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.