INTRODUCTION Ankle fractures are common injuries affecting all age groups and constitute a large proportion of the orthopaedic trauma case load. Patients are usually admitted directly to the ward from the emergency department and a large number of bed-days are spent waiting for the ankle swelling to subside prior to surgery. We audited current practice and then implemented a home therapy programme (HTP). The purpose of the study was to assess the pioneering HTP with respect to cost effectiveness, length of stay and patient satisfaction. PATIENTS AND METHODS If HTP criteria were met, patients with reduced, unstable ankle fractures were taught safe mobilisation by physiotherapists in the emergency department. They were then discharged home to ice and elevate their ankle in a plaster backslab. A provisional operation date was allocated on discharge. They were admitted to hospital the day of surgery and then discharged home when safe and comfortable. RESULTS Forty-three consecutive patients met our inclusion criteria and underwent surgical fixation of unstable ankle fractures over a 3-month period (February-April 2008). The average length of hospital stay was 8 days (range, 1-18 days), 4.5 days pre-operatively and 3.5 days postoperatively. Patients were frustrated and dissatisfied with the whole process. In total, 177 patients underwent surgical fixation of unstable ankle fractures over an 11-month period (November 2008 to October 2009) and, of these, 59 met the home therapy criteria. The average length of hospital stay was 2.4 days, 1 day pre-operatively (range, 0-4 days) and 1.4 days postoperatively (range, 0-5 days). All HTP patients expressed satisfaction with the process. Over the course of the HTP, 354 bed-days were saved which equates to a saving of £81,774. The annual estimated cost saving is £90,000. CONCLUSIONS The home therapy programme has proved effective in reducing hospital stay both pre-and postoperatively. It is cost-effective and well received by patients.

BACKGROUND: Quality of recovery (QOR) instruments measure patients’ ability to return to baseline health status after surgery. Whether, and the extent to which, postoperative ambulation contributes to QOR is unclear, in part due to the lack of valid tools to measure ambulation in clinical settings. This cohort study of the cesarean delivery surgical model examines the accuracy and reliability of activity trackers in quantifying early postoperative ambulation and investigates the correlation between ambulation and QOR. METHODS: A prospective cohort of 200 parturients undergoing cesarean delivery between July 2015 and June 2017 was fitted with wrist-worn activity trackers immediately postpartum. The trackers were collected 24 hours later, along with QOR assessments (QoR-15 scale). The relationship between QOR and various covariates, including ambulation, was explored using multivariable linear regression and Spearman correlation (ρ). Forty-eight parturients fitted with 2 trackers also completed a walk exercise accompanied by a step-counting assessor, to evaluate accuracy, inter-, and intradevice reliability using interclass correlation (ICC). RESULTS: Compared to step counting, activity trackers had high accuracy (ICC = 0.93) and excellent inter- and intradevice reliability (ICC = 0.98 and 0.96, respectively). Correlation analysis suggested that early ambulation is moderately correlated with postcesarean QoR-15 scores, with a ρ (95% confidence interval) equivalent to 0.56 (0.328–0.728). Regression analysis suggested that ambulation is a determinant of postcesarean QoR-15 scores, with an effect estimate (95% confidence interval) equivalent to 0.002 (0.001–0.003). Ambulation was also associated with all QoR-15 domains, except psychological support. The patient’s acceptable symptom state (subjective threshold for good ambulation) in the first 24 hours was 287 steps. CONCLUSIONS: This study demonstrated the accuracy and reliability of activity trackers in measuring ambulation in clinical settings and suggested that postoperative ambulation is a determinant of postoperative QOR. A hypothetical implication of our findings is that interventions that improve ambulation may also help to enhance QOR, but further research is needed to establish a causal relationship.

Background Early postoperative ambulation is associated with enhanced functional recovery, particularly in the postpartum population, but ambulation questionnaires are limited by recall bias. This observational study aims to objectively quantify ambulation after neuraxial anesthesia and analgesia for cesarean delivery and vaginal delivery, respectively, by using activity tracker technology. The hypothesis was that vaginal delivery is associated with greater ambulation during the first 24 h postdelivery, compared to cesarean delivery. Methods Parturients having first/second cesarean delivery under spinal anesthesia or first/second vaginal delivery under epidural analgesia between July 2015 and December 2016 were recruited. Patients with significant comorbidities or postpartum complications were excluded, and participants received standard multimodal analgesia. Mothers were fitted with wrist-worn activity trackers immediately postdelivery, and the trackers were recollected 24 h later. Rest and dynamic postpartum pain scores at 2, 6, 12, 18, and 24 h and quality of recovery (QoR-15) at 12 and 24 h were assessed. Results The study analyzed 173 patients (cesarean delivery: 76; vaginal delivery: 97). Vaginal delivery was associated with greater postpartum ambulation (44%) compared to cesarean delivery, with means ± SD of 1,205 ± 422 and 835 ± 381 steps, respectively, and mean difference (95% CI) of 370 steps (250, 490; P < 0.0001). Although both groups had similar pain scores and opioid consumption (less than 1.0 mg of morphine), vaginal delivery was associated with superior QoR-15 scores, with 9.2 (0.6, 17.8; P = 0.02) and 8.2 (0.1, 16.3; P = 0.045) differences at 12 and 24 h, respectively. Conclusions This study objectively demonstrates that vaginal delivery is associated with greater early ambulation and functional recovery compared to cesarean delivery. It also establishes the feasibility of using activity trackers to evaluate early postoperative ambulation after neuraxial anesthesia and analgesia.

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low‐quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

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(Anesthesiology. 2018;128:598–608) Early ambulation can improve outcomes in surgical patients and is an important component of enhanced recovery. However, there is a lack of evidence on the ideal approach for evaluating early ambulation. Real-time quantification of ambulation is important, as most tools used to collect activity information are influenced by recall bias. This prospective observational study explored the feasibility of the use of activity fitness trackers in objectively quantifying ambulation, hypothesizing that in the 24 hours after delivery, vaginal delivery patients would have greater ambulation than cesarean delivery patients.

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Introduction Epidural and spinal hematoma are rare but potentially devastating complications of neuraxial anesthesia. Individuals with pre-existing bleeding disorders and tendencies are likely at higher risk of these feared complications, however there are currently no comprehensive recommendations to direct the use of neuraxial anesthesia in these patients. Objective Our objectives were to create a set of consensus recommendations to advise clinicians on appropriate treatment thresholds prior to neuraxial anesthesia for patients with a variety of common and uncommon bleeding disorders and tendencies, and to propose safe hemostatic thresholds for administration and removal of neuraxial anesthetics in these individuals. Materials and Methods A steering committee comprised of 14 hematologists, anesthesiologists and methodologists created and refined a set of Delphi statements regarding the use of neuraxial anesthesia in the following pre-existing bleeding disorders and tendencies: von Willebrand disease, immune thrombocytopenia, gestational thrombocytopenia, platelet function disorders, thrombocytopenia associated with hypertensive disorders of pregnancy, coagulation factor deficiencies and fibrinogen disorders. Statements were developed using data obtained from a previously conducted scoping review of existing literature supplemented with the expert opinion of the steering committee in areas where there are minimal published data. Statements include varying hemostatic laboratory parameters in the context of high or low bleeding risk as measured by either a validated bleeding assessment tool (BAT) or pre-defined criteria for excessive bleeding. We plan to recruit approximately 30 international panelists from the fields of hematology and anesthesiology to participate in a modified (i.e. electronic) Delphi technique. Three Delphi rounds will be conducted, during which we will ask panelists to rate their agreement with each Delphi statement on a 5-point Likert scale. Results will be analyzed for statistical consensus, defined as a Cronbach's alpha value of greater than or equal to 0.70. Statements that achieve consensus will be included in the final recommendations. Results Results of the modified Delphi study are pending. Conclusions Administration of neuraxial anesthesia in patients with pre-existing bleeding disorders and tendencies continues to present a significant management challenge for clinicians. We anticipate that the resultant recommendations will become a helpful tool for the future management of neuraxial anesthesia in these patients. Disclosures Martin: Borden Ladner Gervais LLP:Consultancy.Carvalho:Gauss Surgical:Consultancy.Kuter:Dova:Consultancy, Honoraria;Daiichi Sankyo:Consultancy, Honoraria;Actelion (Syntimmune):Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Principia Biopharma:Consultancy, Honoraria, Other, Research Funding;Protalix Biotherapeutics:Consultancy;Shionogi:Consultancy;Protalex:Consultancy, Honoraria, Research Funding;Kezar Life Sciences, Inc:Other, Research Funding;CRICO:Consultancy, Honoraria;Genzyme:Consultancy, Honoraria;Principia:Consultancy, Research Funding;Shire:Consultancy, Honoraria;Shionogi:Consultancy, Honoraria;Sanofi (Genzyme):Consultancy, Honoraria;Incyte:Consultancy, Honoraria;Immunovant:Consultancy, Honoraria;Kyowa-Kirin:Consultancy, Honoraria;Merck Sharp Dohme:Consultancy, Honoraria;Momenta:Consultancy, Honoraria;Novartis:Consultancy, Honoraria;Pfizer:Consultancy, Honoraria;Zafgen:Consultancy, Honoraria;Up-To-Date:Consultancy, Honoraria, Patents & Royalties;UCB:Consultancy, Honoraria;Platelet Disorder Support Association:Consultancy, Honoraria;Argenx:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Bristol-Myers Squibb:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Caremark:Consultancy, Honoraria;Immunovant:Other: Travel Expenses, Research Funding;Alnylam:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Agios:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Amgen:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Takeda (Bioverativ):Consultancy, Honoraria, Other, Research Funding;Rigel:Consultancy, Honoraria, Other, Research Funding;Protalex:Consultancy, Honoraria, Other, Research Funding.Lavin:Tremeau Pharmaceuticals:Membership on an entity's Board of Directors or advisory committees;Siemens Healthineers:Other: Speaker's fees;Takeda:Research Funding;Shire:Research Funding.Sholzberg:Takeda:Honoraria, Other: Scientific Advisory Board, Research Funding;Novartis:Honoraria, Other: Scientific Advisory Board;NovoNordisk:Honoraria, Other: Scientific Advisory Board;Octapharma:Honoraria, Other: Scientific Advisory Board, Research Funding;Amgen:Honoraria, Other: Scientific Advisory Board, Research Funding.