The COVID-19 pandemic further exacerbated disruptions to elective care services in the UK, leading to longer waits for treatment and a growing elective surgery backlog. There have been growing calls for the creation of surgical hubs to help reduce this backlog. Surgical hubs aim to increase surgical capacity by providing quicker access to procedures, as well as facilitate infection control by segregating patients and staff from emergency care. This rapid review aimed to assess the effectiveness, efficiency, and acceptability of surgical hubs in supporting planned care activity, to inform the implementation of these hubs in Wales. The review identified evidence available up until January 2023. Twelve primary studies were included, eight of which used comparative methods. Most of the studies were conducted during the COVID-19 pandemic and described surgical hubs designed mainly to mitigate the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Outcome measures reported included clinical, performance, economic, and patient reported outcomes across a variety of different surgical disciplines. Most of the studies did not describe surgical hubs based on their structure, i.e., standalone, integrated, or ring-fenced hubs. The evidence relating to the impact of surgical hubs on clinical outcomes appeared to be heterogenous and limited. Included studies did not appear to control for the impact of the COVID-19 pandemic on outcomes. Evidence of the impact of surgical hubs on performance outcomes such as efficiency, utilisation/usage, volume of surgeries/treatments, performance, cancellations, and time from diagnosis to treatment is limited. Evidence relating to the economic impact of surgical hubs is also limited, however there is evidence to suggest that total average costs are lower in surgical hubs when compared to general hospitals. Evidence relating to the impact of surgical hubs on patient reported outcomes is limited but indicates there may be a positive effect on patient satisfaction and compliance. Considerable variation in the types of surgical hubs reviewed, surgical disciplines, along with the small number of comparative studies, as well as methodological limitations across included studies, could limit the applicability of these findings.

/pdf/a-rapid-review-of-the-effectiveness-efficiency-and-7ce4omn2.pdf

A rapid review of the effectiveness, efficiency, and acceptability of surgical hubs in supporting planned care activity

The significance of ring-fencing orthopaedic beds and protected elective sites has recently been highlighted by the British Orthopaedic Association and the Royal College of Surgeons. During the pandemic, many such elective setups were established. This study aimed to compare the functioning and efficiency of an orthopaedic protected elective surgical unit (PESU) instituted during the pandemic with the pre-pandemic elective service at our hospital.We retrospectively collected data of all patients who underwent elective orthopaedic procedures in PESU during the pandemic and a similar cohort of patients operated on via the routine elective service immediately prior to the pandemic. To minimise the effect of confounding factors, a secondary analysis was undertaken comparing total hip replacements by a single surgeon via PESU and pre-pandemic ward (PPW) over 5 months.A total of 192 cases were listed on PESU during the studied period whereas this number was 339 for PPW. However, more than half of those listed for a surgery on PPW were cancelled and only 162 cases were performed. PESU had a significantly better conversion rate with only 12.5% being cancelled. Forty-nine percent (87 out of 177) of the cases cancelled on PPW were due to a 'bed unavailability'. A further 17% (30/177) and 16% (28/177) were cancelled due to 'emergency case prioritisation' and 'patient deemed unfit', respectively. In contrast, only 3 out of the 24 patients cancelled on PESU were due to bed unavailability. Single-surgeon total hip replacement showed similar demographic features for the 25 patients on PESU and 37 patients on PPW. The patients on PESU also demonstrated a decrease in length of hospital stay with an average of 3 days. 

/pdf/dedicated-orthopaedic-elective-unit-our-experience-from-a-1f3h36hv.pdf

Dedicated orthopaedic elective unit: our experience from a district general hospital

INTRODUCTION
Patient-reported outcome measures (PROMs) for bilateral staged total hip replacements (THRs) were reviewed to determine whether first-side surgery can predict second-side outcomes.


METHODS
A retrospective review was undertaken of a consecutive cohort of staged bilateral THRs using the same approach, implant and technique, from August 2009 to February 2020. Minimal important change (MIC) in PROMs was set at ≥5.


RESULTS
A total of 296 consecutive staged bilateral THRs were performed in 148 patients. Mean time interval between sides was 25 months (range 2-102). Mean age was 63.2 years for the first side and 65.3 years for the second; 62.8% of patients were female. Mean body mass index was 31.08 for the first side, increasing to 31.57 for the second side (p = 0.248). One-year follow-up PROMs were available for 96.6% and 92.5% of the first and second side, respectively. Mean PROMs improvement at 1 year was 26.4 for the first side and 25.1 for the second side (p = 0.207). Some 97.9% of patients achieved MIC for the first side and 96.3% for the second side (p = 0.092). Eight patients failed to reach an MIC on one side, all were female (p < 0.001); however, MIC was achieved for the contralateral side. Seven of eight patients (87.5%) achieved MIC by 2 years.


CONCLUSIONS
This study identified no significant difference between first- and second-side PROMs improvements following staged bilateral THRs at 1-year follow-up. Failure to reach MIC on one side does not preclude success on the other. Female patients were more prone to not reach MIC at 1 year, but improvement was still subsequently achieved in the majority of cases. The informed consent process is able to reflect this expectation.

Outcomes following staged bilateral total hip replacement: does first-side surgery predict the second?

Treatment options for secondary osteonecrosis of the knee in young adults (Systematic review and meta- analysis).

Morel-Lavallée lesions (MLLs) result from high-energy trauma causing separation of subcutaneous tissue from the underlying tissue, most commonly in the gluteal region or thigh.We report the case of a woman in her 40s with a fluctuant collection of the cervico-thoracic region following trauma. Further imaging identified an MLL. An orthoplastic approach resulted in non-operative management with a spinal brace. Three months from initial injury, the lesion completely resolved. She was symptom free at final follow-up and discharged.We present the only recorded case of MLL developing in the cervico-thoracic region. Management posed difficultly as no literature currently exists. We demonstrated conservative management for cervico-thoracic MLL can be effective.We have described the first documented case of cervico-thoracic MLL. MLL is not exclusive to pelvic injuries and can develop in the cervico-thoracic region. We have shown conservative management is a viable treatment of atypical MLL.

Cervico-thoracic Morel-Lavallée lesion.

The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected. The search strategy used electronic databases (PubMed, Medline, EMBASE, and AMED) for publications between January 1996 and November 2021. All studies that reported mPVR in patients in whom the diagnosis of CES was suspected, followed by MRI, were included. A total of 2,115 studies were retrieved from the search. Seven fulfilled the inclusion criteria. These included 1,083 patients, with data available from 734 being available for meta-analysis. In 125 patients, CES was confirmed by MRI. The threshold value of mPVR reported in each study varied and could be categorized into 100 ml, 200 ml, 300 ml, and 500 ml. From the meta-analysis, 200 ml had the highest diagnostic accuracy, with 82% sensitivity (95% confidence interval (CI) 0.72 to 0.90) and 65% specificity (95% CI 0.70 to 0.90). When compared using summative receiver operating characteristic curves, mPVR of 200 ml was superior to other values in predicting the radiological confirmation of CES. mPVR is a useful tool when assessing patients in whom the diagnosis of CES is suspected. Compared with other values a mPVR of 200 ml had superior sensitivity, specificity, and positive and negative predictive values. In a patient with a suggestive history and clinical findings, a mPVR of > 200 ml should further raise the suspicion of CES. Caution is recommended when considering the mPVR in isolation and using it as an 'exclusion tool', and it should only be used as an adjunct to a full clinical assessment.

Predictive value of post-void residual volume as an adjunctive tool in the clinical evaluation of cauda equina syndrome.

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