Trends and outcomes of non-traumatic major lower extremity amputations in an Irish tertiary referral hospital.

OBJECTIVES: Data on vascular patients following amputation in Ireland is lacking, limiting capability to plan services. This paper seeks to benchmark survival and rehabilitation outcomes among vascular patients in Ireland following lower extremity amputation (LEA), and compare subgroups of those undergoing transfemoral (TFA) or transtibial amputation (TTA). METHODS: A review was conducted of all patients who underwent non-traumatic TFA or TTA from 2000 to 2009 in a tertiary vascular surgery centre. Demographics, surgical data, perioperative outcomes, medium-term functional outcomes, and survival were assessed. RESULTS: One hundred and seventy-two patients (2:1 male: female) underwent 192 non-traumatic LEAs. Median age for TFA was 75 years and TTA 67 (p = 0.002). A percentage of 36.5% had undergone prior attempts at surgical revascularization, 25% had undergone prior distal amputation or debridement. Thirty-three (17%) required stump revision. Twenty-three (13.2%) died in hospital. Median survival for those who died in hospital was 17 days (0-367), versus 17 months (2-106) for those who survived to discharge. CONCLUSION: LEA for vascular pathology has significant morbidity and mortality, with long in-patient stays and short median survival; there is need to focus on improving quality of life in postoperative pathways.

A growing challenge: The rise of femoral periprosthetic fractures - An 11-year observational study.

INTRODUCTION: The demand for joint arthroplasty has risen as our elderly population increases and ages. With this so to has the number of patients suffering periprosthetic fractures (PPF). The aim of our study was to quantify the burden of PPF and provide an up to date reference of the epidemiology of PPF in Ireland. We also sought to assess length of stay (LOS), resource utilisation and mortality associated with this cohort of patients. METHODS: An eleven-year retrospective observational study was conducted of a consecutive series of patients treated for a femoral PPF. Costs were obtained from activity based tariffs provided by the hospital inpatient enquiry system and mortality was confirmed using the national death events publication system. RESULTS: Over the 11-year study period 174 procedures for a femoral PPF were performed. Mean age of patients was 77.6 years (SD 11.1 years) with 44.7% male. Median ASA grade was 3 (range 1-4) and mean LOS was 19 days. There was a 700% increase in patients undergoing surgery for a PPF over the study period. The mean cost of care was €24,413 in 2017. Thirty-day mortality was 2.9% while one-year mortality was 12.4%. CONCLUSIONS: PPF occur in an elderly comorbid cohort of patients. Care of these patients now makes up a considerable part of the orthopaedic workload and consumes a significant portion of healthcare resources. Patients should be treated in tertiary referral centres with surgeons skilled in their management. Better access to rehabilitation is needed.

Where does Pelvic and Acetabular Fracture Treatment fit into the Newly Proposed Major Trauma Model in Ireland?

Aim To provide the most up to date reference of referral patterns for pelvis and acetabular (PA) fractures in Ireland and discuss where services should ideally be located. Methods A retrospective review was conducted of all referrals to the national referral centre for PA fractures in Ireland for 2016 and 2017. Results Over the two-year study period 456 referrals were made. Mean age of patients was 53 years, 62.9% were male. Management was conservative in 60.7%, operative in 38.2% while 1.1% died prior to transfer. Nearly half of fractures (47.8%) were due to falls with 38.6% due to road trauma. Referrals from the proposed central trauma network accounted for 76.1% of referrals. Median length of stay was 7 days. Average cost of operative treatment was €11,774. Conclusions PA trauma is associated with significant morbidity and costs to both patients and society. Consideration needs to be given to where best to place PA services to ensure the highest quality care in this cohort of patients

Saving Blood and Reducing Costs: Updating Blood Transfusion Practice in Lower Limb Arthroplasty

Aim Our aim was to quantify blood transfusion rates in lower limb arthroplasty following the introduction of a multimodal enhanced recovery programme (ERP). We then sought to update the maximum surgical blood ordering schedule (MSBOS) and calculate cost savings achieved. Methods A retrospective cohort study was conducted of all patients who required blood transfusion following primary and revision total hip and knee arthroplasty in 2012 and 2015. A multimodal ERP was introduced in 2015. Cost savings were calculated following the introduction of a new MSBOS. Results During the two-year study period 1467 lower limb arthroplasty procedures were performed. The cross-match to transfusion ratio was 3.6:1 in 2012 and 9.9:1 in 2015. The updated MSBOS resulted in a 46% reduction of cross-matched blood and savings of €54,375 per annum. Conclusion Improved perioperative management in lower limb arthroplasty has reduced blood transfusion rates. Updating blood transfusion practice can result in considerable savings in blood, resources and costs.

A comparison of complication rates between locking and non-locking plates in distal fibular fractures.

BACKGROUND: Locking compression plates have become increasingly popular in orthopaedic surgery. However, the gold standard of treatment for distal fibular fractures remains fixation with a non-locking one-third tubular plate. It has been reported that locking plates in distal fibular fractures are associated with an increased complication rate. HYPOTHESIS: The objective of this study is to assess the complication rates of locking versus non-locking plates in patients who underwent surgical fixation of distal fibular fractures. MATERIALS & METHODS: A retrospective analysis of closed distal fibular fractures that underwent surgical repair over a 2-year period with either a locking or non-locking plate was undertaken, analysing the groups for both wound and overall postoperative complications. RESULTS: A total of 160 patients were treated over 2 years, of which 129 and 31 patients were treated with non-locking and locking plates respectively. There was no significant difference between the non-locking and locking plates overall complication rates (13.5% versus 15.4%, p=0.76) or wound complication rates (3.97% versus 3.85%, p=1.00). DISCUSSION: Distal fibular fractures managed with locking plates do not have a higher complication rate in comparison to those managed with non-locking plates. LEVEL OF EVIDENCE: III (case control study).

Enhanced recovery in lower limb arthroplasty in the Irish setting.

BACKGROUND: In the current economic climate of staff shortages and bed closures, orthopaedic surgeons must look for system efficiencies. Enhanced Recovery Programmes (ERP) have the potential not only to reduce length of stay (LOS) and concurrent costs but also to improve patient outcomes. The aim of this paper is to evaluate the effect of ERP for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) on length of stay (LOS) in the Irish Setting. METHODS: A single-surgeon retrospective case-control study was conducted comparing those who underwent primary lower limb arthroplasty before and after the introduction of an ERP. Patient medical and theatre records were used to determine the operation type, gender, age, LOS and readmission rates. RESULTS: Over the 2-year study period, a total of 310 patients underwent either THA (n = 244) or TKA (n = 66). The mean LOS was 8.79 days in the pre-ERP group and 5.1 days in the post-ERP group (p < 0.001). There was a significant correlation between LOS and age (p < 0.001). Gender or procedure type had no bearing on LOS for any of the subgroups (p > 0.1). CONCLUSIONS: ERP has the potential to significantly reduce overall length of stay after hip and knee arthroplasty and could have a considerable benefit in the Irish setting.

First isolation and outbreak of OXA-48-producing Klebsiella pneumoniae in an Irish hospital, March to June 2011.

Five OXA-48-producing Klebsiella pneumoniae were detected in a tertiary referral hospital in Ireland between March and June 2011. They were found in the clinical isolates of five cases that were inpatients on general surgical wards. None of the cases had received healthcare at a facility outside of Ireland in the previous 12 months. This is the first report of OXA-48-producing K. pneumoniae in Ireland.

Pharmacy-implemented guidelines on switching from intravenous to oral antibiotics: an intervention study.

BACKGROUND: A high proportion of medical in-patients in the UK receive intravenous (IV) antibiotic therapy. This may be inappropriate in non-severe infections, or unnecessarily prolonged. AIM: To assess the impact of guideline implementation on IV antibiotic prescribing in medical admissions to a general hospital. DESIGN: Observational intervention study. METHODS: Data relating to infection and antibiotic therapy were collected for 4 weeks pre-intervention (group 1) and 4 weeks post intervention (group 2). Six months later, data were collected for a further 4 weeks following a second intervention (group 3). Interventions consisted of pharmacy-led implementation of guidelines incorporating criteria for IV therapy and switching to the oral route. The second intervention also included pharmacy-initiated feedback on prescribing. The main outcome measures were IV antibiotic duration, and appropriateness of the IV route and switching. RESULTS: Of 2365 admissions, 757 (32%) had 806 treated episodes. IV therapy was used in 40%, 46% and 36% (groups 1, 2 and 3, respectively) and was appropriate in 92% vs. 100% (group 1 vs. 2). In groups 2 and 3, oral switch timing was appropriate in 90% and 88%, vs. 17% in group 1 (p < 0.001). Between groups 1 and 2, median duration of IV therapy was reduced from 3 to 2 days (p = 0.01). More patients in group 2 received appropriate exclusively IV therapy (65% vs. 96%, p < 0.01). Duration of stay in IV-treated patients reduced from 13 to 10 days in groups 2 and 3 (p = 0.047). IV antibiotic expenditure reduced by 13% per patient admitted between groups 1 and 2. DISCUSSION: Pharmacy-led introduction of antibiotic guidelines appears to result in clinically appropriate reductions in IV therapy.