Home therapy pathway - safe and streamlined method of initial management of ankle fractures.

BACKGROUND: Ankle fractures requiring operative fixation often swell up after 24h and surgery during this period is not feasible as there are several associated risks including infection and wound breakdown. The affected limb is kept elevated usually in hospital and once the swelling has sufficiently subsided then the operation takes place. We conducted a study looking at the impact of a home therapy ankle pathway on the length of stay and safety of patients with ankle fractures requiring surgical fixation. METHODS: The length of stay of a control group was studied from December 2009 to March 2010. The home therapy ankle pathway was then introduced in August 2010. If patients could not have their operation within 24h then they were placed in a Plaster of Paris back slab in casualty with the ankle reduced, limb care advice given - elevation, cooling and DVT thromboprophylaxis - and the patient was discharged home on crutches after a slot was determined on the trauma list typically six days later. The patient was also given an emergency contact number in case an untoward event occurred, and they were called at least once during their home stay by hospital staff to ensure all was well. Patients who were unsafe to be discharged on home therapy were admitted. This cohort of patients was studied between August 2010 and December 2011 RESULTS: In the control group, 49 ankle fractures required operative intervention. The mean pre-operative length of stay was 2.88 days and the mean post op length of stay was 5 days. Between August 2010 and December 2011, after implementation of the pathway, 176 ankle fractures requiring operative treatment presented to the orthopaedic department. Of these, 105 were eligible for home therapy on the ankle pathway prior to surgery. The average pre-operative length of stay on the pathway was 0.17 days. The average post op length of stay was 1.72 days (P<0.001 in all modalities). Home therapy was carried out for an average of 6.63 days. Challenges of home therapy included persistent swelling and blistering (11), loss of reduction (4), poor pain management whilst at home (4) and cancellation due to lack of availability of a theatre slot (6). CONCLUSION: With patients in whom it is indicated, the home therapy ankle pathway has proved to be a safe and resource sparing method of managing ankle fractures prior to surgery.

A comparison of complications requiring return to theatre in hip and knee arthroplasty patients taking enoxaparin versus rivaroxaban for thromboprophylaxis.

BACKGROUND: There is no consensus on the optimal form of venous thromboembolic prophylaxis treatment in hip and knee arthroplasty patients, or on the safety and complication profile of the available chemical prophylaxis modalities. In this study we aimed to measure the return to theatre rate for any cause related to wound complications in patients undergoing total hip replacement and total knee replacement, and compare these rates between patients on oral Rivaroxaban 10mg OD and subcutaneous Enoxaparin 40mg OD in our department. MATERIAL AND METHODS: There were a total of 387 patients included in the study; 227 patients in group 1, who received Enoxaparin 40mg OD, and 160 patients in group 2, who received Rivaroxaban 10mg OD. RESULTS: The primary outcome measure was re-operation rate due to wound complications. Secondary outcome measures were infection rate, incidence of deep vein thrombosis, pulmonary emboli, duration of hospital stay, change in haemoglobin and haematocrit and blood transfusion rate. In this retrospective cohort study we found that patients who received Rivaroxaban were more than twice as likely to return to theatre for wound complications compared to patients receiving Enoxaparin. Although not statistically significant, this increase is in line with previous studies. Infection rates increased from 0.9% to 1.9% after the introduction of Rivaroxaban and microbiologically confirmed superficial infections rose from 1.3% to 3.1% after Rivaroxaban was introduced in our unit. These rises were not statistically significant. CONCLUSION: Our study highlights the need for large randomised controlled trials to assess post-operative complications following the introduction of Rivaroxaban for post-arthroplasty thromboprophylaxis.