The benefit of introducing a virtual trauma assessment clinic during a global pandemic.

Sars-CoV2/COVID-19 pandemic created a national emergency in Ireland. Our institution implemented a virtual trauma assessment clinic to reduce attendance to our district hospital which was stimulated by the development of 'safe-distanced' care. The audit aimed to evaluate the impact of our trauma assessment clinic on care provision and presentation to hospital. All patients were managed according to the newly implemented virtual trauma assessment clinic protocol. Data was prospectively collected over a 6.5 week period from 23rd March 2020 to 7th May 2020. These referrals were reviewed twice weekly by a Consultant-led multidisciplinary team. 142 patients were referred to the virtual trauma assessment clinic. Mean age of referrals was 33.04 years. 43% (n=61) were male patients. Overall 32.4% (n=46) of new referrals were discharged directly to their family doctor. 30.3% (n=43) were discharged for physiotherapy follow up. 36.6% (n=52) required presentation to the hospital for further clinical review and 0.7% (n=1) was admitted for surgical intervention. Overall, this represents a reduction of 63% of patients attending the hospital. A simple virtual trauma assessment clinic model resulted in significant reduction in unnecessary attendance at face-to-face fracture clinics enhancing patient and staff safety during a global pandemic. This virtual trauma assessment clinic model has allowed the mobilisation of staff to assist with other essential duties in other areas of our hospital without compromising care.

The Impact of Body Mass Index on Local Anaesthetic Inguinal Hernia Repair.

BACKGROUND: Open mesh repair of inguinal hernia is acceptable and can be performed under local anaesthesia (LA). Individuals with high BMI (Body Mass Index) have often been excluded from LA repairs for varying reasons including safety concerns. Open repair of unilateral inguinal hernia (UIH) amongst individuals with different BMI groups was studied. Its safety profile was investigated using LA volume and length of operation (LO) as endpoints. Operative pain and patient satisfaction were also evaluated. PATIENTS AND METHODS: A total of 438 adult patients were studied having excluded underweight patients, those requiring any additional intra-operative analgesia, multiple procedures, or records with incomplete data. Operative pain, patient satisfaction, LO and LA volume were retrospectively studied from the existing data from clinical and operative notes. RESULTS: It was a predominantly male population (93.2% males) with an age range of 17-94 years peaking in the 60-69 years age group. BMI ranged 19-39 kg/m2 with BMI above normal at 62.8%. LO was 13-100 minutes (average 37 mins {SD = 12}) utilising an average LA volume of 45 ml (SD = 11) per patient. Across BMI groups, no significant difference in LO (P = 0.168) or patient satisfaction (P = 0.388) was seen. Although LA volume (P = 0.011) and pain score (P<0.001) demonstrated statistically significant differences, these did not appear to be clinically relevant. Over 90% in each BMI group experienced mild or no pain and with severe pain reported in only one patient in the entire population. Overall, LA volume required per patient was low and dosage was safe in all BMI groups with significant proportion (89%) of patients evaluated for satisfaction rating their experience ≥ 90 out of 100. CONCLUSION: LA repair is safe and well tolerated irrespective of BMI. BMI is not a viable reason for exclusion of obese/overweight individuals from LA repair.

Incidence of Symptomatic Venous Thromboembolism (VTE) in 8,885 Elective Total Hip Arthroplasty Patients Receiving Post-operative Aspirin VTE Prophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is a potentially reducible cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Health and Care Excellence (NICE) published updated guidelines in 2018 which recommend the use of both mechanical and pharmacological methods in patients undergoing elective total hip arthroplasty (THA). OBJECTIVES: The aim of this study was to present the symptomatic VTE incidence in 8,885 patients who underwent THA between January 1998 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Intermittent calf compression stockings are routinely used from the time of surgery until mobilization (usually the following day) with prophylactic doses of low molecular weight heparin (LMWH) during inpatient stay (from 2005 onwards) and then Aspirin 150mg once daily for six weeks on hospital discharge (or Aspirin only prior to 2005), with use of other therapies occasionally as required. METHODS: Analysis of prospective data collection from consecutive patients at a single institution undergoing THA was performed with the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within six months of the index operation as the primary outcome measure. Ninety-day all-cause mortality of this cohort of patients was also analysed. RESULTS: 8,885 patients were reviewed. This included 7230 primary, 224 complex primary and 1431 revision cases. The overall incidence of symptomatic VTE after elective THA was 1.11% (99/8885) - with the incidence of symptomatic DVT of 0.59% (52/8885) and the incidence of symptomatic PE of 0.53% (47/8885). There was no significant difference (χ2 test, p=0.239) in the symptomatic VTE incidence between primary (1.20% - 89/7230), complex primary (0.89% - 2/224) and revision cases (0.70% - 10/1431). The 90-day all-cause mortality was 0.88% (78/8885). Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to PE. There was no significant difference (p=0.327) in length of stay (and hence amount of pharmacologic prophylaxis with LMWH received by patients before commencement of Aspirin) with the average length of stay for those patients who did not suffer a VTE of 6.8 days compared with 7.6 days for those who did suffer a VTE. CONCLUSION: Our results support the use of aspirin as an effective form of prophylaxis against symptomatic VTE following THA in contradiction to NICE and American Academy of Orthopaedic Surgery (AAOS) recommendations. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other advantages of using aspirin for VTE prophylaxis.

Saving time in the fracture clinic: 2 weeks post-operative plain films following open reduction and internal fixation of distal radius fractures do not affect management.

INTRODUCTION: Distal radius fractures represent up to one in every sixth treated fracture. The majority of these are intra-articular and require operative management. Many recent studies advocate for the use of volar plating fixation. Following fixation, most patients attend the fracture clinic at 2 and 6 weeks post-operatively and may get repeat imaging at both visits, resulting in longer wait times and repeat exposure to radiation. Revision surgery is however rarely performed in the 2- to 6-week period, raising the question of the necessity of plain film at 2 weeks. AIM: Improve patient satisfaction in the fracture clinic by reducing wait time in fracture clinic and limiting exposure to radiation. METHOD: The number of distal radius open reduction and internal fixation (ORIF) over a 12-month period was retrieved using theatre logbooks. Patient details were used to check whether a plain film radiograph had been performed 2 weeks post-operatively. Subsequently, patients' records were used to determine if revision surgery was performed or planned. RESULTS: In total, 123 distal radius ORIF were performed between January 2018 and January 2019. Two-week check radiographs were performed for 82 patients (67%). One patient (0.8%) underwent revision surgery following review of intra-operative imaging. No patients underwent revision ORIF following 2-week plain film. CONCLUSION: Repeat imaging at 2 weeks following distal radius ORIF did not change management of distal radius fractures in this study. Therefore, our data suggests 2-week plain films should not routinely be ordered for these patients which will reduce wait time and exposure to radiation.

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.

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.

A healthy decline in age- and sex- specific incidence of hip fractures in the elderly in the Republic of Ireland.

AIM: The number of patients sustaining hip fractures in the Republic of Ireland was expected to increase by 100% from 2004 to 2026. This has not been seen either in local or international literature. Our aim is to assess the age- and sex-specific incidence of hip fractures in patients over the age of 65 years and to determine whether the projected increase in incidence is mirrored in the reality of the Irish experience. METHODS: This is a retrospective observational cohort study including all patients with a hip fracture from a tertiary referral centre from 2005 to 2015. Population data was obtained from the Central Statistics Office of Ireland. RESULTS: 3818 hip fractures in the over 65 age group were recorded. The highest incidence of hip fractures occurred in the 85-90 year old age group. For all ages over 65, the incidence of hip fractures in females over the 10 year period is significantly reducing (p < 0.01). There were 955 hip fractures per 100,000 in females in 2010 and 410 per 100,000 in males. In 2014, this had reduced to 668 in females and 332 in males respectively. CONCLUSION: The annual hip fracture incidence has decreased across both sexes in this study period. This may be associated with preventative measures and introduction of fracture liaison services. This study highlights the importance of investment in preventative strategies for a continued reduction in hip fracture incidence and will help to plan future services.

"90/90" Plating of proximal humerus fracture-a technical note.

INTRODUCTION: While locking plates have markedly improved fixation of proximal humerus fractures, a cohort of fractures remains difficult to treat. This cohort has been identified as fractures with marked medial comminution and varus deformity. Loss of reduction and fixation failure are the most frequently reported complications for this cohort. We report the use of an orthogonal 1/3 tubular plate to augment the proximal humerus locking plate. METHODS: The subject underwent osteosynthesis for a four-part proximal humerus fracture with medial comminution. Fixation was performed within 24 h of injury. Standard deltopectoral approach exposed the fracture. Sutures were sited to control the tuberosities and cuff. Initial reduction was held with a K-wire and augmented with a three-hole 1/3 tubular plate. Proximal humerus locking plate was sited in standard fashion including locked medial support screws. Reduction was confirmed both clinically and with intra-operative radiography. RESULTS: The technique provided satisfactory results. At 6 months, the fracture had fully united with no loss of reduction. At 1 year, the patient had excellent range of motion. CONCLUSION: The use of a 1/3 tubular plate to augment fixation of proximal humerus fractures with medial comminution may provide a simple, reproducible, and cost-effective method to decrease loss of reduction and subsequent malunion.

Flap Anchoring Following Primary Breast Cancer Surgery Facilitates Early Hospital Discharge and Reduces Costs.

BACKGROUND: Routine drain placement after breast cancer surgery is standard practice. Anchoring the axillary and mastectomy flaps to the underlying chest wall with sutures has been advocated as a means of avoiding drainage following breast surgery. This study compares outcomes following flap fixation or routine drain placement and uniquely considers the economic implications of each technique. PATIENTS AND METHODS: Data on seroma formation and wound infection following mastectomy and axillary clearance were recorded prospectively. Patients underwent either routine drain placement or flap anchoring using subcutaneous tacking sutures without drainage. Equipment and surgical bed costs were provided by our finance department. RESULTS: Data was available for 135 patients. 76 underwent flap anchoring without drainage and 59 had routine drainage. There was no difference in seroma rates between the two groups: 49% vs. 59% (p = 0.22). However, the length of hospital stay was reduced in the flap fixation group: 1.88 vs. 2.67 days (p < 0.0001). Per patient, flap suturing equated to an estimated financial saving of £ 240. CONCLUSIONS: Flap anchoring resulted in a significantly shorter hospital stay than routine drainage, with a comparable rate of seroma formation. This technique presents a viable alternative to drain placement and could lead to a considerable economic savings.

Perioperative fluid restriction reduces complications after major gastrointestinal surgery.

The physiologic response to surgical trauma promotes sodium and water retention AND weight gain owing to perioperative fluid loading increases morbidity SO perioperative fluid restriction should reduce postoperative complications after gastrointestinal surgery.

Serum calcium slope predicts hypocalcaemia following thyroid surgery.

BACKGROUND: Hypocalcaemia is the single commonest complication of thyroid surgery. Typically, serial calcium levels are performed post-operatively in order to detect hypocalcaemia, often requiring at least a 48-h stay. Our practice is to measure serum corrected calcium pre-operatively, 6 h post-operatively and 24 h post-operatively. Patients are discharged if they have a normal serum calcium value at 24 h. METHODS: We performed a retrospective review to determine if the calcium slope from pre-operatively to 6 h post-operatively predicts serum calcium levels at 24 h, thus allowing early discharge. RESULTS: Fifty-two patients who underwent total or subtotal thyroidectomies were studied. Hypocalcaemia developed in 19 patients within 24 h of surgery (serum adjusted calcium less than 2.15 mmol/dL) within 24 h of surgery. There were no significant differences between the hypocalcaemic and normocalcaemic groups with respect to Graves' disease (p=0.17), total thyroidectomy (p=0.39), number of parathyroids identified (p=0.66), or parathyroid autotransplantation (p=0.29). The serum calcium slope from baseline to 6 h post-operatively correlated with serum calcium values at 24 h (p=0.008). CONCLUSION: Serum calcium slope may be useful in identifying patients suitable for early discharge following thyroid surgery.

Early management of atrial fibrillation in general surgical in-patients.

BACKGROUND: It has been suggested that new-onset atrial fibrillation (AF) in non-cardiac surgical patients should trigger a thorough search for other morbidity. We reviewed our unit's management of new-onset AF to determine whether this target is achieved. METHODS: Patients under the care of a general surgeon who developed new-onset AF during their inpatient stay were identified from a prospectively maintained database of surgical in-patients. Their case-notes were reviewed to determine whether a precipitating cause for the AF was sought or identified. RESULTS: Thirty-one patients developed new-onset AF. Almost half had positive findings on cardiovascular or respiratory system examination and assessment. However, 35% of patients had no respiratory examination, 58% had no cardiovascular examination and 55% had no abdominal examination performed. Eighty-one percent had another underlying complication diagnosed within 24h of the AF. Twenty-six percent had an intra-abdominal collection. Of those with an underlying complication, 52% were not diagnosed at the time of initial assessment for AF. Twenty percent of patients died within 30 days of the AF. CONCLUSIONS: New-onset AF in general surgical patients is associated with considerable morbidity. A thorough clinical evaluation and early involvement of senior surgical staff are recommended.