Can visual aides influence rehabilitation and length of stay following knee replacement? A randomized controlled study.

Arthroplasty is increasingly performed within Australia, with a 2.7% rate increase of total knee arthroplasty (TKR) over the last year. With an increasing burden on the public health system and increasing waiting lists, all efforts are being made to decrease length of stay and improve the post operative rehabilitation process. There is currently insufficient evidence to make a conclusive statement about visual aids and improved goal attainment post TKR. The purpose of this study is to evaluate one such visual aid clinical photographs of patients knee range of motion (ROM) pre-and post-operatively and their effect on length of stay. Photographs of knee range of motion were obtained pre and post-operatively while the patient was anesthetized. In this study, a randomized, single blinded design allocated patients to either be shown or not shown their photographs on day 1 post operatively. Primary outcome measures were the number of days the patient remained in hospital. Secondary measures were Western Ontario and McMaster Universities Arthritis Index scores, Oxford Knee Scores, American Society of Anesthesiologists Score and knee ROM. Thirty-two patients (3 exclusions) were randomized to the photo group and 27 patients (4 exclusions) were randomized to the no photo group. The median length of stay between groups was not significantly different. Currently there is not enough evidence to conclude that visual aids effect length of stay or rehabilitation pathways. Further assessment with larger cohort groups is needed. Preoperative targeting and rehabilitation for patients with lower functional status may shorten post operative length of patient stay in our institution.

Post-operative numbness and patient satisfaction following plate fixation of clavicular fractures.

INTRODUCTION AND AIM: Numbness across the shoulder and upper chest wall is a frequent complication following plate fixation of clavicular shaft fractures. This is usually attributed to damage to branches of the supraclavicular nerve caused by the surgical approach. We investigate whether the use of an incision perpendicular to the long axis of the clavicle (vertical incision) rather than one parallel to it (horizontal incision) is associated with reduced post-operative numbness and improved patient satisfaction. METHODS: We retrospectively assessed a group of patients who underwent plate fixation of a fractured clavicle at our institution. Using a patient-completed questionnaire, we compared differences in numbness, scar satisfaction, pain, and overall satisfaction with the operation, between those who received a horizontal incision (n=21) versus those treated using a vertical incision (n=14). RESULTS: The likelihood of experiencing post-operative numbness was less in the vertical incision group. Those who had undergone vertical incisions also reported a significantly reduced degree of numbness and significantly less awareness of the numbness with clothing and shoulder straps. There was no statistically significant difference between the groups in terms of pain and scar satisfaction. Patients who reported being most bothered by their numbness also tended to report the highest dissatisfaction with the operation. CONCLUSION: Vertical incisions for plate fixation of clavicular shaft fractures may be associated with reduced post-operative numbness and avoid some cases of patient dissatisfaction. Surgeons should consider using this approach in plate fixation of clavicle fractures.

Management of blunt bowel and mesenteric injuries: Experience at the Alfred hospital.

BACKGROUND: The incidence of blunt bowel and mesenteric injury (BBMI) has increased recently in blunt abdominal trauma, possibly due to an increasing number of high-speed motor accidents and the use of seat belts. OBJECTIVE: Our aim was to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with BBMI. This was achieved by reviewing our experience as a major Victorian trauma service in the management of bowel and mesenteric injuries and comparing this to the experiences reported in the literature. METHODS: A retrospective study reviewing 278 consecutive patients who presented to the Alfred trauma center with blunt bowel and mesenteric injuries over a 6-year period. RESULTS: The patient cohort comprised 278 patients with BBMI (66% were male, 34% were female), of whom 80% underwent a laparotomy, 17% were treated conservatively and 3% were diagnosed post-mortem. In terms of time from admission to laparotomy, 67% were treated within 0-4 h, 9% within 4-8 h, 3% within 8-12 h, 10% within 12-24 h, 4% within 24-48 h and 7% at >48 h. A focused abdominal sonography for trauma (FAST) was performed in 86 patients, of whom 51% had a positive FAST, 44% had a negative FAST and 4% had an equivocal FAST. Overall, 13% of the patient cohort did not have a FAST. Computerized tomography (CT) scans were undertaken preoperatively in 68% of the patients, revealing free gas (22% of patients), bowel-wall thickening (31%), fat and mesenteric stranding or hematoma (38%) and free fluid with no solid organ injury (43%). CONCLUSION: The timing of surgical intervention in cases of BBMI is mostly determined by the clinical examination and the results of the helical CT scan findings. The FAST lacks sensitivity and specificity for identifying bowel and mesenteric trauma. A delayed diagnosis of > 48 h has a significantly higher bowelrelated morbidity but not mortality.