A Virtual Clinic and a One Stop Acute Tendo-achilles Clinic

Abstract

Patients with acute tendo-achilles (TA) rupture require prompt diagnosis, investigation and treatment in order to ensure optimum outcomes. This can be prevented by delay in review of patients within secondary care. We present our experience of treating such injuries by establishing a "virtual" fracture clinic (VFC) and a one stop dedicated TA specialist clinic. Patients are referred to the service via the emergency department (ED) and are triaged remotely by the VFC, at which all orthopaedic cases including suspected TA injuries are reviewed by a consultant orthopaedic surgeon using all available medical records and imaging. Suitable patients are then diverted directly to the specialist TA clinic for definitive treatment. We wished to establish the speed and efficiency of this care pathway. Methods: Using our institutions prospectively maintained database, we identified patients treated in the specialist TA clinic between September 2016 and August 2017. We recorded demographic details, injury mechanism, time from injury to diagnosis, ultrasound scan findings, and the speed of progress of the patient along the agreed rehabilitation pathway. Results: Sixty two patients were referred to the VFC with suspected TA injury. Mean age was 49 years, M:F (44:18 female). Mean time to triage in the VFC was 3.5 days (with 42% of patients triaged in the VFC on the same day as initial ED presentation). Mean time from ED consultation to assessment in our TA clinic was 11.7 days. Patients were assessed by a specialist foot and ankle surgeon, supported by a same day musculoskeletal ultrasound service. 45 patients (74%) were diagnosed with TA rupture, of which 69% were acute complete ruptures. Eight patients fulfilled criteria for surgical repair. Mean time from ED consultation to surgery was 13.25 days. Three further patients treated non-operatively developed secondary ruptures requiring delayed operative intervention. Conclusion: We recommend the use of a virtual triage service and a one stop TA clinic led by a dedicated specialist team to improve the accuracy of diagnosis and efficacy of treatment of acute TA rupture. This service provides a robust system for avoiding mis-diagnoses and delays in treatment, as well as ensuring effective implementation of our local care pathway under specialist supervision in a one stop clinic. This also establishes an effective system for monitoring as well as maintaining a research database for further prospective studies.