Value of an orthopaedic admission proforma.

BACKGROUND: Admission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery. PATIENTS AND METHODS: A retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed. RESULTS: In total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied. CONCLUSION: Our study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.

Outcomes and patient perspectives of a novel virtual spinal referral pathway in a non-specialist centre.

INTRODUCTION: In Irish orthopaedic centres without dedicated spinal services, the care of patients is facilitated through tertiary referral centres in Dublin, Cork & Galway. The outpatient waiting list for elective spinal opinion remains lengthy and challenging. Previous practice in University Hospital Waterford (UHW) necessitated an assessment with a local non-spinal orthopaedic specialist following a GP referral, incurring up to a 2-year wait prior to subspecialist spinal referral. These patients subsequently incurred a further wait for an appointment at the tertiary referral centre. A novel virtual spine clinic in collaboration with the Mater Misericordiae University Hospital (MMUH) was developed to fast-track this process. AIMS AND METHODS: A retrospective study was performed to audit efficiency by assessing time to initial consultation and time to virtual consultation, treatment outcomes, and patient satisfaction using an adapted patient-satisfaction questionnaire (PSQ-18) and a semi-structured interview. This study reflected the unique nature of patient experience in this pathway. RESULTS: The median time from referral to being seen in an in-person rapid access physiotherapist combined orthopaedic clinic was 185 days. The median time from initial consultation to virtual consultation was 36 days. The median time interval from virtual consultation to intervention was 110 days. Twenty percent of patients underwent surgery, 14% were further seen in the MMUH outpatients, 7% managed with the trial of physiotherapy, 7% required no follow-up, and 50% planned for radiologically guided spinal injections. DISCUSSION AND CONCLUSION: This novel pathway is efficient for orthopaedic units without a dedicated spinal service. This can easily be replicated across other orthopaedic centres with minimal cost implications.

Sustainable orthopaedic surgery: Initiatives to improve our environmental, social and economic impact.

In response to appeals from the WHO and The Lancet, a collaborative statement from over 200 medical journals was published in September 2021, advising international governments to combat the "catastrophic harm to health" from climate change. Healthcare, specifically surgery, constitutes a major contributor to environmental harm that remains unaddressed. This article provides practical guidance that can be instituted at a departmental, hospital and national level to institute transformative, sustainable efforts into practice. We also aim to provoke healthcare leaders to discuss policy-making with respect to this issue and highlight the necessity for sustainability to become a core domain of quality improvement. The average orthopaedic service produces 60% more waste than any other surgical specialty. Fortunately, simple measures such as a comprehensive education programme can decrease waste disposal costs by 20-fold. Other simple and effective "green" measures include integrating carbon literacy into surgical training, prioritising regional anaesthesia and conducting recycling audits. Furthermore, industry must take accountability and be incentivised to limit the use of single-item packaging and single-use items. National policymakers should consider the benefits of reusable implants, reusable surgical drapes and refurbishing crutches as these are proven cost and climate-effective interventions. It is crucial to establish a local sustainability committee to maintain these interventions and to bridge the gap between clinicians, industry and policymakers.

Distal radius fracture fixation using WALANT versus general and regional anesthesia: A systematic review and meta-analysis.

BACKGROUND: WALANT (wide-awake local anaesthetic no tourniquet) has become a popular technique in upper limb surgery including distal radius fracture fixation. The purpose of this systematic review and meta-analysis is to assess the effectiveness of the WALANT technique in distal radius fracture fixation, and to compare it to both general and regional anaesthesia. METHODS: Pubmed, Embase, and Scopus databases were searched on 26/06/21 according to the PRISMA guidelines with the following search terms: radius, WALANT, "local anesthetic", wide-awake surgery. All studies comparing WALANT with other forms of anaesthesia for distal radius fracture fixation were included. RESULTS: 110 articles were identified, six studies (410 patients) were included, 164 of these patients were in the WALANT group. Two patients (1.2%) in the WALANT group and seven (6.5%) in the regional anaesthesia group required conversion to general anaesthesia. There was no statistically significant difference in post-operative complications, intra-operative VAS pain scores, operative times, functional or radiological outcomes. A statistically significant 8.6 mls increase in pooled mean blood loss in the WALANT group was noted (p = 0.02) although the clinical significance of this is doubtful. CONCLUSION: The WALANT technique for distal radius fracture fixation is non-inferior to regional and general anaesthesia. It is a safe and effective technique that surgeons may consider utilising, especially for patients not suitable for general anaesthetic or in centres in which there is a lack of access to specialist anaesthetic equipment and care.

Telemedicine in Orthopedic Surgery: A Systematic Review of Current Evidence.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has triggered transformative changes in how clinicians interact with patients. There has been a shift toward virtual consultations. The evidence to support this change in practice is unclear. The aim of this study was to systematically review the evidence base for virtual consultations for orthopedics. Materials and Methods: Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing the MEDLINE, EMBASE, and Scopus databases. Only studies reporting outcomes following the use of telemedicine for diagnosis, consultation, rehabilitation, and follow-up were included. Outcomes analyzed were: (1) patient and clinician satisfaction, (2) clinical outcome measures, and (3) cost analysis of traditional versus teleconsultation. Results: A total of 41 studies were included. Fifteen studies compared clinical outcomes of telemedicine against a matched traditional cohort. Of these 15 studies, 2 demonstrated noninferiority, 9 showed no statistically significant difference, and 4 found telemedicine to be superior. Eleven studies recorded patient reported outcomes, which demonstrated high patient satisfaction. Nine studies reported decreased costs when telemedicine was compared to traditional care. The remaining six studies had varied aims and methodologies that didn't fit well with any of these subheadings. Discussion: While the available evidence is limited, the studies assessed here show that telemedicine can deliver high quality health care with good clinical outcomes and high patient satisfaction in a cost-effective manner. Our team thinks what this has highlighted is that communication technology is advancing rapidly and that we as a community of surgeons need to be able to adapt rapidly and adopt innovative technology to continue to improve patient experience and outcomes.

Short-term outcomes of total knee arthroplasty performed with and without a tourniquet.

INTRODUCTION: Not using a tourniquet could improve early postoperative pain, range of motion (ROM), length of stay (LOS), and thromboembolic risk in patients undergoing total knee arthroplasty (TKA). Our aim was to compare these factors, intraoperative blood loss, and gender-related outcomes in patients undergoing primary TKA with or without a tourniquet. METHODS: We performed a retrospective cohort study of 97 patients undergoing TKA with or without tourniquet from 2018 to 2020. Revisions and bilateral TKAs were excluded. Blood loss was estimated using a validated formula. Postoperative pain was tested using the visual analogue scale (VAS). ROM and quadriceps lag were assessed by a physiotherapist on a postoperative day 2 and discharge. The index of suspicion for a thromboembolic event was defined as the number of embolic-related investigations ordered in the first 6 months post-surgery. The Shapiro-Wilk test was used to assess the distribution of the data, Mann-Whitney for the continuous variables, and Fischer's test for the categorical ones. RESULTS AND DISCUSSION: There was a significant difference in blood loss. The non-tourniquet group lost on average 32% more blood (1291 mL vs. 878 mL, p<0.001 two-tailed). We found no difference in pain, ROM, LOS, and quadriceps lag on day 2 and at discharge. There was one thromboembolic event in the tourniquet group, but the thromboembolic index of suspicion did not differ (p=0.53). With tourniquet use, women had a significantly lower day 2 maximum flexion than men (71.56° vs. 84.67°, p=0.02). In this retrospective cohort study, the results suggest that tourniquet use is associated with lower blood loss and similar postoperative pain, range of motion, quadriceps lag, length of stay, and thromboembolic risk. There might be some differences between how men and women tolerate a tourniquet, with women having worse short-term outcomes compared to men.

Virtual Fracture Clinics in Orthopaedic Surgery - A Systematic Review of Current Evidence.

AIMS: Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic visits. In 2014, the Glasgow Fracture Pathway offered an alternative virtual fracture clinic (VFC) pathway with the potential to reduce traditional fracture clinic visits, waiting times and overall costs. Many units have implemented this style of pathway in the non-operative management of simple, undisplaced fractures. This study aims to systematically review the clinical outcomes, patient reported outcomes and cost analyses for VFCs. MATERIALS AND METHODS: Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and COCHRANE Library databases. Studies reporting outcomes following the use of VFC were included. Outcomes analysed were: 1) clinical outcomes, 2) patient reported outcomes, and 3) cost analysis. RESULTS: Overall, 15 studies involving 11,921 patients with a mean age of 41.1 years and mean follow-up of 12.6 months were included. In total, 65.7% of patients were directly virtually discharged with protocol derived conservative management, with 9.1% using the Helpline and 15.6% contacting their general practitioner for advice or reassurance. A total of 1.2% of patients experienced fracture non-unions and 0.4% required surgical intervention. The overall patient satisfaction rate was 81.0%, with only 1.3% experiencing residual pain at the fracture site. Additionally, the mean cost per patient for VFC was £71, with a mean saving of £53 when compared to traditional clinic models. Subgroup analysis found that for undisplaced fifth metatarsal or radial head/neck fractures, the rates of discharge from VFC to physiotherapy or general practitioners were 81.2% and 93.7% respectively. DISCUSSION AND CONCLUSION: This study established that there is excellent evidence to support virtual fracture clinic for non-operative management of fifth metatarsal fractures, with moderate evidence for radial head and neck fractures. However, the routine use of virtual fracture clinics is presently not validated for all stable, undisplaced fracture patterns. LEVEL OF EVIDENCE: IV; Systematic Review of all Levels of Evidence.

Fatigue fracture of tibial arthroplasty implant masked by contralateral knee arthritis.

INTRODUCTION: The wear of polyethylene components is a well-recognised long-term complication of total knee arthroplasty. PRESENTATION OF CASE: We present a case of fatigue fracture of a geomedic tibial tray 17 years after implantation. The symptoms were masked by primary osteoarthritis of the contralateral knee. DISCUSSION: The mode of failure in this case differs from that most commonly reported in the literature in that it occurred late as the result of prolonged use, not due to implant failure, physiological factors, or surgical technique. The case also demonstrates the incredible 'masking' effect of arthritic knee pain. CONCLUSION: This case highlights the importance to clinicians of keeping a high index of suspicion for prosthesis complications in patients with unilateral joint replacement with contralateral arthropathy.

Diagnosis of thoracic neurilemoma incidental to a traumatic clavicle fracture.

This report highlights the importance of thorough examination of the complete radiograph in a fracture setting.