Recent Department of Health guidelines have recommended that bunion surgery should be performed as a day case in a bid to reduce hospital costs, yet concurrently improving patient outcomes. Following an audit in 2012/3, we implemented a number of measures in a bid to improve the rates of day case first ray surgery. In this paper, we look to see if these measures were effective in reducing the length of stay in first ray surgery.

We performed a prospective case note review of all patients undergoing first ray surgery between 01/01/2012 and 01/02/2013, and found the rates of same day discharge in this group to be lower than expected at just 24.19%. We recognised that the most commonly cited reasons for delayed discharge were that patients not being assessed by physiotherapy, and were unable to have their take home medication (TTO's) dispensed as pharmacy had closed. To address this, we implemented a pre-operative therapy led foot school, and organised ward analgesia packs which may be dispensed by ward staff, thus bypassing the need for pharmacy altogether. Together, we coined the term “care package” for these measures. We then performed a post implementation audit between 01/01/2014 to 01/01/2015 to ascertain if these measures had been effective.

We identified 62 first ray procedures in the preliminary audit, with an average age of 50.5 years (range 17–78 years) and a M:F ratio of 1:5. The most commonly performed procedures were Scarf osteotomy, 1st MTPJ fusion, and distal Chevron osteotomy. We compared this to 63 first ray procedures post implementation of the care package. The average age was 55.3 years (range 15–78 years) and the M:F ratio was 1:2.5, and there was a similar distribution in terms of specific procedures. We found the length of stay had reduced from 1.00 to 0.65 days (p= 0.0363), and the rate of same day discharge had increased from 24.6% to 44.6% (p= 0.0310). We also noted that St Helens Hospital (SHH), the dedicated day case surgery unit, had a significantly increased rate of same day discharge than Whiston Hospital (WH- the main hospital) at 87.5% and 28.89% respectively (p= 0.0002).

Preoperative physiotherapy assessment is an important tool in reducing length of stay for first ray surgery. The use ward analgesia packs has a synergistic effecting in increasing day case first ray surgery. We therefore commend its use to other centers. Additionally, we have shown dedicated day case surgery units are more effective at achieving same day discharge than general hospitals.

We reviewed the current screening protocol for MRSA detection in patients admitted for elective lower limb arthroplasty as we thought it may not be cost effective and there is no evidence base for validity of MRSA screening swabs.

The current institutional screening protocol includes MRSA swabs from nose and groin taken on 2 different occasions; the 1st swab taken at time patient was placed on the waiting list and the 2nd swab taken at the Orthopaedic pre-clerking clinic around 6–8 weeks later.

We found that during the study period, of 1791 patients who underwent MRSA screening swabs, only 16 patients had positive results. Of these, 9 patients had known MRSA (2 in care home) and no data was available in 2 patients. However in 5 patients, there was an initial negative swab which later was found to be positive. The time interval in these ranged from 0.6 to 85 weeks (Conversion rate = 0.3%).

The laboratory cost for these screening swabs was £9,027. Given the low prevalence rate of MRSA and low conversion rate at 6 weeks, there is a role for accepting a single-swab screening protocol. This would also result in significant cost savings of around £ 4,500.

We can therefore conclude that in the indigenous population, it is unlikely a patient will de-novo acquire MRSA in the community unless exposed to independent risk factors. We have adopted the new screening protocol where patients are screened routinely for detection and eradication only once prior to admission unless independent risk factors such as previous MRSA colonisation, hospital admission or if being admitted from residential/care home.

There is however no evidence in literature about the time period of validity of MRSA screening swabs.

To review blood transfusion practices during elective spinal surgery procedures

Prospective clinical audit

All patients who underwent elective spinal surgery between January 2009 and March 2009.

Crossmatch: Transfusion ratio (C: T ratio); Transfusion index (TI) (Evaluates cost-effective crossmatch). British Haematological society standards are C:T ratio= 2.5:1 and TI>0.5

Data was collected from electronic records of blood bank, pathology system (NOTIS) and review of patient notes. A total of 194 patients underwent elective spinal surgery in our unit. (Cervical spine = 15, Thoracic spine = 3, Vertebroplasty = 10, Lumbar spine = 142, Deformity = 31, other = 8). Of these, 62 patients had 197 blood products crossmatched but only 37 units were used. C:T ratio in lumbar spine surgery was 22:1. However C: T ratio in cervical spine procedures, thoracic spine and deformity correction were 6:1, 11:0 and 4:1 respectively. TI was <0.5 in all procedures except deformity surgery (TI=1).

Over- ordering of blood products is still common in spinal surgery as routine blood transfusion may not be required in most elective procedures. Therefore implementing Electronic Issue (EI) of blood products for elective spinal procedures for non deformity procedures can be a cost effective and safe practice.

Northumbria Healthcare NHS Trust, Ashington, UK

To assess if a pain diary is useful in assessment and management of patients who undergo diagnostic nerve root block (NRB) for lumbar radicular pain.

Prospective study

23 patients who underwent diagnostic NRB for lumbar radicular pain were given a pain diary. They recorded their response to one of four options from Day 0 to Day 14 (good relief, partial satisfactory, partial unsatisfactory, and no relief of leg pain) and could also add additional comments. A Consultant Spinal Surgeon reviewed the diary with the patient at 6-week follow up appointment to formulate a management plan.

Patient response, completion of the pain diary and final clinical outcome (surgical or non surgical treatment).

The response rate was 91% (21/23). The pain diary was very useful in 43% (9/21), useful in 33% (7/21) and not useful in 24% (5/21) of patients in formulating further management. There was a tendency for patients with complex problems and poor response to add descriptive notes and comments (9/ 23).

Patient compliance with pain diary was good and it has been valuable in making further management decisions. We found the pain diary to be a useful and inexpensive adjunct in the assessment of patients who underwent diagnostic NRB.

Antibiotic prophylaxis for joint replacement surgery is widely recommended and has been shown to reduce infection rates. Cephalosporins have commonly been used but are associated with development of Clostridium difficile associated diarrhoea (CDAD)

The purpose of this study was to assess whether a change of protocol aimed at reducing CDAD, including a change of antibiotic prophylaxis would reduce rates of CDAD and other postoperative complications.

We studied all 7989 patients in our trust that underwent hip or knee replacement from May 2002 to March 2009. These patients fell into two cohorts, firstly those who were prescribed cefuroxime as prophylaxis and secondly those prescribed gentamicin which was introduced following national concern regarding CDAD.

Following the change of prophylaxis from cefuroxime 750mg three doses to gentamicin 4.5 mg/kg single dose the rate of CDAD reduced significantly (0.17% to 0%, p<0.03), however the rate of acute renal failure (0.29% to 0.6%, p=0.04) and pneumonia (0.71% to 1.38%, p<0.01) increased significantly. The rate of urinary tract infection (1.44% to 1.20%, p >0.05) and the overall return to theatre rate (1.86% to 2.30%, p=0.21) were not significantly changed.

The spectrum of bacteria grown from infected joint replacements in the two cohorts was also analysed. The rate of deep MRSA infection was significantly less in the group given gentamicin. The frequency of other bacteria was also different between the cohorts, but not significantly so.

We conclude that changing protocol including antibiotic prophylaxis in joint replacement patients can have the desired effect on a particular outcome namely CDAD but can also result in increased rates of other postoperative complications. It is also likely to result in a change in the bacterial spectrum of infected joint replacements.

Purpose: To determine the incidence and outcome of late costoplasty in surgical management of IdS.

Methods and results: A retrospective review of prospectively collected data on patients with IdS who underwent costoplasty after definitive fusion during a 10 year period (1994–2004).

We reviewed surgical records of 318 patients who underwent instrumented spinal fusion for IdS at our centre. Amongst these, 15 patients had undergone late costoplasty. Pre-operative assessment included rib hump measurement, photographs and plain radiographs. 4 patients had computerised tomography to evaluate deformity. Outcome measures included patient satisfaction and clinical evaluation.

Results [Mean (SD)]: Age at primary operation was 12.3(3.3) years; age at costoplasty 17.1(2.7) years. Pre-operative Cobb angle was 64.1 (19.5) and postoperative Cobb 36.9 (15.7) degrees. Median time between primary operation and costoplasty was 4 years. Median follow up was 7 years. Indication for costoplasty was cosmetic deformity with prominent rib hump (n=9) and curve progression (n=6). Approach at primary operation was anterior 1 case, posterior 3 and combined 9 cases. Median length of stay was 5 days.

All patients except 1 had significant reduction in rib hump deformity. Complications included 1 case of surgical scar tenderness, 1 transient neuralgia and 1 patient required a chest drain due to haemothorax.

Discussion: Costoplasty is a cosmetic procedure for the correction of rib prominence in scoliosis. There is low incidence of late costoplasty (i.e. after definitive spinal fusion) in IdS. Following costoplasty, patients were satisfied with their cosmetic appearance; no major complications occurred and no further reoperation was needed.

Ethics approval: Audit/service standard in trust number: 1236

Interest Statement: None

Purpose: To determine frequency of reoperations after definitive spinal fusion in patients with AIS and identify factors responsible

Methods and results: We undertook a retrospective review of surgical logs of patients with AIS who underwent surgical fixation during 1994–2004 and detailed case notes review of patients who required > 1 operation after definitive fusion. Results were compared according to approach used during primary operation.

We reviewed surgical logs of 310 patients who underwent instrumented spinal fusion for AIS. Approach at primary operation was anterior 101, posterior 109 and combined 100. Of these, 33 patients underwent 58 reoperations (10.6 %) after definitive fusion. Median age was 14.7 years; median follow up 5.4 years. Amongst these, primary operation was Anterior in 5 patients (7 reoperations, 5%), Posterior 13 patients (25 re-ops, 11.9%) and Combined 15 patients (26 re-ops, 15%). 12 patients required more than 1 reoperation.

Common indications were infection (9), failure of fixation either due to curve progression (10), junctional kyphosis (7) or pseudoarthrosis (3). 16 revisions were undertaken due to implant related symptoms. 5 patients with posterior instrumentation requested removal of implant. Only 1 patient had a neurological deficit that required removal of implant. 13 patients required secondary costoplasty.

Discussion: Risk of reoperation after definitive fusion in AIS is 10.6 % in our institution. Reoperation rates were maximal with combined approach and least with anterior approach (15% v 5%). Common indication with posterior instrumentation was implant related and in anterior surgery due to curve progression (wrong level fixation).

Ethics approval: Audit/service standard in trust number: 1236

Interest Statement: None

Aim: To evaluate the outcome of displaced distal radius fracture in children & review our practice.

Methods: A retrospective review of case notes and radiographs of all children requiring orthopaedic intervention under general anaesthetic for displaced distal radius in our hospital over a period of 18 months (January 2005 to June 2006) was carried out. We had treated 72 fractures of the distal radius in same number of children. All but 3 cases were treated by primary closed manipulation & plaster immobilisation. Average age was 11.7 years (range 5 to 16 years).

We looked at the re-displacement rate amongst these children that required a second procedure. We also sought predictive factors for redisplacement if any.

Results: There were 22 female & 50 male patients. All the fractures were closed injuries with no distal neuro-vascular deficit. Of the 72 cases, 16 cases showed more than 50% initial displacement and 6 were completely displaced (off-ended). 9 cases had volar angulation.

Redisplacement of fracture after initial satisfactory reduction was seen in 9 cases (12.7%) & required a second procedure. The secondary procedure involved closed reduction and percutaneous K wire fixation in 4 patients and open reduction in 2 cases. 3 cases had closed remanipulation & change of plaster.

We reviewed the factors responsible for re-displacement after a closed reduction such as initial displacement, angulation, adequacy of initial reduction, associated ulna fracture, type of plaster, and initial post-operative images.

Average age has been 12.7 years. 3 out of 5 (60 %) completely displaced fractures treated by closed reduction and manipulation required a second procedure. Only 1 in 16 cases of incompletely displaced fracture required a second procedure.

Volar angulated fractures tend to redisplace after closed reduction, 3 out of 7cases (42 %) required a second procedure. Associated ulna fracture (22.7%) increased the risks of redisplacement.

5 out of 24 epiphyseal injuries redisplaced but these were either severely displacement or had volar angulation. 3 out of 4 cases (75 %)that were severely displaced had inadequate primary closed reduction & underwent a second procedure.

Conclusion: We would like to conclude that despite achieving a very good initial reduction, offended distal radius fractures & those with volar displacement have high risk of re-displacement. Inadequate primary reduction has invariably resulted in requiring a second procedure. It is advisable to treat such cases by primary open reduction and K wire fixation in order to prevent redisplacement.

In management of paediatric distal radius fractures, primary reduction with percutaneous Kirschner wire has better outcome and lower incidence of redisplacement in selected cases with features of complete displacement and volar angulation especially in the older age group (> 11 years).