This study compared SNS to conservative management with regards to functional and quality of life outcomes. METHODS: Meta-analysis of studies published between 1995 and 2008 on SNS for FI was performed. Outcomes evaluated were functional, physiological and quality of life. A random-effects model was used and sensitivity analyses performed. Subgroup analyses were performed on age and sphincter status. RESULTS: Thirty-four studies were included, reporting on 944 patients undergoing peripheral nerve evaluation; 665 underwent permanent SNS. Weekly incontinence episodes (weighted mean difference [WMD] -6.83; 95% confidence intervals [CI] -8.05, -5.60; p < 0.001) and incontinence scores (WMD -10.57; 95% CI -11.89, -9.24; p < 0.001) were significantly reduced with SNS; ability to defer defecation (WMD 7.99 min; 95% CI 5.93, 10.05; p < 0.001) was increased. Most SF-36 and FIQL domains improved following SNS, and mean anal pressures increased significantly (p < 0.001). Results remained consistent on sensitivity analysis. The under-56 years age group showed smaller functional but greater physiological and quality of life improvements. Results were similar between sphincter intact and impaired subgroups. The complication rate was 15% for permanent SNS, with 3% resulting in permanent explantation. CONCLUSION: SNS results in significant improvements in objective and subjective measures for faecally incontinent patients.