Lech Rymaszewski

Total elbow replacement: outcome of 1,146 arthroplasties from the Scottish Arthroplasty Project.

Background and purpose Total elbow replacement (TER) is used in the treatment of inflammatory arthropathy, osteoarthritis, and posttraumatic arthrosis, or as the primary management for distal humeral fractures. We determined the annual incidence of TER over an 18-year period. We also examined the effect of surgeon volume on implant survivorship and the rate of systemic and joint-specific complications. Methodology We examined a national arthroplasty register and used linkage with national hospital episode statistics, and population and mortality data to determine the incidence of complications and implant survivorship. Results There were 1,146 primary TER procedures (incidence: 1.4 per 105 population per year). The peak incidence was seen in the eighth decade and TER was most often performed in females (F:M ratio = 2.9:1). The primary indications for surgery were inflammatory arthropathy (79%), osteoarthritis (9%), and trauma (12%). The incidence of TER fell over the period (r = –0.49; p = 0.037). This may be due to a fall in the number of procedures performed for inflammatory arthropathy (p < 0.001). The overall 10-year survivorship was 90%. Implant survival was better if the surgeon performed more than 10 cases per year. Interpretation The prevalence of TER has fallen over 18 years, and implant survival rates are better in surgeons who perform more than 10 cases per year. A strong argument can be made for a managed clinic network for total elbow arthroplasty.

Supracondylar fractures of the distal humerus in children

An audit of 32 displaced supracondylar fractures of the humerus in children treated at the Glasgow Royal Infirmary between June 1990 and September 1992 was carried out. Six fractures were classified as Grade 2 (one cortex intact) and 26 were Grade 3 (no cortical contact). All grade 2 fractures were treated non-operatively with good results. Relatively poor results were obtained when displaced fractures were treated non-operatively with manipulation and plaster immobilization. Seven patients underwent manipulation and percutaneous pinning but two developed a cubitus varus deformity. Open reduction and internal fixation with two K-wires gave the best results with no deformity in ten patients. We therefore conclude that this is the optimal method of treatment in a hospital which deals with relatively few completely displaced fractures, with the cosmetic appearance of the scar being minimized by a medial approach.

Effect of a redesigned fracture management pathway and ‘virtual’ fracture clinic on ED performance

Objectives Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance. Design A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change. Setting An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system. Participants 2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol. Outcome measures Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance. Results Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment. Conclusions This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care

Objectives “Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. Methods National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. Results The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. Conclusions The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings. Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33–36. DOI: 10.1302/2046-3758.52.2000506

Functional outcome and satisfaction with a “self-care” protocol for the management of mallet finger injuries: a case-series

BackgroundMallet finger injuries are usually successfully treated non-operatively with a splint. Most patients are reviewed at least twice in a clinic after the initial presentation in A&E. A new protocol promoting “self-care” was introduced at our institution. Patients were provided with structured verbal and written information, and given access to a telephone helpline.MethodsA prospective electronic patient record was used to identify all patients who presented to the emergency department with a mallet finger with a minimum six month follow-up. A satisfaction and patient reported outcome measure was administered via a postal questionnaire. The response rate was 36/47 (77%).ResultsThe median QuickDASH score was 2.3 (IQR 0 to 4.6). All patients were satisfied with the treatment plan provided. Nine used the helpline and all were satisfied with information given. Although 13 patients reported some extensor lag, or bump, they had no functional limitation. Seven patients were reviewed by the general practitioner or other clinicians during their treatment period for issues such a skin care, splint size changes or sickness certification. Five were subsequently reviewed at the end of their treatment period in a clinic at their request, or their general practitioner, but did not require further surgical intervention.ConclusionsSelf-care for mallet finger injuries, with adequate patient information and telephone back-up, leads to acceptable functional results and satisfaction.Level of evidence: III

The virtual fracture clinic: Reducing unnecessary review of clavicle fractures

INTRODUCTION We re-designed the outpatient management of trauma at our institution to eliminate appointments if there would be no change in management or information provision. All cases referred by the Emergency Department (ED) were reviewed at a Virtual Fracture Clinic (VFC) by an orthopaedic consultant and telephoned afterwards by a senior nurse. If face-to-face review was required, it was arranged at a specialist shoulder clinic. AIMS The primary aim of this study was to evaluate the proportion of clavicle fractures that could be discharged without physical review. The secondary aim was to assess the patient reported functional outcome and satisfaction among patients who were discharged without further review. PATIENTS AND METHODS A retrospective review was performed of patients who attended the ED with a clavicle fracture between October 2011 and September 2012. 138 patients were included. The number of patients who were discharged without a physical review was analysed. All radiographs were classified according to the Robinson classification. We recorded the number of undisplaced/minimally-displaced fractures that were discharged virtually. The number of patients with a displaced midshaft fracture who were seen at a specialist clinic was also recorded. A questionnaire was sent to all patients at one year post-injury to evaluate their outcome (QuickDASH and EQ-5D) and satisfaction with the new service. RESULTS 62/138 (45%) were directly discharged from the VFC. The majority of virtual discharges occurred in the undisplaced fracture types (84% versus 13%, RR 6.4, 95% CI 3.5-11.5). 78% patients responded to the questionnaires. 91% of patients were satisfied with their recovery from the injury. 86.4% patients were satisfied with the information provided regarding their treatment. In the virtually discharged group the mean EQ-5D VAS was 78.1 (EQ5D range 0.06-1, SD 0.248). The mean Quick DASH score was 16.1(SD 25.2). CONCLUSIONS Virtual discharge of undisplaced clavicle fractures is appropriate and results in acceptable clinical outcomes and patient satisfaction. This redesigned process has significant benefits for patients as there were far fewer hospital visits by avoiding unnecessary appointments. The orthopaedic service also benefited by having more time available for the management of complex cases.

Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital

Objective Healthcare faces the continual challenge of improving outcome while aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway. Design Discrete event simulation was used to model and analyse cost and resource utilisation with an activity-based costing approach. Data for a full comparison before the process change was unavailable so we used a modelling approach, comparing a virtual fracture clinic (VFC) with a simulated traditional fracture clinic (TFC). Setting The orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study. Outcome measures Our study focused exclusively on patients with non-operative trauma attending emergency department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries are presented in association with activity costs from the models. Results Patients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face (f2f) attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p≤0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI 21.74 to 23.92) per patient compared with £36.81 (95% CI 35.65 to 37.97) for the TFC pathway. Conclusions Our results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional f2f clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings.

Osteoblastoma: a rare cause of stiff elbow

Osteoblastoma is a benign, osseous tumour that is usually found in the femur, tibia, foot and posterior elements of the vertebrae but rarely around the elbow. Elbow stiffness is common after trauma, infection (in particular tuberculosis), synovitis and arthritis, but is rarely caused by a tumour. In this case, an osteoblastoma in the distal humerus was excised through an Outerbridge—Kashiwagi approach, which successfully addressed the patients main complaint of elbow stiffness and restricted function. However, the lesion recurred a few months later and was treated successfully by computed tomography-guided thermoablation.

Management of the post‐traumatic stiff elbow

Restriction of elbow motion after trauma is a well-recognized problem. Most cases improve with time and use, although significant stiffness may persist and interfere with function. Over the last 20 years, surgical procedures have been reported that can safely improve the range of motion in most patients. A wide variety of different operative procedures and postoperative regimes have been described, with comparable results. Surgical techniques range from arthroscopic procedures, through increasingly extensive open releases, up to those requiring a dynamic external fixator to provide stability. Postoperative passive stretching with manipulation or splinting is often advocated, although evidence of effectiveness is lacking. We provide an overview of the current literature, and propose a new surgical guide to aid with the management of stiff elbows.

A virtual pathway reduced the need for physical review in patients with a suspected scaphoid fracture

Objectives: Suspected scaphoid fractures are a common reason for referral from the emergency department to fracture clinics. Few patients actually have a fracture. Cross sectional imaging has the potential to improve early diagnosis and reduce unneccessary immobilisation. The aim of this audit was to investigate the effectiveness of a virtual pathway, incorporating early magnetic resonance imaging (MRI) scan, for suspected scaphoid fractures. The secondary aim was to investigate whether the accuracy of other clinical signs, such as anatomical snuffbox pain on wrist ulnar deviation, was sufficient to reduce the number of patients requiring a MRI scan. Methods: A prospective audit was undertaken of 123 patients in an emergency department and associated minor injuries unit. These patients were managed with an early MRI scan. Where no significant injury was found, they were discharged after a phone call from a virtual fracture clinic nurse. Results: There were 16 (13%) true scaphoid fractures. MRI scanning showed other injuries including significant soft tissue injuries (13%), other carpal fractures (17%) and fractures of the distal radius (19.5%). The number of clinical appointments required was 0.42 per patient. Eighty patients did not have any face-to-face review. Other clinical examination techniques, such as anatomical snuff box pain on ulnar deviation of the wrist were not sufficiently sensitive or specific to reduce the need for MRI scanning or review. Conclusions: A virtual fracture clinic pathway and early MRI scanning reduced face-to-face reviews and unneccesary immobilisation. Clinical examination techniques are not sufficiently sensitive to reduce the need for scanning.