bluuebunny/crossref_metadata_2025 huggingface dataset:
607 A Close Loop Audit on Proper Documentation of Ventriculo-Peritoneal (VP) Shunt Valve Settings in Operation Note
Authors: Porag R
Published: October 2021

Aim

Re-audit the practice of proper documentation of shunt type and settings in VP shunt surgery in Queen's Medical Centre, Nottingham for the period of 1st November 2019 – 31st October 2020. It is very important as programmable shunt setting could get changed during MRI, causing shunt failure.

Method

It was a retrospective collection of data of patients admitted to Queens medical Centre, Nottingham who had undergone VP shunt procedure. Exceptions: 4 files were excluded from study as they did not undergo VP shunt procedure.

Results

Total number of patients: 98. 4 patients were excluded. Actual sample size 94. Total VP shunt procedure done: 107. In 96 out of 107 procedures the shunt valve type and settings were properly documented. In 11 out of 107 procedures the shunt valve type and settings were not documented. In 33 out of 107 procedures programmable shunt valves were used. All 33 procedures had proper documentations.

Previous audit result

Duration of data collection: 2 years (from March 2016 to February 2018). Sample size 200. Total VP shunts done 247. Proper documentation of shunt valve type and settings were done in 209 out of 247 procedures. In 38 out of 247 procedures shunt valve type and settings were not documented. In 55 out of 247 procedures programmable shunt valves were used. 3 out of these 55 procedures (programmable shunt valves) lacked proper documentation.

Conclusions

There is an overall improvement in the practice of documentation of VP shunt valve type and settings in operative notes after implementing the plan of actions decided on first audit.
618 Management of Rectal Cancer in England And Wales. Is the Rate of Abdominoperineal Excision of Rectum Associated with The Pre-Operative Radiotherapy Rates?
Authors: Nowinka Z , Soussi D , Stanley A
Published: October 2021

Aim

Rectal cancer treatment has improved over the years, but variations in practice remain. Abdominoperineal resection (APER) is associated with significant morbidity and pre-operative radiotherapy (RT) is only recommended for advanced rectal cancer. As such, APER and RT should be reserved for patients with an appropriate clinical need. The aim of the study is to evaluate the association between the rates of APER and RT, and whether any other factors are associated.

Method

Data on rectal cancer cases was extracted from National Bowel Cancer Audit 2019. Primary outcomes were: APER rate, RT rate. Pearson’s correlation coefficient was calculated. The means for APER and pre-operative radiotherapy were plotted on a four-quadrant matrix. The differences were analysed using Mann-Whitney U and Student T-test.

Results

3,764 patients were included. A mean of 25% (95%CI: 10.3-14.9%) underwent APER and an average of 34% (95%CI: 30.5-36.8%) received RT. There was a weak positive correlation between rates of APER and RT (r = 0.356, p < 0.001). 43 (37%) trusts had proportions of both APER and RT below the overall mean, whilst 30 (26%) had both proportions above. No significant differences were found when comparing other variables between the high to low-rate trusts (p > 0.05).

Conclusions

There is a weak positive correlation between the proportion of rectal cancer patients undergoing APER and the proportion receiving RT in trusts across England and Wales. It is unknown whether this finding has a clinical significance and further analysis on trust/surgeon performance and patient demographics is needed, allowing for prevention strategies to be implemented.
623 Completed Audit Cycle of Indications for Excision of Fibroadenomas At A University Hospital
Authors: Beattie A
Published: October 2021

Aim

This audit looked at indications for excisions of fibroadenomas one year on from the first audit cycle and following intervention of presentation and teaching at local departmental meeting. This audit was motivated by a drive to reduce operations on benign breast conditions including fibroadenoma excisions. ABS (Association of Breast Surgery) guidelines advise excision for fibroepithelial lesions (B3) on biopsy, pain and increasing size. Local consensus is excision of fibroadenomas over 30mm on ultrasound.

Method

Patients who underwent surgical excisions of fibroadenomas over 6 months at one hospital were analysed for size on ultrasound, biopsy histology and reason for excision, and compared to previous audit results over 24 months.

Results

Over 6 months, 18 patients underwent excisions. Histology specimens showed 13/18 were fibroadenomas, 4/18 benign phyllodes and 1/18 other benign conditions. This was similar to the previous audit, although there was an increase in the rate of benign phyllodes.

Pre-operatively, 11/18 of patients met the ABS criteria for excision (7/11 were B3 lesions, 3/11 for increasing size and 1/11 pain). 11/18 patients met the local criteria. 2/18 patients met neither criteria. This had improved compared to the first audit cycle.

Conclusions

88.9% of patients met ABS or local criteria, compared to 83.7% previously, and so this had improved following intervention. One outcome from the first audit cycle was patients need greater reassurance about the benign nature of fibroadenomas to avoid unnecessary morbidity due to surgical procedures, and this appears to have improved on re-audit. Both patients not meeting criteria had histology showing fibroadenomas.
646 A Review of The Urodynamic Referral Pathway and The Accuracy of Urodynamic Study Requests
Authors: Breish M , Harding C , Biswas S
Published: October 2021

Aim

Urodynamic studies (UDS) are physiological measurements of voiding and storage function of the lower urinary tract that are commonly performed in clinical practice to investigate bothersome lower urinary tract symptoms. Despite considerable efforts to improve UDS, standardisation of the practice remains to be challenging. This audit thus, presents a review the current UDS referral process and analysis of the clinical details included on urodynamic requests.

Method

This audit included retrospective data from 112 patients between March and Oct 2020, 98 of which had UDS performed. Patient electronic records, referral forms and clinic letters were all used for data collection.

Results

Data shows that 47% of patients were females with average age of 56 years, range (16-86) years. The reason of UDS was clearly stated in 8 referrals only and the clinical examination findings were clearly mentioned in 31% only. More than three quarters of patients (i.e., 77%) had assessment of post void residual prior to UDS, but half of the proportion had no history of relevant medications. In 98 patients who had UDS done, the main findings showed that 4 patients had normal studies, 3 with dysfunctional voiding, 7 had bladder outflow obstruction, 32 patients were diagnosed with detrusor overactivity, 12 had stress incontinence and 7 showed detrusor underactivity.

Conclusions

Finding of this audit clearly suggest a level of unclarity in the great majority of referrals. Evidently, key history of relevant medication is overlooked in half of the referrals. Improvements to the current pathway to UDS is therefore pivotal.
649 Smoking Cessation as A Variable Risk Factor in Head and Neck Cancer
Authors: Kabaso M , Paterson T , Marshall J
Published: October 2021

Aim

Smoking is the leading cause of preventable death and disability worldwide and is a well understood risk factor in a number of diseases, including cancers of the head and neck. In 2019 over half of UK smokers reported interest in quitting, however, continue to do so. We assessed referrals made to the cessation service by the Ear Nose & Throat (ENT) department across the health board with the aim of raising awareness and improving smoking cessation referrals.

Method

Working with the smoking cessation team, we retrospectively assessed the clinical information of all patients referred by ENT over an 8-month period during 2019. The results of which, were presented departmentally with the goal of raising awareness of the service. Posters were also created detailing the referral process to aid junior doctors on surgical wards. Data was then re-audited over the subsequent 9-month period.

Results

Initially, 33 patients were referred over the first 8-month period, averaging 4 per month with 44% of patients already having laryngeal cancer. After our interventions, the total number of referrals increased with 74 over the 9-month period, averaging 8 referrals per month with 28% of patients having laryngeal cancer association.

Conclusions

Overall, there was a significant 135% increase in the number of referrals made, both cancer and non-cancer. The increase made in monthly referrals suggests a sustainable change. The percentage decrease of cancer patients referred and overall increase in number of referrals, represents the reduction of smoking being a risk factor of developing laryngeal cancer in ENT patients.
651 An Audit of Negative Appendectomy Rate at A District General Hospital in the UK
Authors: Al-Hamid Z , Jaskani S , Chattopadhyay D
Published: October 2021

Aim

There is significant variation in management of acute appendicitis across the UK. Despite advancements in imaging modalities, acute appendicitis is still a clinical diagnosis. The primary aim of this study was to determine the negative appendectomy rate (NAR) and secondary aim was to look for the imaging results and hospital readmission rate in case of a normal appendix.

Method

It is a retrospective analysis of all the patients admitted with a suspicion of acute appendicitis from Jan 2018 to April 2019. For data collection hospital medical record was used. Information about patient demographic details, blood results, outcome, operative findings, and histology of appendix if removed, was collected. For Patients having negative appendectomy, hospital admission rate was calculated.

Results

Total 517 patients were admitted with suspected acute appendicitis and only 45.6% (n = 236) patients underwent surgery. Females=52.1%, Males 47.9%. Mean age was 31 years. NAR was 10.6% (n = 25). (Females= 9.3%, Males=1.3%), 8.4% female patients were below 35 years of age. Patients were divided into 3 groups (Normal appendix NA, Uncomplicated appendicitis UA, complicated appendicitis CA). There was a statistically significant difference in inflammatory markers between the groups. In NA group 17/25 patients underwent prior imaging and imaging suggested acute appendicitis in 7/17 patients. Post NA hospital readmission rate was 20%, all of them were females, and gynecology opinion was sought in all of them.

Conclusions

The negative appendectomy rate is at 10.6%, comparable to national database. It is more common in young females due to a range of differential diagnoses.
661 Improving Antibiotic Prescribing in a District General Hospital: A Closed Loop Audit
Authors: Ng Z H , Kamran T
Published: October 2021

Aim

Broad-spectrum antibiotics are effective in decreasing wound infection and postoperative intra-abdominal abscesses for patients undergoing appendicectomy. Compliance with local hospital antibiotic guidelines is important in ensuring antibiotic efficacy and reducing potential for toxicity and antibiotic resistance. The aim was to assess the impact of educational interventions on the adherence to local antibiotic guidelines in patients undergoing appendicectomy at a Scottish district general hospital.

Method

Preoperative antibiotic prescribing in consecutive adult patients aged ≥ 16 years undergoing appendicectomy were audited against hospital guidelines over a four-month period between March 2019 and July 2019. We implemented change through antibiotic prescribing teaching for doctors in the surgical team and anaesthetic team. This change was subsequently evaluated through a re-audit over a three-month period between December 2019 and February 2020.

Results

The baseline audit demonstrated 68.8% (n = 11/16) compliance to local antibiotic guidelines among patients undergoing appendicectomy. The remaining patients had the correct choice of antibiotics, but gentamicin was prescribed in different doses. Gaps in prescriber awareness of antibiotic guidelines were identified. Following departmental teaching sessions regarding antibiotic prescribing and use of the gentamicin dosing calculator, the re-audit showed 93.8% (n = 15/16) compliance with local antibiotic guidelines among prescribers in the surgical team and anaesthesic team.

Conclusions

Education interventions were instrumental in improving adherence to antibiotic prescribing guidelines. This highlights the importance of regular audit and prescriber education in the promotion of antibiotic stewardship in hospitals.
672 Emergency Laparotomy Patients: Is the Current Local Consent Process Compliant with Local and National Guidelines?
Authors: Barghash M , Rehman J , Salimi F , Mansour M
Published: October 2021

Aim

Obtaining valid consent is crucial to patient care. It also minimises the chance for claims regarding legal action for battery, breach of human rights and/or successful clinical negligence claims. In this project, we assessed whether a documented discussion took place prior to signing consent forms and whether consent forms were being completed adequately.

Method

This was a retrospective audit based on the Royal College of Surgeons’ (Good Surgical Practice) guidelines and the local trust policy. We assessed 50 case notes of patients who had a laparotomy from January 2019 to April 2020 in a busy district general hospital in the UK.

Results

We noted that our practice was fully compliant with documenting patient demographics, signatures, and the name of the procedure in consent forms. On the other hand, we found that, in the majority of cases there was no documentation of detailed benefits, risks, alternatives of surgery in case notes where compliance was only 21%. In addition, poor compliance was noted in documenting some of the possible risks e.g., hernia (50% compliance), leak (46% compliance) and ileus (26% compliance).

Conclusions

A detailed discussion with the patient and family including benefits, risks and alternatives of surgery should take place and this should be documented clearly in the case notes prior to signing the consent form.
673 Checklists Are A Spinal Surgeon’s Best Friend - A Post-Intervention Closed-Loop Re-Audit of Post-Operative Care in Patients Undergoing Surgery for Adolescent Idiopathic Scoliosis (AIS)
Authors: Carr H , Honeyman C , Prasad M , Hekal W
Published: October 2021

Introduction

The post-operative care (POC) of paediatric patients undergoing spinal surgery is essential. Initial audits (2015/17) identified shortcomings in POC practice.

Aim

To evaluate improvements in compliance with local AIS guidelines following application of a simple POC checklist. To identify reasons where standards are not met with formulation of an action plan to ensure the AIS POC pathway continues to improve and provide optimum levels of care for our patients.

Method

Data was collected retrospectively for 30 patients over 2 years. Standards assessed were taken from local AIS guidelines consisting of 25 distinct domains (Appendix 1).

Results

Our post-intervention results showed that, 100% compliance within individual AIS guideline domains improved significantly from 12/25 domains (2015), to 21/25 (2019/20). In the domains that did not meet 100% compliance, post-intervention, 2 reached 93.33% compliance and 2 reached 80% (2019/20), a significant improvement upon 2015/17 where several domains were within 20-70% compliance.

Conclusions

The results demonstrate that our intervention, a simple checklist, significantly improved the POC of our AIS patients and current practice is of an excellent standard. Standards were still not met in 2020 for a handful of measures. This was due to patients declining planned antiemetic/analgesic medication or rarely, incomplete documentation by health care professionals who were not yet fully familiar with the new checklist. Other centres offering surgical intervention for AIS may benefit from adopting/adapting this POC checklist and a similar audit may prove useful to optimise care for these paediatric patients undergoing significant surgery.
676 Paediatric Circumcisions- Compliance with RCS Standards
Authors: Rea W , Sturch P , Anjum F
Published: October 2021

Introduction

Variation in regional paediatric circumcision rates suggested some circumcisions were being performed unnecessarily. In 2016, the Royal College of Surgeons (RCS) released a clinical commissioning guide on foreskin conditions to standardise the indications for circumcision. We retrospectively audited the foreskin procedure practice at our urology department and its adherence to RCS clinical commissioning guidance.

Method

We assessed electronic health records for all paediatric patients (<17 years) having undergone a foreskin procedure from 1st Jan 2018 to 1st Jan 2019. Records were assessed for referral source, trial of medical treatment (steroid cream), indication, operative management carried out, daycase or inpatient cases, and histological analysis.

Results

198 patients (mean age 8.7, range 2-16) underwent foreskin procedures in the set time frame. 98.9% were referred from GP surgery, and the remainder directly from A&E. 29.8% had documented trials of steroid creams prior to surgery. 51.5% of procedures were performed for ‘non-retractile foreskin’ and 11.6% for pathological phimosis. 87.4% of patients underwent circumcision and 11.1% had freeing of adhesions. All of procedures were performed as day-case. Histology was sent for 17.3% of circumcisions, with non-specific inflammation being the most common finding (46.7%), followed by lichen sclerosus (40%).

Conclusions

In our series large number of foreskin procedures were carried out over a 12-month period with a minority for the only absolute indication of pathological phimosis We have introduced stringent guidelines in the department since this audit, which will prevent circumcision in children who may otherwise avoid surgery.
701 Resuscitation and Escalation Status Documentation in Acute Surgical Admissions: A Re-Audit Feb 2020
Authors: Chan D M L , Yalamarthi S
Published: October 2021

Aim

Resuscitation and escalation of care are not always in the best interests of all patients. Planning ahead for patient’s escalation and CPR status, along with clear documentation can prevent inappropriate cardiac arrest calls. Previous audits on CPR and escalation status were conducted in 2017, 18 and 19 and the completion of CPR and escalation documentation was 0, 2 and 12% prospectively, with an improvement to 42% after an intervention in the 2019 audit. A re-audit for 2020 is conducted.

Method

A snapshot audit of patients who were admitted or referred to General Surgery between 10-17 Feb 20 were identified, admission record and medical notes reviewed. CPR and escalation status, presence of a DNACPR form, record of discussion with the patient or their family and the medical notes entry were reviewed.

Results

46.6% (34/73) of admissions had CPR and escalation status completed. Out of the admissions, all patients who were deemed not for resuscitation had DNACPR forms in their admission notes. All of these were discussed with either the patient or with their family, and the decisions appropriately documented in their medical notes.

Conclusions

This re-audit had shown improvement in the documentation on escalation and CPR status. This area can be improved further. Our recommendations include: 1. To present this finding in the education meeting and 2. Junior doctors to highlight the documentation to the oncall consultant/ or registrar during the first senior review and 3. To conduct a questionnaire to explore the surgeons’ views on this subject.
635 Expectations and Concerns of Patients Attending a Spinal Outpatient Clinic
Authors: Jones T , Stanley A , McCarthy M J H
Published: October 2021

Aim

Identifying expectations and concerns of patients is vital during clinical consultation in patient-centred healthcare systems. Most spinal surgery is elective and focussed on improving quality of life. Understanding what patients want from treatment at baseline may improve experience and outcomes.

Method

New patient data from the caseload of a single orthopaedic spinal surgeon (from April 2012-18) was analysed with expectations and concerns reported in the outpatient clinic letter (standard practice for surgeon).

Results

Of 940 patients (498 NHS, 442 private), mean age was 58.3 with 46.0% male and 54.0% female. Nearly 1-in-6 patients underwent previous surgery. The most common expectation was ‘reduce pain’ (41.8%), followed by diagnosis (23.0%), treatment options (13.5%), unsure (10.5%). The most common concern was ‘continuation/worsening of pain’ (27.0%), followed by loss of function (15.9%), work-related (8.3%), permanent disability (7.8%). NHS patients were significantly more unsure of expectations (19.7% vs 4.5%, p<.001) and less frequently raised concerns (39.0% vs 18.8%, p<.001). NHS patients had significantly worse Oswestry Disability Index (ODI) scores (46.8% vs 42.0% p<.001), were more depressed (PHQ-9: 11.5 vs 8.9, p<.001) and anxious (GAD-7: 8.2 vs 5.9, p<.001). Private patients were significantly more likely to report problems sleeping (79.4% vs 51.0%, p<.001). Patients concerned about permanent disability had significantly worse ODI (51.0% vs 42.7%, p<.001), PHQ-9 (12.6 vs 10.2 p=.013) and GAD-7 (9.0 vs 7.1, p=.017) scores.

Conclusions

This study identified patient expectations and concerns in spinal outpatient clinic in both healthcare sectors. Future work should explore these findings in context with clinical outcome.
660 Trapeziectomy Versus Joint Replacement for First Carpometacarpal (CMC-1) Joint Osteoarthritis: A Systematic Review and Meta-Analysis
Authors: Raj S , Clay R , Ramji S , Shaunak R , Dadrewalla A , Sinha V , Shaunak S
Published: October 2021

Aim

The challenge of managing first carpometacarpal (CMC-1) joint osteoarthritis is the lack of guidance on which surgical intervention is superior. This systematic review and meta-analysis compares joint replacement (JR) and trapeziectomy techniques to provide an update.

Method

In August 2020, MEDLINE, Embase and Web of Science were searched for eligible studies that compared these two techniques for the treatment of CMC-1 joint osteoarthritis (PROSPERO registration ID: CRD42020189728). Primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH), QuickDASH and pain visual analogue scale (VAS) scores. Secondary outcomes, such as total complication, dislocation, and revision surgery rates, were also measured.

Results

From 1909 studies identified, 14 studies (1005 patients) were eligible. Our meta-analysis found that post-operative QuickDASH score was lower for patients in the JR group, indicating decreased disability following this technique (5 studies, p = 0.0002). However, pain VAS scores were similar between the two groups (5 studies, p = 0.22). Interestingly, JR techniques had significantly greater odds of overall complications (12 studies; OR 2.27; 95% CI 1.17-4.40, p = 0.02) and significantly greater odds of revision surgery (9 studies; OR 5.14; 95% CI 2.06-12.81, p = 0.0004).

Conclusions

Overall, based on low to moderate quality evidence, we found that JR treatments may result in better function with less disability with comparable pain (VAS) scores; however, JR has greater odds of complications and greater odds of requiring revision surgery. More robust RCTs that compare JR and TRAP with standardised outcome measures and long-term follow-up would add to the overall quality of evidence.
706 Frailty Score Is an Independent Predictor of Outcome Following Fragility Fracture
Authors: Brown R , Gatfield S , Rogers M , Peter N
Published: October 2021

Background

Frailty has been linked to greater hospitalisation, morbidity, and mortality, and is being increasingly recognised as a possible factor affecting outcomes in trauma. A 2017 TARN report identified that further research was needed to determine the effect of frailty on outcomes in trauma patients. With fragility (low energy) fractures now make up a significant burden of trauma within UK hospitals, this retrospective cohort study investigated whether frailty has a significant effect on outcomes in patients presenting with fragility fractures.

Method

Notes from all patients aged >60 admitted to a large District General hospital over 1 year with any fragility fracture were reviewed. Age, injury, length of stay, and mortality were recorded. A Rockwood Clinical Frailty Score (CFS) was assigned retrospectively.

Results

886 patients were reviewed (male:female 266:620, mean age 82.75). CFS was independently associated with a significant increase in mortality, with every step up in CFS increasing 30-day and 1-year odds of death by 54.8% and 56.2% respectively (P < 0.001). Every step up in CFS independently increased percentage length of stay by 10.1%.

Conclusions

CFS independently predicts adverse outcome in hospitalised trauma patients with fragility fractures. CFS should be used routinely to identify patients at risk and may assist in allocating limited orthogeriatric resources and supporting national guidelines. Future research should investigate how resources impact outcomes for patients of varying CFS.
730 Is The Total Hip Arthroplasty For Hip Fracture Comparable With Matched Elective Cohort ? A Prospective Study
Authors: Tan T K , Lim J W , Alkandari N , Ridley D , Sripada S , Jariwala A
Published: October 2021

Aim

Total hip replacement (THR) has been effective in managing osteoarthritis but its effectiveness in managing neck of femur fracture (#NOF) is debatable due to higher risk of morbidity and mortality. We aimed to review the selection criteria for trauma THR and to compare the functional outcomes and complication profiles of trauma THR cohort with elective THR cohorts.

Method

we prospectively reviewed patients undergoing THR for #NOF with follow-up. The functional outcomes, any further complications-related admissions and death within a year were noted for subsequent analysis. All the patients and data collected were subsequently matched with the elective cohort.

Results

Forty-one matched cases were included in our study. The Modified Harris Hip Score (mHHS) was significantly lower pre-operatively in elective cohort (41.4±14.3 VS 60.3±22.2, P < 0.001) and achieved significantly higher score than trauma cohort 1-year post operatively (88.2±10.9 VS 82.6±12.7, P = 0.029). As for the mHHS Function, the trauma cohort achieved similar value with the pre-operative score post-operatively, and no significant difference was witnessed between the trauma and elective cohort post-operatively (35.1±7.4 VS 37.6±7.7, P = 0.142). mHHS Pain score was significantly higher in trauma cohort pre-operatively (19.8±15.3 VS 12.7±6.3, P = 0.034), but the score was significantly higher than trauma cohort 1-year postoperatively (42.7±4.4 VS 40.7±7.7, P = 0.027). Both cohorts had similar complication rate.

Conclusions

Our study further justified the clinical indication of THR for #NOF. With careful selection, trauma THR can achieve similar HHS function and better pain score. Further randomized controlled trials are warranted to justify our findings.
799 Do Not Attempt Cardiopulmonary Resuscitation Decisions in Neck of Femur Fractures – Is Documentation Adequate?
Authors: Williamson T , Hughes K , Osborne-Grinter M , Philip V , Dall G , Raghavan R
Published: October 2021

Introduction

‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation is essential to communicate decisions regarding ceilings of care for patients to the clinical team. Patients admitted to hospital with a fractured neck of femur (#NOF) are often elderly with multiple comorbidities, and so robust and clear anticipatory care plans are especially indicated.

Method

All patients admitted to a large district general hospital in Scotland with a #NOF over a three-week period between 23/10/2020 and 12/11/2020 were identified prospectively and included in this audit. Patients’ demographic information, DNACPR status and the quality of their DNACPR documentation was recorded.

Results

20 patients (85% Female, 15% Male) were identified and included. Median ASA grade was 3, with 77.8% of patients ASA grade 3 or 4. 63.2% of patients had DNACPR documentation in place, all of which were ASA grade 3 or above. Most DNACPR documentation had patient information clearly identifiable (91.7%), was completed preoperatively (90.9%), and involved either the patient or appropriate relative or power of attorney (91.6%). However, only 75% of patients’ documentation had the rationale for the DNACPR decision documented and only 25% of DNACPR decisions were reviewed by a senior clinician within 72 hours. No DNACPR decisions were documented as having been communicated to the wider healthcare team.

Conclusions

DNACPR documentation is a crucial for anticipatory care planning in #NOF patients. This audit shows improvement is needed in documenting whether decisions have been reviewed by senior clinicians, and if they have been communicated to the wider healthcare team.
873 The Keystone Challenge- Volar Displaced Intra-Articular Distal Radius Fractures with Lunate Fossa Fragment
Authors: Cheruvu M S , Dass D , Ford D J , Roushdi I
Published: October 2021

Aim

Volar displaced fractures of the distal radius are unstable and warrant operative management. A subset of patients with volar displaced fractures also has a separate lunate fossa fragment, a specific injury with greater instability that may precipitate carpal subluxation. We aim to review our long-term experience in the management of this complex injury, exploring surgical technique which may improve treatment.

Method

We retrospectively reviewed all volar displaced distal radius fixations between 2015 and 2020. Inclusion criteria: any displaced intra-articular volar distal radius fracture with lunate fragment involvement undergoing volar fixation and over 16 years of age. Exclusion criteria: shaft fractures, extra-articular fractures, open fractures, fractures fixed using k-wires or external fixation, revision surgery and patients without follow-up. We adapted our surgical approach in order to address this more complex fracture pattern, and all operations were performed by specialist hand surgeons.

Results

468 distal radius fractures were assessed, of which 29 (6%) cases included a lunate fossa fragment. 20 (69%) of patients were female, mean age was 59 years (SD 12.4). Mean length of stay was 5 hours and mean operative time was 96 mins (range 79-95). No patients had carpal subluxation, fracture fixation failure or return to theatre for any reason.

Conclusions

From our experience as a specialist orthopaedic institution, we recommend the extended FCR approach and intra-focal exposure to manage this complex injury. In particular, the lunate fossa fragment is the keystone which requires dedicated reduction prior to tackling the remaining fracture configuration.
940 Neck of Femur Fracture Management and Outcomes during COVID-19: Overview of the Results from a District General Hospital in Wales
Authors: Waterman J , Jayaraju U , Nadimi J , Morgan D
Published: October 2021

Introduction

The COVID-19 pandemic has delivered significant challenges to the Orthopaedic community. Our study aims to assess the impact of COVID-19 on the management and outcomes of patient’s presenting with Hip Fractures to our DGH.

Method

Retrospective data analysis was performed on a cohort of hip fracture patients who presented to our DGH before the COVID-19 pandemic (23/03/2019 to 05/05/2019) and were compared to those who presented during the COVID-19 pandemic (23/03/2020 to 05/05/2020). Minimum follow up was 30 days postoperatively.

Results

38 patients with hip fractures presented to our unit in the pre-COVID-19 period compared to 27 patients in the COVID-19 period. Total time from presentation to discharge, during COVID-19, demonstrated a 70.23% decrease when compared to the pre-COVID cohort. 30-day Mortality rates were higher in the COVID-19 cohort.

Conclusions

During the COVID-19 pandemic our time to theatre and discharge of hip fractures has seen an improvement, with time to discharge decreasing by 70.23%. Comparison of our mortality rates has seen a fourfold increase likely influenced by the detrimental effects of COVID-19. Further work and larger numbers are required to see the true impact of COVID-19 on the management and outcomes of hip fractures in our DGH.
1001 Atraumatic Bilateral Compartment Syndrome; A Case Report
Authors: Warren M , Dhillon G , Abdulkarim A
Published: October 2021

Introduction

We present a rare case of lower leg atraumatic bilateral compartment syndrome (ABCS). To date there have only been three similar cases reported where no cause was identified.

Case Study

A 33-year-old male presented 12 hours following sudden onset lower leg pain. There was no history of trauma, drug, or alcohol use. On assessment he was in significant pain, not relieved by analgesia, and had clinically tense anterior compartments bilaterally. Both feet were held in fixed dorsiflexion. Creatinine kinase (CK) was 35,166 on admission. X-rays of both legs were normal. He was immediately taken to theatre for bilateral four compartment fasciotomies which revealed significant swelling in the anterior and lateral compartments with patchy pre-necrosis. Post-operatively he deteriorated, required intubation, and was admitted to ITU for acute haemofiltration to treat acute kidney injury secondary to rhabdomyolysis. Multiple operations were required for debridement, resulting in exposed tendons. Closure of the medial wounds was achieved primarily as an inpatient and he was discharged with bilateral lateral VAC dressings in situ. Lateral wounds were closed with Biodegradable Temporising Matrix followed by split skin grafting. In his second admission he suffered a pulmonary embolism.

Literature Review and Discussion

20 case of ABCS have been reported, largely attributable to drugs, alcohol, or leg position. Most cases had an element of diagnostic delay. In addition to compartment pressure monitoring, testing CK can demonstrate muscle necrosis and supports the decision to proceed to surgery.
805 A Dangerous Wait: The Impact of Prolonged Waiting Times in Endocrine Surgery
Authors: Shuttleworth R , Eatock F
Published: October 2021

Aim

In Northern Ireland on 31/12/19 90,514 patients were awaiting admission/day case procedure. The 2019/2020 Ministerial waiting time target states that by March 2020, 55% of patients should not wait longer than 13 weeks for inpatient/day case treatment, and no patient should wait longer than 52 weeks. This audit investigates the impact of long waiting times in endocrine surgery and how they impact patient safety.

Method

Data was collected from the endocrine surgery waiting list in the Royal Victoria Hospital, Belfast, up to 6/2/20. Number of days spent on the waiting list, disease complications and the number of days before they occurred were collated.

Results

118 patients were awaiting endocrine surgery. The average waiting time was 533 days. 21 patients experience 27 complications related to their endocrine disease whilst waiting for surgery. The average duration before complications was 490 days; 4 required admission, 11 required medical intervention and 3 required a surgical intervention.

Conclusions

The average waiting time for endocrine surgery is greater than 52 weeks. In Northern Ireland no one should be waiting more than 52 weeks. The length of the waiting list has resulted in 1 in 5 experiencing complications and prolonged suffering from under-treated disease. This is a significant patient safety concern. Urgent action to address waiting lists is required and the disruption caused by COVID-19 should be used as a catalyst for reform.
1125 Proximal Tibial Giant Cell Tumor in A 25-Year-Old Female Treated with Two Stage Extended Curettage, Cementing and Arthrodesis. Key Words: GCT, Two Stage, Curettage, Cementation, Arthrodesis
Authors: Khadilkar S , Handralmath S
Published: October 2021

Introduction

Giant cell tumor of bone is a benign but locally aggressive tumor accounting for approximately 20% of benign osseous neoplasms. Female gender predominance, common in second to third decade of life. Commonly seen around knee, with the distal femur being more frequently involved.

Method

Presenting a 25year old lady with history of progressive pain and swelling around right knee for 2 years and inability to walk for 6 months. Radiography and biopsy revealed giant cell tumor of the right proximal tibia involving the medial condyle. Two staged procedure planned. Stage 1 extended curettage, cementation of cavity with PMMA and a knee spanning fixator was done. In stage 2 at 12 weeks cement was removed and knee arthrodesis using allograft performed retaining the fixator in place.

Results

Patient was able to partially bear weight 6 weeks post 2nd stage of surgery and was able to bear full weight after 12 weeks. A solid arthrodesis was achieved at 5 months post 2nd stage, when the fixator was removed. There is no recurrence at end of one year

Conclusions

This is a novel method of low-cost treatment using bone cement and external fixator for stability. Cement gives immediate structural support and fixator allows ambulation and early weight-bearing. The importance of thorough curettage cannot be overemphasized in preventing recurrence. This can be a viable alternative treatment option for patients presenting with large giant cell tumors around the knee joint who cannot afford options like wide local excision and joint replacement using mega-prosthesis.
1213 Cycling-related Trauma Admissions to the Major Trauma Centre in the Cycling Capital of the United Kingdom
Authors: Arshad Z , majeed M , Thahir A , Anwar F , Rawal J , Hull P , Carrothers A , Chou D
Published: October 2021

Aim

The number of cyclists travelling on roads in the United Kingdom (UK) is increasing. The government has recently introduced initiatives to promote cycling uptake and so these numbers are likely to increase. This study aims to characterise cycling related injuries presenting to a major trauma centre located within a region with the highest rates of cycling in the UK.

Method

A retrospective review of cycling related trauma admissions occurring between January 2012 and June 2020 was performed. All patients were split into three groups based on the mechanism of injury. Our institution’s electronic patient record system was used to collect data including age, gender, mechanism of injury, Glasgow coma scale score on arrival, incident date and time, injured body regions, 30-day mortality, helmet use, and length of stay.

Results

A total of 606 cycling related trauma cases were identified, with 52 being excluded due to incomplete data. The ‘cyclist v vehicle’ group was associated with a significantly higher Injury Severity score (ISS), lower GCS and longer hospital stay than the other two groups. Helmet wearers were significantly older than non-wearers and helmet use was associated with a significantly reduced risk of head injury, lower ISS and higher GCS.

Conclusions

With a likely increase in future cycling uptake, it is crucial that effective interventions are put in place to improve the safety of cyclists. A multi-faceted strategy involving driver and cyclist education, road infrastructure changes and helmet promotion campaigns targeting the younger generation could be employed.
836 DIEP Flap Monitoring Adherence
Authors: Muscat E , Thomson R , Ghattaura A
Published: October 2021

Aim

The popularity of Deep Epigastric Perforator (DIEP) free flaps for breast reconstruction after mastectomies have increased due to their natural aesthetic results and reliability. Free flaps require strict post-operative monitoring by nursing staff during the early post-operative period where they should notify the surgeons to anticipate vascular compromise in order to salvage the flap. To ensure success the DIEP guidelines were introduced to Morriston Hospital, Swansea. This was a first cycle closed loop re-audit.

Method

Interventions from initial audit were implemented in 2018. Retrospective analysis of patient notes over an 8-month period (August 2019- March 2020) and compared with DIEP checklist. Clinical notes, nursing cartex and flap observations and medication charts were reviewed.

Results

100% had bear huggers, antiemetics (87% in 2018), correct thromboprophylaxis (75% in 2018) and laxatives (37% in 2018). 100% had senior reviews daily post op (75% in 2018). 100% had flap observations performed as guidelines immediately post op.

Conclusions

This was a successful re-audit showing significant improvements in adherence rates amongst the surgical and nursing staff in the plastic surgery department. Implementation of the DIEP operation note template may help maintain such adherence amongst staff.
1279 Does Multimorbidity Influence the Outcomes of Total Hip Replacement for Osteoarthritis?
Authors: Ferguson R , Prieto-Alhambra D , Peat G , Jordan K , Valderas J , Yu D , Glyn-Jones S , Silman A
Published: October 2021

Introduction

Limited data are available on the influence of multimorbidity on the outcomes of total hip replacement for patients with hip osteoarthritis, including the rate of complications and degree of functional benefit. The aim of this study was to investigate the influence of multimorbidity on the outcomes of total hip replacement in the UK.

Method

A cohort study was performed, with cohort comprised of all patients over 65 years with a diagnosis of hip osteoarthritis recorded in Clinical Practice Research Datalink and receipt of primary total hip replacement recorded in Hospital Episode Statistics Admitted Patient Care. Severity of multimorbidity burden was measured using four different scores (Charlson Comorbidity Index, Electronic Frailty Index, count of drugs prescribed, count of primary care interactions). The outcomes were (i) the risks of total hip replacement, assessed by serious post-operative complications within 90 days (analysed with logistic regression), and (ii) the benefits of surgery, assessed by post-operative Oxford Hip Score (OHS) and EQ-5D quality of life score (analysed with linear regression).

Results

6,682 patients were included. The rate of complications was 3.2%. Patients with severe multimorbidity burden were at 1.5 to 2.5 times increased risk of complications than patients without multimorbidity. There was no clinically meaningful difference in the benefits of surgery between patients with and without multimorbidity, irrespective of the method of scoring multimorbidity.

Conclusions

Even for patients with severe multimorbidity burden, the potential benefits of total hip replacement for osteoarthritis remain substantial, while the increase in risk is relatively small.
1283 The Management of Multiple Morton’s Neuromas in the Same Foot: A Systematic Review
Authors: Arshad Z , Alshawani A , Bhatia M
Published: October 2021

Aim

The optimal treatment strategy for the presentation of multiple Morton’s neuromas in adjacent intermetatarsal spaces of the same foot is yet to be determined. This systematic review aims to summarise and assess the efficacy of current treatment strategies.

Method

A systematic review was performed using the PRISMA guidelines. The review is registered in the international prospective register of systematic reviews (CRD42020213631). A computer-based search was completed in PubMed, Embase, Cinahl, Web of Science, Scopus and Emcare, for articles reporting the treatment of multiple neuromas in the same foot. Two authors independently performed title/abstract and full text screening according to a-priori selection criteria. Considering the four studies reporting treatment of a cohort containing both patients with a single neuroma and those with multiple neuromas, the proportion of cases in the latter group was 51/354 (14.41%).

Results

A total of 253 articles were identified, with 7 articles, involving 383 patients being included in the review. The most common treatment strategy reported was simultaneous neuroma excision using a single incision, whilst two studies each describe simultaneous excision with two separate incisions and delayed excision, respectively. The proportion of patients

Discussion

There is no strong evidence favouring use of delayed excision or multiple incisions. However, there is currently a lack of evidence focusing on this presentation of neuroma specifically. A number of studies fail to separate results of single and multiple neuroma excision. Further high-quality research is therefore required to make more definitive conclusions and future research should investigate other strategies such as non-operative treatment.
1300 Version Abnormalities of the Femur and Acetabulum in Patients with Femoroacetabular Impingement: A Systematic Review
Authors: Arshad Z , Maughan H D , Pettit M H , Kumar K H S , Arora A , Khanduja V
Published: October 2021

Aim

This systematic review aims to understand the relationship between version abnormalities of the femur and acetabulum in patients with primary and secondary femoroacetabular impingement (FAI).

Method

A systematic review was conducted according to PRISMA guidelines. A computer-based search was performed using the EMBASE, MEDLINE, PubMed and Cochrane databases for articles relating to version and torsional abnormalities in FAI, Legg-Calve-Perthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). The study was registered in the Open Science Framework. Two authors independently performed title/abstract and full text screening according to predetermined inclusion criteria.

Results

A total of 1206 articles were identified 55 articles, involving 10, 091 hips, met the inclusion criteria. All studies evaluating femoral/acetabular version in FAI reported ‘normal’ mean version values (10o to 25o). However, distribution analysis revealed that an estimated 31.4% and 51.3% of patients with FAI displayed abnormal acetabular and femoral version, respectively. Abnormal femoral version was reported in an estimated 74.5% of hips with LCPD, and abnormal acetabular version in an estimated 20%. Acetabular version was significantly lower in hips with SCFE compared to controls (Z=-3.26, P < 0.01).

Conclusions

Patients presenting with hip pain attributed to FAI are likely to display an abnormality in femoral or acetabular version. This highlights the importance of evaluating these parameters during assessment of these patients, in order to guide clinical decision making.