The Role of a Seven-Day Physiotherapy Service in Reducing Length of Stay and Improving Cost-Effectiveness in Arthroplasty Surgery.

Background Length of hospital stay post hip and knee arthroplasty is influenced by several factors, including gender, home circumstances and underlying diagnosis. Due to increasing demand for hip and knee arthroplasty, elective units, operating within already stressed healthcare systems, must identify methods of increasing efficiency and capacity. We sought to establish whether the lack of a seven-day inpatient physiotherapy service resulted in an increased hospital length of stay post primary hip and knee arthroplasty. Methods One hundred consecutive joint replacements (50 total hip replacements and 50 total knee replacements (TKRs)), performed in our institution from January to February 2020, were assessed. The length of stay for the cohort was analysed, and delays to discharge were identified. T-test was used to analyse the difference in length of stay based on the day of the week the surgery was performed. Results The mean length of stay for all primary hip and knee arthroplasties was 3.42 (standard deviation (SD): 1.62) days. Hip and knee arthroplasties performed on a Thursday or Friday had a significantly higher average length of stay than those performed on Monday, Tuesday or Wednesday (3.89 versus 3.02, p=0.006). We calculated that operating a six-day versus seven-day physiotherapy service in our unit cost 318 bed days per year equating to €986,535. Conclusion Length of stay post total hip and knee arthroplasty in our unit is significantly affected by the day of the week that surgery is performed. Elective orthopaedic units should consider all means of maximising efficiency and lowering costs given the future challenges in service provision.

The effectiveness of radiotherapy in the treatment of head and neck mucosal melanoma: Systematic review and meta-analysis.

INTRODUCTION: Mucosal melanoma (MM) is a rare condition with a poor prognosis. Surgery is the corner stone of treatment, however, radiotherapy has been commonly employed as a treatment strategy and recent studies suggesting that survival outcomes may be improving are emerging. METHODS: A systematic review and meta-analysis comparing risk ratios of radiotherapy and surgery and radiotherapy (SRT) with surgery for 5-year overall survival, local recurrence and distant metastasis in head and neck mucosal melanoma (HNMM). RESULTS: SRT has a lower risk of death compared to surgery [RR 0.93 [95% CI = 0.87, 0.98] (P = .01)] and a reduced risk of local recurrence [RR 0.63 [95% CI = 0.48, 0.82] (P = .005)]. SRT has no effect on distant metastasis. Radiotherapy has worse survival when compared to surgery [RR 1.2 [95% CI = 1.03, 1.33] (P = .0006)]. CONCLUSIONS: SRT confers a moderate survival advantage in HNMM compared to surgery. This is most likely secondary to reduced local recurrence.

Splenectomy for isolated splenic metastasis from primary lung adenocarcinoma.

A 73-year-old woman was referred to a tertiary centre with isolated splenic metastasis from previous pT1aNo stage 1a lung adenocarcinoma. The patient underwent a right lower lobe lobectomy and mediastinal lymph node dissection 2 years ago for invasive adenocarcinoma with no adjuvant therapy. An incidental finding of new splenic cyst was noted on surveillance imaging, which was fluorodeoxyglucose positive on positron emission tomography, and confirmed on cytology to be metastatic lung adenocarcinoma. After multi-disciplinary team's review, the patient underwent splenectomy, with partial excision of diaphragm due to local infiltration. Her postoperative course was eventful, and was complicated by a simple fluid collection in the surgical bed (amylase negative), a left sided pneumonia and atelectasis and left sided pleural effusion, requiring antibiotics and radiological drainage of the abdominal and pleural collection. The patient recovered well and is currently doing well 9 months postoperatively with no evidence of recurrence or metastatic disease.

The Annual Trip to the Ice-rink: A Seasonal Cause of Wrist Trauma in Irish Hospitals.

Fractures of the distal radius are a common orthopaedic presentation in Irish emergency departments. As a nation, Irish people tend to ice-skate seasonally with a peak of interest seen during the Winter months in temporary ice-rinks. This case series describes winter ice-skating as a significant cause of wrist fractures in the younger patient, including five cases of distal radius fractures, four of which ultimately required internal fixation, under general anaesthesia, over a single weekend in the month of December. Despite all five patients being amateur ice-skaters, all denied ever having taken ice-skating lessons. This demonstrates the dangers of wrist trauma in the inexperienced or beginner ice-skaters on temporary ice-rinks; the seasonal morbidity suffered as a result.

Two-hole versus four-hole plate dynamic hip screw: a systematic review of current evidence.

BACKGROUND: The dynamic hip screw (DHS) is a common device used in the fixation of hip fractures. Traditionally, this involves the use of a four-hole side plate. Reducing the length of the side plate would theoretically reduce the amount of surgical exposure required, decrease surgery duration, and decrease perioperative morbidity and mortality. Our study aims to review the current evidence regarding the use of two-hole side plates, their use and potential complications. METHODS: Using PRISMA guidelines, two independent reviewers performed a search to collate the available literature from medical databases PubMed, EMBASE, Web of Science, and the Cochrane library. Only clinical and biochemical studies were included. The reference lists of articles included for full text review were searched for any additional primary or review publications. RESULTS: Four online libraries were searched, with a combined total of 5344 titles reviewed. Following title, abstract, and full text review, 8 articles were considered suitable for inclusion in qualitative analysis. There was a trend towards equal efficiency between two- and four-hole plates when used in stable fractures in terms of blood loss, failure/revision rates, operative and hospital stay durations, collapse loading testing, maximum stress, and fragment migration. CONCLUSION: The results of this study show that DHS constructs with two- or four-hole side plates have comparable outcomes when used in patients with stable fracture patterns. However, the majority of the clinical data regarding the use of two-hole DHS plates come from retrospective case series; further prospective, randomised control trials would be of significant benefit. LEVEL OF EVIDENCE: Level II; systematic review of all levels of evidence.

Assessing the Time to Ward Transfer in Patients Presenting to the Emergency Department with an Acute Hip Fracture: A Closed-loop Audit.

Introduction The British Orthopaedic Association and British Geriatric Association Blue Book guidelines for patients presenting acutely with a hip fracture stipulate that the patient should be admitted to an acute orthopedic ward within four hours of presentation to the emergency department (ED).  Materials and methods A retrospective review of all patients who presented to the ED with a hip fracture diagnosed on plain film X-Ray over an eight-week period by a single auditor. Time of arrival, time to X-ray, time of blood draw, time to orthopedic referral, time to orthopedic review, and time to arrival at the orthopedic ward were documented. A policy change stipulating that orthopedics on call would prospectively review potential hip fracture patients prior to definitive workup was initiated. The same parameters were re-audited following this intervention over a six-week period. Results Pre-intervention, the mean time to orthopedic review was 83 minutes with a mean time to ward of 417 minutes. Post-intervention, the mean time to orthopedic review was 76 minutes with a mean time to ward of 333 minutes. When orthopedic trainees were on call, the mean time to review was 37.5 minutes with a mean time to ward of 294 minutes. Conclusions While we were able to demonstrate an improvement in orthopedic response times, this did not significantly improve time to ward transfer. This highlights a number of other areas that need to be optimized to improve compliance with best practice guidelines.

The Effectiveness of Negative Pressure Wound Therapy Versus Conventional Dressing in the Treatment of Open Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: To compare the efficacy of negative pressure wound therapy (NPWT) versus conventional dressings (CD) in the management of open fractures. DATA SOURCES: A systematic search of English articles in the PubMed/MEDLINE, Embase, and the Cochrane Library through April 2019 comparing NPWT versus CD in the management of open fractures. STUDY SELECTION: Inclusion criteria were articles in English language, comparing NPWT with CD in skeletally mature individuals who had sustained an open fracture at any anatomical site, reporting on rates of deep infection, flap frequency, flap failure, nonunion, amputation, length of hospital, or intensive care unit stay. DATA EXTRACTION: Two authors independently extracted data from selected studies, and the data collected were compared with verify agreement. DATA SYNTHESIS: Pooled odds ratios were calculated for dichotomous outcomes, whereas continuous data were analyzed using the standard weighted mean difference. A random or fixed effect model was used depending on the level of heterogeneity between the studies. CONCLUSIONS: NPWT results in decreased likelihood of deep infection and flap failure compared with CD in the management of open fractures not directly amenable to early closure. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.