Ambulatory Management of Bite Injuries to the Hand: A Safe and Cost-Effective Option.

Introduction Animal or human hand bites are a common presentation to the emergency department. If hand bites are not treated adequately, they can give rise to significant local and systemic complications, potentially leading to functional deficits that impact patients' lives. Traditionally, hand bites require hospital admission for the administration of intravenous antibiotics and, in some cases, surgical intervention. A combination of the increasing incidence, hospital admission rates, and in-patient bed pressures prompted a change in our bite management protocol and a move toward ambulatory management of bite injuries. We found this new protocol to be safe, efficient, and cost-effective with a scope for wider implementation. Aim The primary outcome is to assess the feasibility of safely managing hand bites on an outpatient basis, by reviewing the local data before and after the change in practice. The secondary outcome is to compare the financial implications of treating hand bites with an outpatient approach. Material and methods All first-presentation adult consultations referred to Trauma and Orthopaedics from the emergency department over a three-month snapshot period were reviewed in 2017. This was repeated after the implementation of the updated handbite guidelines in 2023. Initial admission documentation as well as operation notes and clinic follow-up letters were each reviewed retrospectively.  Results  In 2017, 36 patients were identified over three months. The average time to surgery was 1.19 days with an average inpatient stay of 2.36 days. There were two re-operations and follow-up of two cases of osteomyelitis.  In 2023, 63 patients were identified over three months. The average time to surgery was 1.03 days with an average inpatient stay of 0.56 days. Thirty-seven surgeries were performed for 33 patients with 32% (20/63) of patients admitted directly from the emergency department. There were no documented cases of osteomyelitis on follow-up. The cost per patient episode decreased by 40% from 2017 to 2023, without accounting for inflation. Conclusions With the implementation of the new departmental guidelines, there has been a reduced average inpatient stay and reduced time to surgery without an increase in documented osteomyelitis. There is also a significant decrease in the average patient cost. This data suggests that without compromising patient safety it is possible to cost-effectively manage hand bites without the need for long inpatient stays.  However, it is imperative that there is close patient follow-up as well as prompt time to surgery to ensure patient safety. Our findings suggest a need for further research to strengthen the evidence supporting our conclusions.

Rare Cause of Skull Base Osteomyelitis: A Challenging Diagnosis and Management With a Literature Review.

This is a case of skull base osteomyelitis (SBO) caused by a rare fungal species, Scedosporium apiospermum. This is a clinical case report with a review of the literature. SBO is a potentially life-threatening infection of the temporal bone. The patient presented to our hospital with a two-month history of left otalgia, otorrhea and reduced hearing, after failed initial intravenous antibiotic therapy. Thorough examination and further investigation confirmed the diagnosis of SBO caused by a rare fungal species, S. apiospermum. The patient was subsequently started on a long-term course of antifungals which led to an improvement of symptoms. This case highlights the importance of early recognition and considering early antifungal treatment in patients with persistent otalgia and otorrhea, particularly in those who have failed to respond to intravenous antibiotics. Further research is needed to better understand the optimal timing and duration of antifungal therapy in these patients.

Patient-related risk factors associated with poorer outcomes following total ankle arthroplasty.

Aims: This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA). Methods: A scoping review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-based literature search was performed in PubMed, Embase, Cochrane trials, and Web of Science. Two reviewers independently performed title/abstract and full-text screening according to predetermined selection criteria. English-language original research studies reporting patient-related factors associated with a poorer outcome following TAA were included. Outcomes were defined as patient-reported outcome measures (PROMs), perioperative complications, and failure. Results: A total of 94 studies reporting 101,552 cases of TAA in 101,177 patients were included. The most common patient-related risk factor associated with poorer outcomes were younger age (21 studies), rheumatoid arthritis (17 studies), and diabetes (16 studies). Of the studies using multivariable regression specifically, the most frequently described risk factors were younger age (12 studies), rheumatoid arthritis (eight studies), diabetes (eight studies), and high BMI (eight studies). Conclusion: When controlling for confounding factors, the most commonly reported risk factors for poor outcome are younger age, rheumatoid arthritis, and comorbidities such as diabetes and increased BMI. These patient-related risk factors reported may be used to facilitate the refinement of patient selection criteria for TAA and inform patient expectations.