Initial experiences with a multidisciplinary approach to decreasing the length of hospital stay for patients undergoing unilateral mastectomy

BACKGROUND

We hypothesized that the introduction of a short-stay pathway would result in a significant reduction in length of stay for patients undergoing unilateral mastectomy, without a negative impact on patient safety.

MATERIALS AND METHODS

As part of a quality improvement project, a multidisciplinary committee designed a 1-day stay program for unilateral mastectomy patients. The study period was the first year after the 1-day pathway had routinely been implemented. We report on consecutive patients undergoing unilateral mastectomy ± tissue expander at Memorial Sloan-Kettering Cancer Center from July 1, 2009 to June 30, 2010. The primary endpoint was the percentage of patients discharged on postoperative day 1. Secondary endpoints included the incidence of postoperative complications within 30 days of surgery, reoperations, readmissions, and urgent-care visits within 7 days.

RESULTS

Over a 12-month period, 537 patients underwent unilateral mastectomy. Of those, 82.7% (444/537) were performed on a 1-day hospitalization basis, compared with 9.6% in 2008, before implementation of the 1-day plan. The 30-day complication rate was 6.1% (33/537). Overall, 2.6% of all patients had reoperation for hematoma (14/537), 0.9% had to be readmitted (5/537), and 1.5% (8/537) attended the urgent-care department. If all patients had stayed in the hospital for more than 1 day, none of the readmissions and only 2 urgent-care visits would have been prevented.

CONCLUSIONS

This study shows that a 1-day stay following mastectomy is easy to implement and safe for patients if a multidisciplinary team is involved in planning and implementation.

Elastic intramedullary nailing of paediatric fractures of the forearm

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

A systematic review of laparoscopic port site hernias in gastrointestinal surgery

INTRODUCTION

Port site hernia is an important yet under-recognised complication of laparoscopic surgery, which carries a high risk of strangulation due to the small size of the defect involved. The purpose of this study was to examine the incidence, classification, and pathogenesis of this complication, and to evaluate strategies to prevent and treat it.

METHODS

Medline was searched using the words "port site hernia", "laparoscopic port hernia" "laparoscopic complications" and "trocar site hernias". The search was limited to articles on cholecystectomy, colorectal, bariatric or anti-reflux surgery published in English. A total of 42 articles were analysed and of these 35 were deemed eligible for review. Inclusion criteria were laparoscopic gastrointestinal surgery in English only with reported incidence of port site herniation. Studies were excluded if insufficient data was provided. Eligible studies were also cross-referenced.

RESULTS

Analysis of 11,699 patients undergoing laparoscopic gastrointestinal procedures demonstrated an incidence of port site hernias of 0.74% with a mean follow-up of 23.9 months. The lowest incidence of port site herniation was for bariatric surgery with 0.57% in 2644 patients with a mean follow-up of 67.4 months while the highest incidence was for laparoscopic colorectal surgery with an incidence of 1.47% in 477 patients with a mean follow-up of 71.5 months.

CONCLUSION

All fascial defects larger than or equal to 10mm should be closed with peritoneum, while smaller defects may require closure in certain circumstances to prevent herniation. Laparoscopic port site herniation is a completely preventable cause of morbidity that requires a second surgical procedure to repair.

The reliability and variation of measurements of the os calcis angles in children

The databases of the Picture Archiving and Communication Systems of two hospitals were searched and all children who had a lateral radiograph of the ankle during their attendance at the emergency department were identified. In 227 radiographs, Bohler's and Gissane's angles were measured on two separate occasions and by two separate authors to allow calculation of inter- and intra-observer variation. Intraclass correlation coefficients were used to assess the reliability of the measurements. For Bohler's angle the overall inter-observer reliability, the intraclass correlation coefficient was 0.90 and the intra-observer reliability 0.95, giving excellent agreement. This reliability was maintained across the age groups. For Gissane's angle, inter- and intra-observer reliability was only fair or poor across most age groups. Further analysis of the Bohler's angle showed a significant variation in the mean angle with age. Contrary to published opinion, the angle is not uniformly lower than that of adults but varies with age, peaking towards the end of the first decade before attaining adult values. The age-related radiologic changes presented here may help in the interpretation of injuries to the hindfoot in children.

Current prescribing patterns of elastic compression stockings post-deep venous thrombosis

Objectives

Post-thrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) characterized by chronic pain, swelling and heaviness, and may result in ulceration. Elastic compression stockings (ECS) worn daily after DVT appear to reduce the incidence and severity of PTS. The aims of our study were to investigate practices and perceptions of DVT patients and physicians regarding the use of ECS after DVT.

Methods

Two surveys were conducted. The first was sent to 225 staff and trainee clinicians and the second was administered to 150 DVT patients.

Results

The results demonstrated that the majority of senior staff (75%) believed that ECS were effective in preventing PTS and in managing venous symptoms. However, this was in contrast with junior trainees (21%) ( P < 0.05). This resulted in only 63% of patients being prescribed ECS post-DVT. There was a lack of consensus as regards the optimal timing of initiation of ECS, duration of therapy and compression strength. Nearly all DVT patients who were prescribed ECS purchased them, 74% wore them daily, and most (61%) reported that ECS relieved swelling and symptoms. Physicians correctly predicted the main reasons for non-compliance, but misjudged the scale of patient compliance with ECS.

Conclusions

Our findings suggest that there is a lack of consensus among doctors regarding ECS use after DVT and widespread education regarding the latest evidence of the benefit of ECS after DVT.

Orthopaedic aspects of paediatric non-accidental injury

Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures.

Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death.

Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.