bluuebunny/crossref_metadata_2025 huggingface dataset:
431 Electronic Structured Response Tool for Deteriorating Surgical Patients
Authors: El-Koubani O , Barnett-Vanes A
Published: October 2021

Aim

The Scottish Patient Safety Programme created the National Early Warning Score to have early recognition of deteriorating patients. Clear communication and documentation during and after episodes were found to improve outcomes. SIGN guidance recommended 9-component that should be included in structured response, creating a paper-based structured response tool (SRT). We aimed to review medical assessments of deteriorating patients in general surgical wards and compare to a formulated electronic SRT in promoting best practice.

Method

Patients scoring over NEWS 4 were identified at eight 2-week time points over a 18-month period and initial assessments evaluated.

Results

101 patients were identified with a NEWS ≥ 4 between July 2018-Feb 2019. Implementation of electronic SRT occurred in Nov 2018 and Feb 2019. Average NEWS was 5.9 (range 4-12). Comparing collection periods, following electronic SRT implementation, documentation of re-review times rose from 37.5% to 79.5%. Documentation of frequency of observations and management plans increased from 24.5% to 65% and 79% to 97% respectively. There was a statistically significant rise in recording of escalation plans following implementation of electronic SRT from 35% to 94% (p = 0.008).

Conclusions

Usage of electronic SRT promoted documentation of all components recommended by SIGN. There is further scope to extend usage outside of surgical wards for all junior doctors by introducing electronic SRT at medical induction.
466 Surveillance Flexible Cystoscopy in Bladder Cancer Follow-up
Authors: Goodman D , Taggart R , Salmond J , Day E H
Published: October 2021

Aim

This study addresses surveillance cystoscopy in patients diagnosed with bladder and upper tract cancer. Managed Clinical Network (MCN) guidelines have clear recommendations for the timetable of follow-up cystoscopy, and we conducted this audit to study regional compliance.

Method

Using a multisite pathology database of bladder cancer cases from 2016, we collected and analysed data on 100 non-muscle invasive bladder cancers. We took the first 10 cases from each month to ensure cross-regional representation. Each case was stratified according to MCN guidelines. Electronic medical records were examined to assess upper tract follow up. We allowed for +/- 1 month each side of the target timeframe.

Results

We had 64 male and 36 female subjects. In our risk categories, we had 31 low risk, 37 intermediate risk and 32 high risk bladder cancers. 67 were new cases, 33 were recurrent tumours.

10 (43.4%) of low-risk and 19 (79.2%) of intermediate-risk patients underwent surveillance cystoscopy earlier than the recommended 12-month timeframe. 18 (78.3%) of low-risk patients continued to have further surveillance cystoscopies after a 12-month disease-free period.

Conclusions

43.4% of low-risk bladder cancer patients are receiving surveillance cystoscopy earlier than recommended. 78.3% of these patients are then undergoing unnecessary procedures following a 12-month disease-free period against regional guidelines and recommendations. This places an increased burden on clinic/theatre time and contributes to patient anxiety surrounding cancer follow-up. Evidence-based medicine guidelines have shown that less is more when it comes to low-grade bladder cancer surveillance. We now need to assess why we are deviating from our own guidelines.
495 Audit on Blood Ordering Requests in Mastectomies: The Need for a Routine Group and Hold
Authors: Chan K Y , Keogh S , Aucharaz N , Buckley J , Merrigan A , Tormey S
Published: October 2021

Aim

A group and hold (G&H) forms part of the pretransfusion compatibility testing and is commonly requested in anticipation of a possible blood transfusion. Requests made in the context of elective procedures with a low transfusion probability, such as a mastectomy, are associated with added financial burden and increases workload in a healthcare system. This audit aims to analyse the cost-benefit associated with the routine request for a preoperative G&H in patients undergoing mastectomies.

Method

A total of 100 patients undergoing mastectomies from the period of September 2019 to October 2020 were included in the audit. Data regarding blood order requests, units of blood transfused, perioperative haemoglobin and the type of mastectomy (right, left or bilateral) were collected.

Results

All patients had a routine G&H as part of their preoperative assessment. The average age in this cohort was 60.3. Right-sided mastectomy was the commonest procedure in this cohort (N = 52). The average preoperative haemoglobin was 13.0g/dL. 2/100 patients received post-operative blood transfusions. The transfusion probability in this cohort was 2%. Only 15% of the cohort had a post-operative haemoglobin level checked. The average drop in haemoglobin in this cohort was 2.3g/dL.

Conclusions

This audit demonstrates the low prevalence of blood transfusions in patients undergoing mastectomies, consistent with current literature. The projected cost savings associated with selective requests for G&H are significant. However, the implementation of a safe and targeted blood ordering approach in patients with high bleeding risks will require a validated stratification system.
501 Antiplatelet Therapy Following Coronary Artery Bypass Grafting: A Closed Loop Audit in a Tertiary Centre
Authors: Scarborough A , Bleetman D
Published: October 2021

Aim

Guidelines recommend 12 months of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) followed by emergency coronary artery bypass grafting (CABG). In patients with stable coronary artery disease (CAD) undergoing CABG, DAPT does not give a survival benefit but may prevent venous graft occlusion. Variation exists in practice between consultants with regards to duration of DAPT after CABG in stable CAD patients.

Method

All patients who underwent CABG in our centre in October and November 2020 were identified. Type and duration of antiplatelet and/or anticoagulant were recorded, as was history of MI and/or PCI. An antiplatelet prescription aid, taking into account surgeon preference, was designed and the effect on prescribing re-audited.

Results

35 patients underwent CABG. All patients except 2 received lifelong aspirin or a DOAC/NOAC. 3 patients had STEMI/NSTEMI in the preceding 12 months; two received DAPT and one received aspirin and a DOAC. Variation exists for DAPT prescribing duration following CABG for stable CAD. Re-audit results shows improvement in consistency of prescribing following implementation of the prescription aid.

Conclusions

Adherence to DAPT guidelines following PCI and CABG is good. However, variation exists in DAPT prescribing in stable CAD patients, between consultants and between patients for the same consultant. Consistency improved with implementation of the prescription aid.
524 Effectiveness of Burns Wound Cleansing by Comparison of Prewash and Post Wash Swab Reports
Authors: Sayed M A , Jabeen S , Soueid A
Published: October 2021

Aim

The main aim and objective were to optimise wound healing through infection prevention. This clinical audit aimed to investigate the effectiveness of burn wound cleansing in decreasing bacterial load by comparing pre-wash and post-wash swab results against local burn wound management and aseptic non touch technique (ANTT) guidelines.

Method

The audit was conducted retrospectively on children admitted to Burns Unit during August 2019, excluding resuscitation burn patients. Pre- and post-wash swabs taken on admission were included and the results obtained from Chameleon database. Data were collected on excel spread sheets including demographic variables such as age, sex, type of injury, percentage total body surface area (TBSA) and mechanism of injury. Data were analysed and results compiled.

Results

Fifty patients were admitted over a month period; amongst those 60% were male and 40% female of ages ranging from 5 months to 14 years. Scald (50%) was found to be the most common mode of injury followed by contact burn (36%) involving 0.30 to 9% TBSA. Among 50 patients, 30 (60%) showed no growth in pre-wash and 36 (72%) in post-wash swabs. However, 6% post-wash swabs that were initially negative later showed bacillus cereus, staph aureus, Enterobacter, and Acinetobacter. Similarly, another 4% post-wash swabs developed new microorganisms as compared to pre-wash swabs.

Conclusions

The most common bacteria colonising both pre- and post-wash swabs was staph aureus. Overall, cleansing had reduced the bacterial load significantly around 82% very effective. It is imperative to stick to local guidelines to reduce morbidity and mortality in burn patients.
530 An Audit of Appropriate Documentation Following Urethral Catheterisation
Authors: Dokubo I , Armitage J
Published: October 2021

Introduction

Urethral catheterisation is a procedure frequently done in the hospital by medical personnel. Appropriate documentation is necessary to ensure safe clinical care and to reduce the risk of litigation.

Method

We randomly reviewed electronic notes of patients seen by the on-call urology team who had a urethral catheter inserted in September 2020. Reviewing the trust’s guidelines, we considered that appropriate documentation should include reference to the following 10 items; indication, chaperone present, consent obtained, groin examination, catheter size, catheter type, insertion process, urine colour, water in balloon and residual volume were reviewed.

Results

A total of 50 patients were included. 72%(36/50) were inserted by a member of the urology team. Only 28%(14/50) had all 10 items documented. Indication for catheterisation was best documented at 94%(47/50) while presence of a chaperone and groin examination (i.e. presence of a foreskin and its replacement post-catheterisation) were the lowest at 44%(22/50).

Conclusions

This study shows there is low compliance to adequate documentation of urethral catheterisation. A ‘smart phrase’ has been developed for use with our Trusts electronic medical records system to assist clinicians with appropriate documentation. Clinicians that use the phrase ‘.icat’ are prompted to document all 10 requisite items. This uses the mnemonic i-CATHETAR [indication, Chaperone and consent, groin Assessment, Tube (catheter size and type), insertion process (Hard/Easy), urine Tint, Aqua in balloon, Residual volume]. A second audit cycle is currently being done to review the effectiveness of this intervention.
552 A Single Centre Retrospective Study of Outcomes in Open Liver Surgery
Authors: Shrestha D , Gungadin P , Sonanis S , Sultana A , Subar D
Published: October 2021

Aim

Despite advances in laparoscopic surgery for liver resections, an open approach remains the most frequent approach for complex liver resections for benign and malignant conditions. The aim of this study was to evaluate the clinical outcomes of patients undergoing open liver resections at a single tertiary HPB centre.

Method

All patients undergoing open liver resections between March 2018-July 2020 were included. Clinical and pathological data was reviewed for all patients and data collected including demographics, indication for surgery, complications, length of hospital stay and 30- and 90-day mortality.

Results

A total of 51 patients underwent open liver resection with median age of 65 (IQR 60.5-70.5). Indication for surgery included CRC metastasis (45%), HCC (27%), Intrahepatic cholangiocarcinoma (8%), Cholangiocarcinoma (8%), other metastasis (8%). The median hospital stay was 8 days (IQR 6-15). Complications were noted in 17 patients (Clavien-Dindo Classification III (8%) and IV (12 %). 6 patients had post op bile leaks, 4 with grade B and 2 with grade C bile leaks. 8 patients had post hepatectomy liver failure (5 Grade A, 2 Grade B, 3 Grade C). No mortality was noted at 30 and 90-day time-points.

Conclusions

Our outcomes in terms of morbidity, mortality and hospital length of stay are similar to that in published literature.
633 Improving the Quality of AKI Management Within a District General Surgery Department
Authors: Dougal J , Crawford J , Kourounis G , Whalen H
Published: October 2021

Introduction

Acute kidney injuries (AKI) affect 1/5 patients requiring acute hospital admission. The NCEPOD report (2009) described only 50% of AKI care as “good”. Swift identification and appropriate management of AKI is vital. We aimed to assess and improve our adherence to NICE guidance(QS76, NG48) on managing AKI.

Method

Retrospective review of paper notes was conducted in patients admitted under general surgery at Royal Alexandra Hospital found to have a > 50% increase in the serum creatinine. We assessed the completion of a urinalysis and withholding of nephrotoxic medications within 24 hours of AKI identification, and duration of AKI. First cycle was conducted in August 2020. An AKI alert card was introduced outlining the identification of an AKI and initial management. This provided an effective method of recording interventions in patient notes and accessible education on current guidelines to foundation doctors. The second cycle commenced mid-December and is ongoing.

Results

First cycle included 30 patients; median age was 77(IQR:67-85). Adherence to urinalysis and nephrotoxic guidance was completed in 9/30(30%) and 13/30(43%) respectively. Median duration of AKI was 7(IQR:5-12) days. Second cycle has identified 17 patients so far; median age is 75(IQR:68-91). Adherence to urine dip and nephrotoxic guidance improved to 11/17(65%)(p < 0.05) and 16/17(94%)(p < 0.05) respectively. Median duration of AKI also improved to 3(IQR:2-7) days (p < 0.05).

Conclusions

Our interim results show a positive effect to the management of AKI following the introduction of our AKI Alert Cards. Reduction in overall duration of AKI highlights patient benefit.
642 A Closed Loop Audit Looking at The Use of a Checklist in Surgical Ward Rounds to Improve Documentation. Can We Improve Patient Safety?
Authors: Liao Christopher , Sheaff Emma , Wilkins Harry
Published: October 2021

Introduction

Ward rounds are essential in assessing and planning patient care, but they are often subject to variable quality and structure. A ward round checklist could improve documentation and patient safety.

Method

We performed a closed-loop audit with a different novel ward round checklist in each audit, the second made from improving the first, based on feedback. We looked at checklist utilisation, and the quality of documentation in notes. We compared the quality of documentation in notes with the checklist, to notes without the checklist. The data was then collated and analysed. Standards from the Royal College of Physicians’ “Ward Rounds in Medicine”.

Results

In the first audit, our sample was 68, in the second, it was 64. With the use of a checklist (M = 67%, SD = 22%) documentation was significantly better than without (M = 26%, SD = 10%), t(64)=8.85, p<.00001. Ward documentation was especially improved regarding fluid balance, analgesia, and assessing physiotherapy needs. The second version of the checklist (M = 56%, SD = 28%) was used significantly more than the first checklist (M = 13%, SD = 22%), t(75)=7.59, p<.00001.

Conclusions

With the growing role of clinical notes as a legal document, a tool for handover, and a pillar of care planning, improving the quality of the documentation is imperative. This study shows that a systematic checklist significantly improves ward round documentation, which has already established in an improvement in clinical care. We hope to follow-up this study with a third audit, focusing on patient satisfaction and determining reduction in harm caused to patients with a ward round checklist.
648 The Use of Antibiotics in Acute Pancreatitis - A Re-Audit of Current Practice
Authors: Rai A , Kudchadkar S , Munasinghe A
Published: October 2021

Introduction

The NICE guidelines do not advocate the use of prophylactic antibiotics in the management of acute pancreatitis. In severe pancreatitis with necrosis, local antimicrobial guidelines state that it ‘maybe reasonable to use antibiotics with good spectrum anaerobic cover’ and suggest the use of Amoxycillin, Metronidazole and Gentamicin as first line, and Meropenem as second line if needed. Previous audit showed 74% of patients receiving antibiotics without clear indication.

Method

A retrospective re-audit of the use of antibiotics in patients admitted with a clinical or radiological diagnosis of acute pancreatitis was undertaken in a single-centre University Hospital between July and October 2020.

Results

78 patients were admitted during this period, with a mean age of 52years (range 6-89 years), and male preponderance. All patients were conservatively managed with intravenous fluids, analgesics and antiemetics. 31(40%) received intravenous antibiotics, of whom, 14 (45%) had no clearly documented indication for their use. The remaining 17 had pancreatic necrosis (4), cholangitis/cholecystitis (4), infected pseudocyst (2), UTI (2), fever spike (1), positive blood cultures (1) and pancreaticoduodenal fistula (1). Metronidazole was the most commonly used antibiotic (58%), followed by Amoxicillin (38.7%), Co-amoxiclav (35.4%), Gentamicin (22.5%) and Meropenem (22.5%).

Conclusions

In line with the recommendations made from previous audit and improved awareness, there was a significant improvement in the number of patients receiving antibiotics without indications from 74% to 45%. We hereby stress the importance of the use of appropriate clinical judgement in decision-making and avoiding the unwarranted use of antibiotics in acute pancreatitis.
670 Documentation and Communication of National Emergency Laparotomy Audit (NELA) Mortality and Morbidity Scoring with Patients Prior To Consenting: Are We Following the Best Practice?
Authors: Barghash M , Rehman J , Salimi F , Mansour M
Published: October 2021

Aim

Patients presenting as an emergency have a greater risk of dying than those admitted electively. The ability to stratify risk and calculate a percentage chance of death, not only gives the clinical team a common language to be able to formulate a management plan but also enables them to communicate this with patients and their families. This includes a full explanation of potential risks, benefits, a ceiling of care and management alternatives. In this project, we assessed if the NELA score has been properly calculated, documented prior to surgery for every emergency laparotomy patient and whether such patients were aware of NELA risk predictions prior to consenting.

Method

This was a retrospective audit based on the NELA guidelines of pre-operative risk stratification and the fifth report NELA recommendations. We assessed 50 case notes of patients who had laparotomies from January 2019 to April 2020 in a busy district general hospital in the UK.

Results

We noted that NELA risk prediction score was not utilised/documented in most of the patients with compliance of only 26%. We also found that, in the majority of notes, no NELA score discussion with the patient/family was documented, even with patients who had their NELA score calculated preoperatively. Compliance was only 14% in relation to this category.

Conclusions

A formal assessment of the risk of mortality and morbidity should be made explicit to each patient and should be recorded clearly in the consent form and medical record.
680 Excelling in Adversity - Maximising Training Opportunities by Reducing Cancelled Operations
Authors: Holden C , Warrell D , Addams-Williams J
Published: October 2021

Aim

Viral swabs for Covid-19 are an essential part of a patient’s pre-operative checklist. Patients require negative swabs before proceeding to theatre. Delay in this process may lead to a cancelled operation with physical and mental health implications for the patient. There is a knock-on effect on surgical training, with fewer procedures and operations for teaching.

Method

Previous guidance required 2 staggered swabs prior to admission. This was simplified on 19th August 2020 to a single pre-operative swab. A retrospective audit was established within the Otolaryngology department at the Royal Gwent Hospital to assess whether the simplification of guidance reduced the rate of cancellations and the number of same-day swabs needed to maintain operating.

Results

In a 4-week period prior to the simplification in guidance there were 34 listed procedures, 3 of which were cancelled due to swab related issues. 1 patient required a same-day swab to facilitate surgery. In a 4-week period after the simplification in guidance there were 48 listed operations and no cancellations due to swab issues. 6 patients required same-day swabs to facilitate surgery.

Conclusions

Whilst the simplification of swab guidance has improved the rate of operations cancelled, the reliance on same-day swabs to maintain operating has increased. This could reflect better availability of same-day swabs. It is in the interest of trainees to ensure that patients are fully prepared for operations pre-operatively to minimise unplanned cancellations, associated patient harm and loss of training opportunities.
690 Orthopaedic Trauma Surgery: Has the COVID Pandemic Affected Surgical Outcomes?
Authors: Edwards T , Hristova K , Shiels S , Frostick R , Lostis E , Kumar N
Published: October 2021

Aim

To compare the surgical outcomes following orthopaedic trauma surgery before and during the COVID pandemic in an adult Major Trauma Centre.

Method

A retrospective chart review was conducted for all patients undergoing orthopaedic trauma surgery before (01/12/2019 to 29/02/2020) and during (01/03/2020 to 10/06/2020) the COVID pandemic. A Chi-square test was used to compare frequencies of type of anaesthetic used, postoperative ITU admission, any surgical complications and mortality. Data was collected 90 days after surgery.

Results

During the pre-COVID period, 501 patients (mean age at surgery 64y 4m; 222 male (44%)) underwent orthopaedic trauma surgery (395 lower limb (79%); 86 upper limb (17%); 28 pelvis (6%)) compared to 474 patients (mean age at surgery 61y 8m; 219 male (48%)) during the COVID period (388 lower limb (82%); 58 upper limb (12%); 23 pelvis (5%)). There was a significant increase in the use of a spinal as the main anaesthetic during the pandemic (9 (2%) vs 115 (24%), p < 0.001) and fewer trauma patients were admitted to ITU postoperatively (42 (8%) vs 16 (3%), p0.001). There was no difference in the rate of postoperative complications (103 (21%) vs 95 (20%), p0.841) or mortality at 90 days (42 (8%) vs 43 (9%), p0.703). Of the 244 COVID swabs done during the COVID period, 8 (3%) were positive.

Conclusions

Despite widespread operational disruption and a change in anaesthetic practice, there was no change in the rate of postoperative complications or mortality following orthopaedic trauma surgery.
773 The Impact of Introducing an Enhanced Recovery Nurse Practitioner on Colorectal ERP Protocol Compliance and Surgical Outcome: A Single-Unit Experience
Authors: Teng W H , Mastoridis S , Shield E , Khanna A , Singh A
Published: October 2021

Introduction

The enhanced recovery programme (ERP) is a validated perioperative care plan that has consistently shown to reduce morbidity and improve patient outcomes. Our trust introduced ERP for major elective colorectal procedures in 2007. However, it had been noted that compliance to protocol was variable. This audit was conducted to see if introduction of an enhanced recovery nurse (ERN) improved compliance.

Method

This was a single-centre, retrospective, closed-loop audit; each cycle consists of resectional cases over a 1-year period. Perioperative data were collected from preoperative assessment documents, anaesthetic charts, operation notes and post-operative patient records. Compliance to 20elements of the agreed ERP protocol and length of stay (LOS) were assessed. First-cycle results were presented locally, leading to protocol revision and introduction of a dedicated ERN. Two years following ERN introduction, data were re-audited and compliance assessed. Statistical analyses were performed using Chi-squared test or independent t-test as appropriate.

Results

Among 101 procedures analysed in the first-cycle, compliance to ERP elements ranged between 30-95%. Following intervention, among 113 cases, compliance improved to 46-99%. Statistically significant improvements were observed in post-operative ERP elements. Compliance to early cessation of intravenous fluids increased from 44% to 61% (p = 0.02), and early urinary catheter removal increased two-fold, from 30% to 62% (p < 0.01). Patients resumed light diet earlier and mobilised out of bed sooner. LOS improved from median of 7(1-48) to 6(2-50) days (p = 0.03).

Conclusions

This study demonstrates that the introduction of a dedicated ERN is associated with significantly improved protocol compliance and reduced LOS following major colorectal resection.
627 Trauma & Orthopaedic National Selection – What Is Really Going Through the Mind of Applicants?
Authors: Curtis A
Published: October 2021

Aim

Obtaining a training number in Trauma & Orthopaedics (T&O) remains highly competitive. This study aims to provide an insight into applicant’s perceptions and preparation for the T&O national selection interview.

Method

162 junior doctors applying to T&O national selection in 2021 were sent questionnaires using SurveyMonkey in December 2020. Applicants were identified from those attending the annual OrthoRevision ‘ST3 Core Knowledge Interview Course’. In total, 74 junior doctors (45.7%) covering all 16 surgical training regions in the UK completed feedback.

Results

There were wide variations in how much applicants would spend on preparation for the interview (e.g., books, revision websites, courses): 45.9% spend £100 - £500; 21.6% spend £500-£1,000; and 6.8% spend >£1,000. Most start preparation 3 months prior to the interview (42.5%) with the preferred method being practice with colleagues (49.3%). Almost all candidates (80.2%) use the ‘OrthoInterview’ question bank. Free mock interview courses were only available to 27% with candidates strongly in favour (78%) of the study budget covering preparatory courses in addition to study leave being granted to attend these courses (86%). At the first attempt at obtaining a training number, 69.9% were selective about where they would accept a job; in subsequent years candidates would be more willing to accept a job in any deanery (40.3%).

Conclusions

For the first time, we present the perceptions of applicants to T&O national training in the UK. Many candidates dedicate a large amount of time and money to the process and are initially more selective about where they apply.
643 How the Straight Leg Raise and Crossed Straight Leg Raise Sign Influence Patient Reported Outcome Measures in Patients with a Lumbar Disc Herniation
Authors: Stanley A , Jones T , McCarthy M
Published: October 2021

Aim

Low back pain (LBP) with associated lumbar radiculopathy is common. Clinical assessment utilises the straight leg raise (SLR) test and the more specific crossed straight leg raise (XSLR) test. Patient reported outcome measure (PROMs) scores can assess the contributary biopsychosocial factors to pain. Evidence shows links between radiculopathy and psychosocial issues, but little has assessed them in relation to clinical examination. The aim of this study was to assess the significance of the SLR and XSLR sign on PROMs in patients with an MRI-confirmed lumbar disc herniation.

Method

Patients with an MRI-confirmed lumbar disc herniation who presented with LBP and lumbar radiculopathy were identified. Collected data included the clinical examination outcome, level and side of disc prolapse, interventions and PROMs scores (VAS, ODI, EQ5D, GAD7, PHQ9). Statistical analysis was performed using SPSS.

Results

216 patients were included in this study (mean age 50.4, 41% female, 59% male), 102 had negative straight leg raise (NSLR), 94 had positive SLR and 20 had both a positive SLR and positive XSLR. Patients with a positive clinical test on examination had ‘worse’ PROMs scores, with a positive XSLR sign associated with the ‘worst’ PROMs scores. For each PROM, t-test analysis reported a significant difference between the NSLR and SLR groups and NSLR and XSLR groups (P < .01).

Conclusions

PROMs scores indicating a lower health-related quality-of-life, increased levels of disability, pain, anxiety and depression and greater expectations are associated with a positive SLR or XSLR test.
702 The Role of Scapular Morphology in Traumatic Rotator Cuff Tears and Greater Tuberosity Fractures: A Retrospective Study
Authors: de Stadler K , Musbahi O , Ibrahim E
Published: October 2021

Aim

Traumatic Rotator Cuff Tears(RCT) and Greater Tuberosity fractures(GT) are associated with high morbidity and reduced quality of life. Diagnostic and treatment pathways for both RCT and GT fractures are different. In this study we look at whether scapular morphology features can aid in our understanding of these traumatic injuries and influence patient pathways.

Method

A retrospective study was conducted at 2 hospitals. All patients between the period of 2010 and 2020 with Traumatic GT fractures or RCT were identified. Patients were case matched by age and laterality of injury. Primary outcome measurement was the Critical Shoulder Angle(CSA) and timing to further imaging. Statistical analysis was conducted using STATA™.

Results

Eighty patients met the inclusion criteria(40 traumatic RCT and 40 GT). Mean age was 61.8 years with 58(72.5%) left sided injuries. The difference between RCT and GT was 3.96 degrees(95% CI 2.5 to 5.41, p < 0.05). An CSA of 33.73 gave a sensitivity of 0.68 and a specificity of 0.8 to differentiate between RCT and GT fractures. The Area under the Curve(AUC) was 0.8 indicating high reliability. The overall difference in presentation to further scan between the 2 groups was 78. 3 days( P < 0.05, 95% CI 48.7 – 108).

Conclusions

Patients with a traumatic RCT and GT fractures have different scapular morphology and radiographic features which predisposes them to have these injuries. Patients presenting with a traumatic RCT are more likely to have a higher CSA and have a greater delay to further scan.
741 Restarting Elective Orthopaedic Surgery During The COVID-19 Pandemic: Experiences and Patient Outcomes
Authors: Laurent E , Saleh M , Vusirikala A , Castillo T , Kuzhupilly R , Fahmy A , Tsekes D
Published: October 2021

Aim

The COVID-19 pandemic resulted in postponing all non-urgent elective surgeries from April 2020. As we emerged from the first peak, restarting non-urgent services such as elective orthopaedic surgery was important for patients with chronic debilitating conditions. Our hospital successfully restarted orthopaedic surgery during the pandemic to help improve the quality of life of patients. This study describes the development of local protocols and pathways to allow for a safe restart of elective orthopaedic surgery in a COVID-19 free site. It presents the morbidity and mortality outcomes of those patients.

Method

This is a prospective cohort study evaluating all patients undergoing non-emergency orthopaedic procedures through a COVID-19 free pathway in a DGH from 18th May – 10th July 2020. 104 patients were identified, and their outcomes analysed during the 2 weeks following their surgery.

Results

No patients developed COVID-19 in the 2-weeks post-operative period. There were no ITU admissions or in-hospital deaths. 22(21.15%) out of 104 patients developed 23 complications within 2 weeks of surgery. These included: TIA, PE, AF, superficial wound infection, oozy wound and post-operative anaemia. They all made full recovery. There was no statistical difference in the development of complications for age (< 70; >70), gender, BMI, or ASA grades.

Conclusions

This study describes a roadmap to setting up a protocolised elective operating service for orthopaedic surgery. It has shown that standardised protocols in a COVID-19 free site, pre-operative COVID-19 testing and adherence to national guidelines on self-isolation prior to surgery can help prevent COVID-19 infection and its related risks post-operatively.
854 Mortality Associated with Conversion of Total Hip Arthroplasty for Failed Fixation/Hemiarthroplasty for Neck of Femur Fractures
Authors: Khan W , Baig A , Afzaal Q , Davison J , Hutchings S , Kulkarni A , Brown A , Ashford R
Published: October 2021

Aim

To identify the mortality associated with failed internal fixation and hemiarthroplasty of neck of femur fractures.

Method

Patients undergoing conversion of internal fixation / hemi arthroplasty were identified from theatre records and surgical databases. Data was stored in Microsoft Excel spreadsheet. Clinical outcomes at 30 days, 1 year and 5 years post conversion total hip replacement.

Results

60 cases were collected between June 2006 and November 2016. 46 females and 14 males involved in the case. The mean age of male patients was 66.5 and for females 67.9. 32 patients had previous sliding hip screw fixation,12 had intra-medullary nails, 8 had cannulated screw fixation and 5 patients had hemiarthroplasty. The mean time to failure was 22 months (Range: 2 weeks to 60 months) and there were 6 cases of late posttraumatic arthritis (range 4 yrs to 23 yrs). Average time from documented failure to conversion THR was 2 months. There were 2 superficial wound infections which were successfully treated with antibiotics. There were 2 cases of deep infection which required multiple debridement, washout, and prolonged inpatient stay. Average duration of hospital stay was 5.7days. 18 patients died before 5 years for reasons unrelated to their hip. All had a functional prosthesis at time of last review. 42 patients alive at 5 years had a functional prosthesis at last review

Conclusions

Total Hip Arthroplasty is a successful procedure for failed fixation / hemiarthroplasty despite the technical challenges. A 3–5-year mortality rate of 33.33 % reflects well against the NHFD 1year mortality of 30 %.
910 The Value of a Compressive Base Layer Bandaging in Post-Surgical Plaster Application: Reductions in Early Face-To-Face Times and Early Dressing Changes. Improved Patient and Plaster Technician Satisfaction
Authors: Tebby J , Ahmadi M , Gadd R , Van Breevoort C , Farndon M
Published: October 2021

Aim

Plaster immobilisation alongside wound compression after surgery is often required but not easy to balance. If a plaster is too loose then it may not produce sufficient wound compression but if the cast is too restrictive it may be uncomfortable and lead to complications. Our aim is to provide a technique that addresses these imbalances.

Method

Compressive base layer banding technique involves tightly wrapping the wound dressing with wool and crepe then applying a well-padded plaster on top. The technique was prospectively audited and compared to other practice within our centre. The aims were to show that the technique was safe and to look for potential benefits for patients and healthcare staff. Both groups included trauma and elective patients treated by a similar set of foot and ankle operations. We audited patients on their experiences, concerns and time spent having their cast changed.

Results

Primarily, the results showed that the technique was safe with no severe complications. The time for a plaster change reduced by a third, from 24 minutes (control group n = 28) to 16 minutes (intervention group n = 27). Dressing changes at the same time were reduced by 80%. The intervention group were happier with their casts, had lower levels of concerns regarding their attendance and their risk of infection.

Conclusions

Our audit has shown that the compressive bandaging technique is safe (non-inferior) compared to current practices at our hospital. The technique has the benefit of reducing the time patients spend being face-to-face during plaster change and reduces both their discomfort and concern.
965 Complication Rates in Operatively Managed Ankle Fracture/Dislocations - The Effect of Pre-Reduction Imaging and Compliance with BOAST 12 Guidance
Authors: Phoon K M , Ward A , O'Dowd D , Pitcher F , Amos L , Butler J , Brewer P , Davies M , Chadwick C , Davies H , Blundell C
Published: October 2021

Aim

The BOAST-12 guidelines for the management of ankle fractures aims to optimise functional recovery and reduce complications. They advise against having radiographs prior to urgent reduction of clinically deformed ankles as it could cause an unacceptable delay to subsequent management. Our study aimed to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction.

Method

This was a retrospective observational study of patients with ankle fracture-dislocations between 2013 to 2017 at the Northern General Hospital’s Emergency Department (ED). Information collected from 2 patient groups (with and without pre-reduction radiographs), included patient demographics, time to accepted reduction, number of manipulations, operations, and subsequent complications.

Results

242 patients were identified. Time from arrival in ED to acceptable reduction was significantly longer in patients with pre-reduction radiographs versus patients without (184.5 vs 82 minutes, p < 0.00), but did not increase the overall risk of complications (p = 0.62). Pre-reduction radiographs were associated with insignificantly higher rates of post-traumatic osteoarthritis (p = 0.17) and slightly longer wait time for definitive intervention (1 vs 2 days, p = 0.72). However, this had no relationship with the number of manipulations (p = 0.53).

Conclusions

The use of pre-reduction radiographs significantly increased time to acceptable reduction of ankle fracture-dislocations. However, this was not associated with increased risk of complications or time to definitive management.
1013 Dupuytren’s Contracture Treatment with XIAPEX Injection: Reviewing A Single Surgeon's Experience
Authors: Malik M , Fourie B
Published: October 2021

Aim

To review a single surgeon's experience for the treatment of Dupuytren's disease with XIAPEX injection and the clinical outcomes as measured by a URAM score.

Method

Retrospective review of patient notes, clinical photography and URAM scores for patients who underwent the procedure between August 2013 and October 2016.

Results

33 patients underwent the procedure. 25 patients completed pre and post URAM scores. Average pre procedure score was 19.4 and avergae post procedure score was 3.28 a difference of 16.12 (clinically important change for URAM score is 2.9). Average pre procedure MCPJ contracture was 46.67 degrees and average post procedure contracture was 3.3 degrees. Average pre procedure PIPJ contracture was 66.8 degrees and average post procedure contracture was 8.2 degrees. Where both MCPJ and PIPJ affected of the same digit average pre procedure MCPJ and PIPJ contracture was 60 degrees. The post procedure contracture was 0 degrees in the MCPJ and 29.7 degrees in the PIPJ. 1 patient underwent surgery for progressive disease.

Conclusions

XIAPEX injection has shown a clinically significant result in the treatment of Dupuytren's disease. There were minimal complications and only 1 patient needed further surgery. However, a small sample size thus conclusions have to be cautious.
1036 Operative Versus Non-Operative Management of Osteoporotic Femoral Fractures
Authors: Lenihan J , Waseem S , Rawal J , Hull P , Carrothers A , Chou D
Published: October 2021

Background

he incidence of diaphyseal and distal osteoporotic femoral fractures (OFFs) is increasing. This cohort of patients is often frail with multiple medical co-morbidities. No published data exists neither reporting severity of pain associated with these fractures nor pain in managing their fractures. There are no comparative studies investigating outcomes between conservative (CM) and surgical management (SM). We investigated pain and outcomes between CM and SM OFFs.

Method

We retrospectively analysed all OFFs admitted to our unit between 2018-2019. We analysed electronic patient records including patient-reported pain scores (PRPS). PRPS were calculated for set time periods: admission; 0-24hours CM versus day 1 post-operative; day 2-3; day 4-5. Primary outcome measure was PRPS. Secondary outcome measures included use of traction; PCA use; weightbearing status; length of stay (LOS); 30 day and 1 year mortality. Data was statistically analysed using SPSS software.

Results

22 patients were recruited (11CM, 11SM). There was no statistical difference between groups in terms of age; sex; cognition; Charlson Index; nor pre-morbid mobility status. There was no statistical difference for pain at admission nor PCA use. SM were less painful in the first 24-hour period postoperatively and in the first 3-day postoperative period compared to the same time period in CM. There was no difference in PRPS for the 72–120-hour period. There was no statistical difference between LOS; NWB status; 30 day nor 1 year mortality.

Conclusions

Operating on OFFs reduces pain in the perioperative period without increasing mortality or LOS in this frail population.
1049 Outcomes After Proximal Femoral Replacements in Metastatic Femoral Disease. A Systematic Review and Meta-Analysis
Authors: Gardner A
Published: October 2021

Aim

The aim of the study was to assess outcomes after a proximal femoral replacement (PFR). More PFRs are being performed in accordance with the British Orthopaedic Oncology Society (BOOS) best practice guidance 2016. The population studied was patients with metastatic proximal femoral disease with actual or impending fractures. The intervention and comparator were PFR and intra-medullary nailing (IMN) respectively. The primary outcome was hospital readmission rate (all cause). Secondary outcomes were reoperation rate (all cause, infection) and dislocation rate.

Method

A literature search was performed in Medline, Embase, Web of Science and the Cochrane Library. The search strategy combined free and MeSH search terms related to population (e.g., “femoral neoplasms” OR “pathological femoral fracture”), intervention and comparator (e.g., “osteosynthesis” “surgery” OR “proximal femoral replacement ”). To pool the outcome data of the studies Freeman–Tukey double arcsine transformation was used. Readmission rates were generated based on complications requiring absolute hospital admission.

Results

After exclusions, the search provided 12 studies. The pooled rate of hospital readmission (all cause) was 0.08 (95% CI 0.04 - 0.12) (Figure 2). The pooled rate of reoperation (all cause), reoperation for infection and dislocation rate was 0.05 (95% CI 0.03 – 0.08), 0.01 (95% CI 0.00 – 0.04) and 0.02 (95% CI 0.00 – 0.05) respectively.

Conclusions

Following a PFR for proximal metastatic femoral disease, patients have low rates of hospital readmission and reoperation. Compared to IMN, reoperations are performed for deep infection and dislocations. The major complication with IMNs of metalwork fatigue and failure is overcome with the use of PFRs.
1071 SUFE and the Internet: Are Healthcare Information Websites Accessible to Parents?
Authors: Mc Carthy A , Taylor C
Published: October 2021

Background

Slipped upper femoral epiphysis(SUFE) is an adolescent hip disorder requiring rapid surgical intervention. Faced with the prospect of their child undergoing surgery, many fearful parents will turn to the internet to provide information and reassurance. Previous studies have shown the orthopaedic information can be difficult to comprehend.

Objective

Assess the readability of healthcare websites regarding SUFE.

Method

The term Slipped Upper Femoral Epiphysis was searched in Google, Bing and Yahoo and evaluated using readability software with seven specialised readability tests. A Flesich Read Ease Score (FRES) score above 65 and a Reading Grade Level (RGL) of sixth grade and under was considered acceptable.

Results

21 unique websites were assessed. The average FRES was 52.5 +/- 15.4. Only 3 websites scored 65 or higher (14%). There was a statistically significant difference between website scores based on affiliation, with physician websites having the overall highest mean(P = 0.004). The average RGL was 8.67 +/- 1.8. Only two websites met the accepted RGL criteria (9.5%) while five websites were marked as extremely difficult to understand (23.8%). Only five websites offered translations (23.8%). There was no statistically significant difference in readability scores between websites which offered translation and those which did not. One-way t-tests showed that both the RGL (p < 0.001; CI: 1.83-3.49) and the FRES (P < 0.001, CI: -19.4 to -5.4) scores were significantly different from the accepted standard.

Conclusions

Most websites reviewed were deemed inaccessible. Improving readability would enhance the internet’s usability as a healthcare tool for parents.
1085 Equestrian Related Pelvic and Acetabular Fractures – Experience from a Major Trauma Centre in England
Authors: Hussain A , Ghobrial M , Davies B , Hull P , Carrothers A , Rawal J , Chou D
Published: October 2021

Introduction

Equestrianism is enjoyed by three million people in the UK; however, there is a lack of literature on pelvic and acetabular (P&A) injuries incurred through the sport. We aim to describe P&A injuries sustained in equestrian accidents, discuss management, and establish their outcomes.

Method

Data was extracted from a prospectively collected database of referrals to the P&A Service of a Major Trauma Centre (MTC) from 01/01/2016 to 31/12/2020 and cross-referenced with medical records.

Results

60 of the 1,218 P&A referrals were secondary to horse-riding accidents. Mean age 45 (SD 16.59); 46 female; 33 managed non-operatively and 27 managed operatively at the MTC. There was sufficient information for 59 cases to be classified; 46 of the injuries were pelvic fractures (10 anterior-posterior compression; 29 lateral compression; 4 sacral and 3 pubic rami fractures) and 13 were acetabular (2 anterior column; 1 anterior wall; 2 associated both columns; 1 posterior column and posterior wall; 1 posterior wall; 2 T-shaped and 4 transverse fractures). The operative group were managed by examination under anaesthesia (n = 3), open reduction internal fixation (n = 22) or percutaneous fixation (n = 2). Mean hospitalisation was 9.2 days (SD 5.44). 81% were non-weight-bearing post-operatively and mean time to independent mobilisation was 12.6 weeks (SD 7.09). Return-to-riding information was available for 8 patients with a mean of 29.5 weeks (SD 11.55).

Conclusions

Equestrianism can result in significant P&A injuries. Patients should be counselled that they may have a long recovery, a protracted return-to-riding time and some may never return to the sport.
1128 Fracture Neck of Femur Patients in The Age of Covid-19
Authors: Karagiannidis G , Toma O
Published: October 2021

Aim

The current climate of the COVID19 pandemic has forced various changes in the function of Trauma & Orthopaedic department and the management of fracture neck of femur (NOF) patients.We aim to assess the effect of reduced theatre capacity and delayed time to operative management due to the COVID19 outbreak on the 30-day mortality rate of fracture neck of femur (NOF) patients admitted to our trust.

Method

Retrospective data collection for all patients admitted to a single centre with NOF fractures since lockdown came into effect in England on March 23rd up to July 31st 2020 and the same time frame in 2019.

Results

During that period 129 patients were admitted with NOF fracture and of those 110 (85%) had outdoor injury and 19 (15%) were care home residents. The mean Length of Stay (LOS) was 8 days. In 2019, 121 patients were admitted, of whom 87 (72%) had outdoor injury and 34 (28%) were care home residents and the mean LOS was 22 days. In 2019 84% of patients went into theatre before 36 hours post-injury while only 70% in 2020. In 2020 8 patients treated conservatively while only 1 patient received conservative management in 2019.In total, during the COVID19 period there were 14 (11%) inpatient deaths, while only 2 (2%) inpatients deaths in 2019. The 30-day mortality rate was similar in both periods.

Conclusions

Due to COVID19 we noted a significant decrease in length of stay and increase in the conservative management of NOF fractures and inpatient deaths compared to 2019.