Effect of an independent-sector treatment centre on provision of elective orthopaedic surgery in east and north Hertfordshire.

Introduction Independent Sector Treatment Centres (ISTCs) were created to relieve pressure from Acute Hospital Trusts. In October 2011, an ISTC opened on the grounds of a hospital within the East and North Hertfordshire NHS Trust. Most elective orthopaedic procedures were transferred there. We investigated the effect on productivity of operating theatres working in the ISTC compared with those working in the Acute Hospital Trust (AHT). Methods A 3-month period of working at the AHT was compared with the same period 9-months later in the ISTC, which were termed 'pre-' and 'post-ISTC' opening, respectively. Data for upper limb (UL) as well as foot and ankle (F&A) surgery were collected. Differences in the number of lists and patients per list constituted usage analyses. Financial productivity was calculated from the latest Payment by Results (PbR) data. A two-tailed Mann-Whitney U-test at a confidence level of 95% was employed to compare costs between groups. Results The UL surgeon undertook 18 lists in both years with 66 patients (pre-ISTC) and 32 (post-ISTC), eliciting a reduction in productivity of 51.5%. There were 13 lists for F&A surgery pre-ISTC with 67 procedures, and 20 lists with 49 patients post-ISTC. Allowing for the difference in the number of lists, a reduction of 52.5% was noted. PbR analyses confirmed productivity of £169,695 (pre-ISTC) and £95,760 (post-ISTC) at a loss of £73,935 for the UL surgeon. F&A data revealed £97,801 (pre-ISTC) and £91,960 (post-ISTC) at a loss of £54,742 when correcting for the difference in the number of lists. There was a combined reduction in potential financial productivity of £128,677 over 3 months or £514,708 over 1 year. Discussion Implementation of the ISTC was detrimental to departmental efficiency, with <50% of the number of patients being treated and a marked reduction in financial productivity.

Early weight-bearing in operatively fixed ankle fractures: a systematic review.

BACKGROUND: Ankle fractures are among the most common lower limb fractures and they can cause significant detrimental effects on quality of life and work. OBJECTIVE: The objective of the review was to evaluate if there is any advantage of early weight-bearing after open reduction and internal fixation of the ankle. METHODS: Electronic databases, reference lists of included studies and relevant systematic reviews were searched for randomized and non-randomized controlled trials in adults comparing early and late weight-bearing after open reduction and internal fixation of the ankle. The search was inclusive up to February 2012. RESULTS: Nine studies comprising 555 subjects were included for review. There were significantly better outcomes for improved early dorsiflexion, time to full weight-bearing, early return to previous work and shorter hospital stay (patient<60 years of age) in the early weight-bearing group. CONCLUSION: The evidence base contained many methodological limitations and was generally poor, and so any conclusion drawn from the research must be done so with caution. The literature suggests that early weight-bearing may allow for quicker rehabilitation and earlier return to work. Future studies should focus on randomized controlled trials with narrow range of clinically useful outcome measures and consistent immobilization strategy between experimental groups.

Well differentiated endometrioid adenocarcinoma of the uterus: a cancer unit or centre case?

OBJECTIVE: The purpose of this study was to investigate what proportion of cases showing a well differentiated endometrioid endometrial adenocarcinoma in the hysterectomy specimen removed at two UK cancer centres had adverse pathological features or advanced stage disease at the time of presentation. STUDY DESIGN: Ninety-eight patients who were operated on at either the South East London Cancer Centre, London or the Kent Oncology Centre, Maidstone had a histological diagnosis of well differentiated (grade 1) endometrioid adenocarcinoma in their hysterectomy specimen. These were identified using the multidisciplinary meeting database as well as the respective pathology department databases. The histology reports for these patients were examined and analysed for the purpose of this study. RESULTS: Of the initial 98 cases, 65 patients (66.3%) were referred with a preoperative curettage showing a well differentiated endometrioid adenocarcinoma, 25 cases (25.5%) were referred with atypical endometrial hyperplasia, seven patients (7.1%) were referred with a moderately differentiated endometrioid adenocarcinoma, and one case (1.0%) was referred with a possible malignant mixed Mullerian tumour. Subsequent histological examination of the hysterectomy specimens revealed that all of these cases had a well differentiated endometrioid adenocarcinoma. In 20 of the 98 cases (20.4%) there was no myometrial invasion, 56 cases (57.1%) showed invasion of the inner half of the myometrium and 22 cases (22.4%) showed outer half involvement. There was no cervical involvement in 78 cases (79.6%), endocervical gland involvement in eight patients (8.2%) and cervical stromal involvement in 12 patients (12.2%). The total percentage of cases with cervical involvement was 20.4%. Thirty-eight cases (out of the 98) underwent a bilateral pelvic lymphadenectomy. Of these 38 cases, four cases had locoregional nodal metastases (10.5% of the patients who underwent lymphadenectomy). There were ovarian metastases in one case and metastasis to one fallopian tube in another. From our study, 33.6% of cases with a well differentiated endometrioid adenocarcinoma of the uterus were Stage Ic or more at the time of presentation; 12.2% were at least FIGO Stage Ic, eight patients (8.2%) were FIGO Stage IIa, seven patients (7.1%) were Stage IIb and six patients (6.1%) were Stage III. In these patients a full surgical staging operation with a pelvic lymphadenectomy was indicated according to FIGO recommendation. CONCLUSION: A significant proportion (33.6%) of well differentiated tumours in a hysterectomy were found to have Stage Ic disease or more at the time of presentation, and thus full surgical staging including a lymphadenectomy should have been carried out in these cases. Cases with a preoperative biopsy showing atypical hyperplasia or well differentiated adenocarcinoma should have a preoperative MRI scan or preferably an intraoperative frozen section examination to identify those cases with adverse pathological features which need to be fully staged with pelvic and paraaortic lymphadenectomy.