Lean thinking: can it improve the outcome of fracture neck of femur patients in a district general hospital?

We present our experience in the management of hip fracture patients after the application of a value-stream approach, the Lean framework, in our trust. This system uses available resources in an efficient manner whilst eliminating waste. A statistically significant reduction of 5% and 9.3% was noted in the 30-day and overall mortality, respectively, after implementing ‘Lean thinking’. Further improvements were also noted in door-to-theatre time, use of trauma beds and early discharge from hospitals. To our knowledge, this is the largest study in the literature where the Lean framework has been successfully employed for the management of a very challenging health-care issue faced by the National Health Service. Future prospective studies are, however, needed to reconfirm these results and to evaluate the components that are most critical to the success of the implemented framework.     

Total knee replacement with intra-articular resection of bone after malunion of a femoral fracture: can sagittal angulation be corrected?

Intra-articular resection of bone with soft-tissue balancing and total knee replacement (TKR) has been described for the treatment of patients with severe osteoarthritis of the knee associated with an ipsilateral malunited femoral fracture. However, the extent to which deformity in the sagittal plane can be corrected has not been addressed. We treated 12 patients with severe arthritis of the knee and an extra-articular malunion of the femur by TKR with intra-articular resection of bone and soft-tissue balancing. The femora had a mean varus deformity of 16° (8° to 23°) in the coronal plane. There were seven recurvatum deformities with a mean angulation of 11° (6° to 15°) and five antecurvatum deformities with a mean angulation of 12° (6° to 15°). The mean follow-up was 93 months (30 to 155). The median Knee Society knee and function scores improved from 18.7 (0 to 49) and 24.5 (10 to 50) points pre-operatively to 93 (83 to 100) and 90 (70 to 100) points at the time of the last follow-up, respectively. The mean mechanical axis of the knee improved from 22.6° of varus (15° to 27° pre-operatively to 1.5° of varus (3° of varus to 2° of valgus) at the last follow-up. The recurvatum deformities improved from a mean of 11° (6° to 15°) pre-operatively to 3° (0° to 6°) at the last follow-up. The antecurvatum deformities in the sagittal plane improved from a mean of 12° (6° to 16°) pre-operatively to 4.4° (0° to 8°) at the last follow-up. Apart from varus deformities, TKR with intra-articular bone resection effectively corrected the extra-articular deformity of the femur in the presence of antecurvatum of up to 16° and recurvatum of up to 15°.     

Is it possible that most of the displaced acetabular fractures can be managed through a single ilioinguinal approach? 2�C7?Years experience results

This is a prospective study on the medium and long-term results of the operative treatment of 54 patients with displaced acetabular fractures of different types in a 7 years period. All patients were operated through a single ordinary ilioinguinal approach. The patients were followed for an average of 60 months (range 24–84 months). The postoperative reduction was anatomical in 42.6%; satisfactory in 44.4%; and unsatisfactory in 13% of the cases with the mean of 13 mm residual gapping. The radiological results were excellent in 37%; good in 46.3%; fair in 11.1%; and poor in 5.6% of the cases. Clinically, 24.1% of the cases had excellent scores, 59.2% had good scores, 9.3% had fair scores, and 7.4% had poor scores. Al unsatisfactory clinical results were related to the ipsilateral posttraumatic hip arthritis. There was a strong correlation between the preoperative fracture displacement and: the postoperative residual displacement (P = 0.008); the clinical results (P = 0.001); and the radiological results (P = 0.001). Complications occurred intraoperatively in 13%, early postoperatively in 22.2%, and lately in 24.1% of the cases. No awkward neurovascular injuries or cumbersome heterotopic ossification were encountered in any case. The results show that the spring plate is a good adjunct for posterior column and quadrilateral surface screws fixation, also that the single ilioinguinal approach can address most of the displaced acetabular fractures involving the weight bearing dome with the least possible complications and morbidity.     

The reliability of clinical and biochemical assessment in symptomatic late‐onset hypogonadism: can a case be made for a 3‐month therapeutic trial?

OBJECTIVE: To assess whether testosterone (T) supplementation in men considered to have symptomatic late-onset hypogonadism (SLOH) can be evaluated clinically and biochemically. PATIENTS AND METHODS: To assess the relevance of the clinical and biochemical diagnosis of hypogonadism we investigated patients referred for the diagnosis and treatment of SLOH. Patients were assessed clinically and completed a screening questionnaire. The pituitary-adrenal-gonadal axis was comprehensively assessed biochemically. Those with a clinical diagnosis of hypogonadism and serum levels of T supporting such a diagnosis received exogenous T for >/= 3 months and were assessed for any clinical and biochemical response. Of an initial group of 45 men (mean age 59.2 years) 38 completed the study. RESULTS: Most men presented with symptoms of sexual dysfunction, lack of energy and/or depression. There were differences before and after treatment only in bioavailable T (BT), with none in the levels of total T (TT). There was a strong correlation before and after treatment in the levels of luteinizing hormone and follicle-stimulating hormone, and a weak negative correlation between gonadotrophins and BT. Neither TT nor BT had predictive value for the treatment response. There was a trend to a correlation between BT levels and treatment success. Changes in serum prostate specific antigen were insignificant during the limited period. CONCLUSION: The lack of accurate methods for diagnosing SLOH suggests that a therapeutic trial of T supplementation is warranted in men in whom there are no contraindications. The 3-month period largely circumvents the placebo effect and has minimal risks for serious adverse effects (mostly in relation to prostate safety). This controversial position needs further evaluation with a larger cohort and other biochemical measurements.