BOA Annual Congress 2023

National Staffing Levels in Trauma & Orthopaedics

Liam Kilbane¹, Roxanne Haasbroek², Nicholas Evans³

^1. Specialist Registrar . Defence Deanery / Salisbury NHS Foundation Trust

^2. Trust grade locum in Orthopaedic and Plastic Surgery, Salisbury NHS Foundation Trust

^3.Consultant Spinal Orthopaedic Surgeon, Salisbury NHS Foundation Trust.

Aims                
Since April 2014all hospitals are required to publish information about the number of nursing staff working on each ward to help better meet established safe staffing guidelines. The medical profession has not been required to publish the same information. Hospital departments consistently face staff shortages across different grades and roles and this is no different within Trauma & Orthopaedics. Our aims were to attempt to compare staffing numbers across the country and to provide poorer staffed trusts evidence from which to drive better staffing.

Methods      
Questions were sent to 112 NHS hospital trusts through a Freedom of Information request. Staffing numbers at different grades including Consultant, Registrar, Junior. Specialist Nurses and Trauma coordinators were surveyed together with metrics of bed numbers and admissions from which to generate a scaled comparison. Admissions and theatre sessions per consultant could infer the output of the department with the admissions per SHO inferring the workload on juniors.

Results            
61/95 (64%) trusts with level 1 to 3 T&O departments responded. 11 Level1 (MTC centres), 44 Level 2 (Trauma Units), 5 Level 3 (Local Emergency Hospitals). Average number of admissions per consultant 264 and theatre sessions per consultant 2.7. Average number of admissions per SHO 442. There was an average Consultant to SpR Ratio of 1.51. Trauma Co-ordinators were employed by 79% of trusts.

Conclusion  
There are significant differences across the healthcare trusts in staffing levels. Most notably in the SHO level who are likely responsible for much of the daily ward work and clinical contact for admitted patients and their turnover. Trusts could use our data to leverage additional funding to increase staffing levels, lessen workload on juniors and improve patient safety.

When stochasticity meets precision: Using single cell genomics to refine cell therapies in bone and cartilage repair

M Seah, M Birch, I Moutsopoulos, I Mohorianu, A McCaskie

Division of Trauma and Orthopaedic Surgery, University of Cambridge, UK

Background
Despite osteoarthritis (OA) representing a large burden for healthcare systems, there remains no effective intervention capable of regenerating the damaged cartilage in OA. Mesenchymal stromal cells (MSCs) are adult-derived, multipotent cells which are a candidate for musculoskeletal cell therapy. However, their precise mechanism of action remains poorly understood.

Methods
The effects of an intra-articular injection of human bone-marrow derived MSCs into a knee osteochondral injury model were investigated in C57Bl/6 mice. The cell therapy was retrieved at different time points and single cell RNA sequencing was performed to elucidate the transcriptomic changes relevant to driving tissue repair. We compare this with transcriptomic data obtained from in vitro modelling data.

Results
Histological assessment reveals that MSC treatment is associated with improved tissue repair in C57Bl/6 mice. Single cell analysis of retrieved human MSCs showed spatial and temporal transcriptional heterogeneity in the repair tissue and synovium. A transcriptomic map has emerged of some of the distinct genes and pathways enriched in human MSCs isolated from different tissues following osteochondral injury. Several MSC subpopulations have been identified, including proliferative and reparative subpopulations at both 7 days and 28 days after injury.

Conclusions
MSC therapy is associated with improved histological and clinical outcomes following osteochondral injury. The transcriptomes of a retrieved cell therapy were studied for the first time and their heterogeneity described. An important barrier to overcome in the translation of MSC therapies is a lack of understanding of the heterogeneity that exists, and the consequent lack of precision in its use. MSC subpopulations with different functional roles may be implicated in the different phases of tissue repair and this work offers further insights into the repair process.

Disclosures
This work was supported by the Addenbrookes Charitable Trust and the Wellcome Trust.

Feasibility of Triaxial Accelerometers in Quantifying Adherence to Shoulder Sling Wear

Authors: Ahmed Barakat, Abdurrahmaan Manga, Aneesa Sheikh, Ryan McWilliams, Alex Rowlands, Harvinder Singh

Background
Shoulder sling wear is usually advocated after shoulder surgeries. Self-reported adherence to treatment is liable to recall bias rendering it unreliable due to over/under estimation of adherence to recommended duration of sling wear.

Aim
We aim to develop an algorithm quantifying shoulder sling non-wear and assess its accuracy utilising slings pre-fitted with triaxial accelerometers.

Methods
Triaxial accelerometers detecting both inertial movement and temperature were lodged in sutured inner sling pockets. Recorded data including acceleration in three axes and temperature (as a proxy to identify sling wear times) was collected in 10 normal participants. Participants were asked to wear the pre-fitted slings for 8 hours (480 minutes) with progressive non-wear times embedded to their wear schedule with prior randomization. Sling wear and non-wear were determined from variability in acceleration in three axes and temperature change. Participants were asked to log sling donning, doffing, and wear times in log sheets to accurately cross-reference with motion/temperature recorded by the accelerometers. Data was statistically analyzed used sensitivity analysis.

Results
10 participants logged 480 minutes/participant of wear. The sensor detected mean duration wear was 479.1 minutes/participant (SD = 2.0). The mean sensitivity for all 10 participant’s data was 94.3% (range = 86.3 – 98.3, SD =3.5) and mean specificity was 99.1% (range = 93.7 – 100, SD = 0.8). Minute-by-minute agreement of sensor-detected wear and non-wear with participant reported wear (from donning and doffing times)  was 97.3% (range = 85.8 – 117.5,SD= 1.5%). Sensor-determined and self-reported total non-wear was compared using paired t-test with no statistical difference found (P=0.14).

Conclusion
An algorithm based on accelerometer-assessed acceleration and temperature can accurately identify shoulder sling wear/non-wear times, thus an accelerometer can be used to define adherence to sling wear. The ramifications of using this high accuracy method can be extrapolated to assessing whether sling wear adherence after shoulder surgeries have any bearing on patient functional outcomes.

Paediatrics Word count: 300 Staph Auerus Infection: A Risk Factor for Failed Successful Single Surgical Washout in Paediatric Septic Arthritis

Mr D Samy1 , Mr A Behbahani1 , Mr M Khattak1 , Mr C Talbot1 Authors: Mr David Ananth Samy, Alder Hey Children’s Hospital, Liverpool. Mr Ayoub Behbahani, Alder Hey Children’s Hospital, Liverpool. Mr Mohammed Khattak, Alder Hey Children’s Hospital, Liverpool Mr Christopher Talbot, Alder Hey Children’s Hospital, Liverpool.

Background
Septic arthritis is an orthopaedic requiring prompt investigation and treatment. Joint washout is the definitive treatment, and some patients require repeat washouts. This patient group must be identified early and monitored closely to minimise long-term complications.

Objectives
We investigated and identified risk factors for paediatric patients requiring repeat joint washouts for septic arthritis in view of developing a prognostic probability algorithm. This is the first study focussing on paediatric patients with septic arthritis. Design and Methods Data was collected at Alder Hey Children’s Hospital. Our data was collected retrospectively from 2012 to 2019. Data were statistically analyzed using SPSS to determine risk factors between the successful single washout (SSW) group and the failed single washout (FSW) group.

Results
124 culture positive patients (69 Male, 51 female) were included. 92 patients (74.2%) underwent a successful single washout (SSW) and 32 patients (25.8%) required more than one washout (FSW). Statistically significant differences were found in admission CRP (SSW = 61.292, FSW = 144.7, p < 0.001), duration of symptoms(in days) prior to admission (SSW = 6.11, FSW = 11.45, p = 0.017), number of positive joint aspirate samples taken on the first washout (SSW = 44.8 ± 33.1, FSW = 67.03 ± 37.3, p = 0.004) and the proportion of joint aspirate samples positive for Staphylococcus Aureus (SSW= 0.098, FSW = 0.552, p < 0.001). Patients with positive Staphylococcus aureus joint aspirate cultures required repeated joint washouts (Odds ratio: 5.827, 95% CI 1.704 – 19.924). Staph aureus on joint aspirate culture (p = 0.005) and a higher CRP value (p = 0.01) added significantly to the model, but the presence of positive joint cultures did not (p = 0.385).

Conclusion
The presence of a high CRP value and Staph aureus positive cultures have a higher risk of requiring multiple joint washouts.

Arthroscopy: The Journal of Arthroscopic and Related Surgery Long Term Outcomes of Arthroscopic Rotator Cuff Repair – A Systematic Review at 10-Years Minimum Follow-Up

Martin S. Davey, MB BCh MCh, Eoghan T. Hurley, MCh PhD, Patrick J. Carroll, FRCS (Tr&Orth), John G. Galbraith, FRCS (Tr&Orth), Fintan J. Shan, MCh FRCS(Tr&Orth), Ken Kaar, FRCS (Tr&Orth), Hannan Mullett, MCh FRCS(Tr&Orth)

Background
The purpose of this study was to perform a systematic review of the literature to evaluate the functional outcomes, radiological outcomes and revision rates following arthroscopic rotator cuff repair (ARCR) at a minimum of 10-years follow-up. Methods Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using Pubmed, Embase and Scopus databases. Only studies reporting on outcomes of ARCR with a minimum of 10-years follow up were considered for inclusion.

Results
Our search found 9 studies including 455 shoulders in 448 patients (51.6% males), with average age of 70.7 ± 3.7 years (45-90) and mean follow-up of 146.9 ± 21.8 months (120-216). At final follow-up, anges of American Shoulder & Elbow Surgeons (ASES), age & sex adjusted Constant-Morley (CM) and University of California Los Angeles (UCLA) scores were reported in 5, 6 and 3 studies respectively as 79.4 - 93.2, 73.2 – 94 and 26.5 – 33 respectively. Of the included studies, satisfaction rates varied in 6 studies from 85.7% to 100% in the long-term. Furthermore, the ranges of forward flexion, abduction and external rotation were 142.4 0 - 170 0 , 116.2 0 – 166 0 and 22.9 0 – 64 0 respectively as reported in 3, 2 and 3 studies respectively. Additionally, the overall radiological re-tear rate ranged from 9.5% to 63.2% overall. The overall surgical revision rates ranged in 6 studies from 3.8% - 15.4%; with from 0% to 6.7% requiring revision-ARCR and from 1.0% – 3.6% requiring revision sub-acromial decompression in 6 and 2 studies respectively at minimum 10-years follow-up.

Conclusion
Our systematic review established that ARCR results in very high satisfaction rates, excellent clinical outcomes, as well as low revision rates at minimum 10-years followup, despite modest evidence of re-tears rates in asymptomatic patients.

Look after the pennies and the pounds will look after themselves: the carbon footprint of skin clips vs absorbable sutures

Lamb J., Gibbs J., Chan G.

Introduction:
The world is in the midst of climate emergency and healthcare has remained one of the last sectors to confront its own contribution to the impending global climate and associated health catastrophe.

The NHS’ annual carbon emissions account for 5% of the U.K.’s total annual emissions and is comparable to that of the whole of Croatia, with Surgery accounting for the greatest contribution.

Small changes in practice have the potential to summate into big emission reductions.

Methods:
A life-cycle analysis (LCA); which is a “cradle to grave” quantification of the material and/or energy inputs and outputs required to produce a product through to its final disposal, was performed for absorbable skin sutures (Caprosyn) and surgical skin clips (Teleflex Vistat Skin Stapler).

The LCA was performed using EcoChain Mobius in following internationally agreed LCA metholodgy and using ISO 9001:2015 and ISO 27001:2017 standards.

Results:
The absolute weight of the suture was 3.460 grams compared with 73.795 grams for the skin clips. This equates to 26.24Kg of CO₂ emissions/Kg for absorbable sutures compared with 317Kg of CO₂ emissions/Kg for skin clips.

Conclusions:
Skin clips result in an over 10x higher emissions per Kg of skin clips used compared to the equivalent amount of absorbable suture.

Admittedly, the contribution of both skin clips and absorbable sutures to the overall emissions from the operation is small. However, THRs and TKRs account for 50% the top 5 commonest surgical procedures cases in the U.K., even the smallest change and yield significant results.

Title: An alternative approach to spinal navigation

Authors: P McCormac, A Mercer, N Darwish

Background
The project aim was to develop an affordable off the shelf alternative to spinal navigation systems. Pedicle screw placement poses a risk to the patient in the form of potential  iatrogenic neurovascular injury. Navigation been shown to reduce this risk by three fold (freehand OR=2.9). However navigation is expensive and not widely available. Our aim was to develop an alternative solution with similar accuracy, and a lower barrier to entry, than existing robotic systems

Methods
We prototyped and tested various designs of jig, finally creating a design that provides the required stability and degree of freedom needed to place a pedicle screw safely.

We tested the final design with simulated surgeries on full size spinal models. The planning model was drilled and then the plan transferred using the guide to the surgical model. A high resolution laser scanner was used to scan both the planning and simulated surgery models.

The pre and post surgery scans were aligned and a best fit cylinder was applied to the raw trajectory scan data. The angular error was then calculated.

Results
The jig was easy to apply and stable when drilling. No cortical breaches outside the pedicle were observed.

The mean angular error was 0.61 degrees between plan and simulated surgery (max 1.16°, min 0.02°).

Conclusion(s)

The device performed well during simulated surgeries. Trajectory deviation was minimal, 0.61 ± 0.51° and comparable with robotic guidance where literature reports deviation of 2.90±2.30°. The next step is to perform simulated surgeries with human cadaveric specimens with a long term goal of clinical use.

Implications
This system presents a potential alternative to robotic navigation. Results indicate the accuracy is comparable, if not better. The comparative size and cost is substantially smaller, providing a more affordable, and, portable solution for safe pedicle screw placement.

Female Orthopaedic Surgeons and their Experiences of Pregnancy

Christina Kontoghiorghe, Catrin Morgan, Deborah Eastwood, Scarlett McNally

Abstract

Background
The number of females within the specialty of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy, 2) any barriers faced towards pregnancy with a career in orthopaedic surgery and 3) areas for improvement.

Methods
This is a cross-sectional study using an anonymous 13- section web-based survey distributed to female-identifying orthopaedic Trainees, Specialty and Associate Specialist Surgeons (SAS) and Locally Employed Doctors (LED), Fellows and Consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out.

Results
A total of 226 UK female orthopaedic surgeons responded to the survey. All regions of the UK were represented. Forty-four percent (N=99/226) of respondents had at least one child, whilst 9.3% (N=21) did not want children. Two- thirds (66%, N=149) of respondents delayed childbearing due to a career in orthopaedics and 61.9% (N=140) of respondents had experienced bias from colleagues directed at female orthopaedic surgeons having children during training. Nearly 20% (N=24/121) of respondents required fertility assistance to get pregnant, 28.9% (N=35/121) had experienced a miscarriage and 43.8% (N=53/121) had experienced obstetric complications.

Conclusions
A large proportion of female orthopaedic surgeons have and want children. Orthopaedic surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female orthopaedic surgeons with decision making, as well as raising awareness for Training Programme Directors (TPDs) and employers and can be used to assist with workforce planning. Further steps are necessary in order to support female orthopaedic surgeons having families.

Neck of femur fractures treated with DUal mobility total hip arthroplasty: a Regional Experience (N-DURE)

Lee Hoggett, Dinesh Alexander, Anthony Helm, NWORC Collaborative

Background
Dislocation of a total hip replacement is a recognised complication. Dual Mobility acetabular components have been suggested to be advantageous in reducing dislocation post-operatively. Our study is the largest study to date comparing post-operative dislocation rates between conventional acetabular bearing (CAB) and dual mobility acetabular bearing (DMB) total hip arthroplasty performed for neck of femur fracture.

Method
A retrospective multicentre observational study at 10 hospital trusts in the United Kingdom of all total hip replacements performed for trauma between January and June 2019.

Results
A total of 295 operations were performed. 64% (189) were CAB and 36% (106) were DMB. Average age was 75 years (38-98). 223 Female: 72 Male. The follow up period was an average of 42 months (27-48). The posterior approach was more commonly used in patients undergoing DMB 96% (102) vs CAB 74% (140) p=0.001. Dislocation was 4 times more likely in patients treated with a CAB 4.2% (8) compared to DMB 0.9% (1) p=0.114. Revision rate 2.7% (8) with no difference seen between groups p=0.667. All revisions were for instability or periprosthetic fracture. Overall mortality was 9.8% (29) with no difference between groups 0.813.

Conclusion
Our study has demonstrated that the risk of dislocation following total hip arthroplasty for trauma may be up to four times higher when CAB are used compared to DMB components. The use of either component does not impact mortality or revision rate.

Implications
We would encourage the use of dual mobility acetabular bearings in patients undergoing total hip arthroplasty for fracture via a posterior approach.

Orthopaedic Trauma Hospital Outcomes - Patient Operative Delays (orthopod) study

Thomas Baldock^a, Reece Walker^a, Thomas Walshaw^a Nicholas Wei^a, Hussam Elamin-Ahmed^a, Sharon Scott^b, Alex Trompeter^c, William Eardley^ad

^aAcademic Centre for Surgery (ACeS), Middlesborough, United Kingdom

^bLiverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

^cSt George's University Hospitals NHS Foundation Trust, London, United Kingdom

^dDepartment of Health Sciences (York University), York, United Kingdom

Introduction
There is a paucity of evidence surrounding contemporary national trauma capacity, cancellations and the time to surgery for orthopaedics injuries. This multicentre prospective service evaluation aimed to address this and investigated injury burden, theatre capacity and time to surgery across the United Kingdom.

Methods
Prospective data capture was conducted by collaborative approach. Patients scheduled for orthopaedic trauma procedures from 22/08/22 and operated on before 31/10/22, were included. Arm one captured weekly caseload and operating theatre capacity. Arm two identified patient and injury demographics, and time to surgery for specific injury groups.

Results
Data was available from 90 hospitals across 86 Data Access Groups (70 in England, 2 in Wales, 10 in Scotland and 4 in Northern Ireland). After exclusions, 709 weeks of data on theatre capacity and 23 138 operations were analysed. The average number of cases per operating session was 1.73. Ambulatory patients accounted for 29% of patients yet the median number of day-case trauma sessions was 0 with 42.8% of hospitals having dedicated day case trauma lists. 12.3% of patients experienced cancellations.

Time to surgery after decision to operate were longest in Northern Ireland (2.5 days) and shortest in England and Scotland (1 day). There was marked variance across all fracture types. However, open fractures and hip fractures in those over 60 years old, which are covered by national guidelines and performance renumeration, had a short wait, and varied least.

Conclusion
There is great variability in orthopaedic trauma operative demand and list provision across the United Kingdom. There is marked variation in nearly all injuries apart from those associated with performance monitoring. Day case operating and pathways of care are underused and are an important area for service improvement.

Disclosure
The British Orthopaedic Association provided funding for this study to cover database construction and data analysis

Title: Combining Zoology and Surgery – development of a new medical device for nerve repair

Background
Damage to peripheral nerves through trauma and cancer surgery results in loss of function and significant morbidity.  Annually, there are ~1.5 million cases of peripheral nerve injury surgery (PNI) worldwide, with an average patient age of 38, and 85% affecting the upper limb function, with <60 % of patients returning to work within one year. The key issue with effective nerve regeneration is the size of the defect gap size. We describe here the pre- clinical development of a novel medical device for nerve repair.

Methods
A reconstituted silk conduit was designed to exploit the required characteristics required for nerve regeneration, as well as bespoke luminal fibres from moths (B. mori and A. pernyi) and spiders (N. edulis). Pre-clinical testing in rats, sheep, non-human primates – and early Human testing data has been performed in gaps from 1-16cm and assessed for functional recovery, axonal re-growth and re-myelination using immunofluorescence and histomorphometric analyses.

Results
Testing to date shows equivalent, or greater, functional and histomorphometrical regeneration of nerve injuries with the use of luminal silk fibres and silk conduits compared with Autografting.

Conclusion
Our findings demonstrate that silk-in-silk nerve conduits achieve a similar regenerative performance as autografts and, thus, represent a promising treatment approach for off-the-shelf peripheral nerve defects in Trauma & Orthopaedic patients. Development of key steps in Manufacture, Sterilisation and Quality Assurance for regulatory approvals are now required.

ORTHO-ALERT - Implementing a departmental e-bulletin to encourage blame-free, accessible distribution of feedback

R Brown, N Hutt, W Mason.

Background

Moments of mastery and mistakes happen. Blame, fear of consequences and concern around damaging professional relationships can prevent surgeons from sharing theirs and others mistakes or tips so that others may learn and avoiding repetitions. The aviation industry employs a system of voluntarily submitted incident reports and dissemination of learning points to lessen the likelihood of further events. It was thought that a similar approach within an orthopaedic department in the form of an e-bulletin of anonymised staff submissions may have similar positive impacts on accessibility and culture.

Methods

A survey was distributed to an orthopaedic department investigating satisfaction with current constructive feedback methods and opinions regarding introduction of an e-bulletin. The bulletin was designed, a dedicated email address created, three-week submission period advertised, and pilot edition emailed to the department thereafter.

Results

Amongst 19 survey respondents, in both giving and receiving feedback, face-to-face conversations were the most positive experience and datixes the most negative. 26% admitted taking no action when mistakes occurred. Barriers included lack of time or confidence, concerns regarding bullying accusations and diminishing morale, and uncertainty as to the appropriate recipient. SpRs were unable to attend M+M meetings, SAS doctors only able every 2-4 months, and consultants monthly.

100% felt an e-bulletin would be educational and would change practice, 95% felt it would encourage feedback and improve patient care and safety. 63% felt it would reduce blame culture.

In the 3-week pilot period, 6 submissions were received and were included in a departmentally disseminated e-bulletin. Positive qualitative feedback was received. Further quarterly bulletins have been produced locally, and ORTHO-ALERT has also been successfully introduced to a second trust.

Conclusion

There is variable quality and satisfaction with feedback and learning amongst orthopaedic staff regarding mistakes. An anonymised e-bulletin of staff submissions increased access to learning, removed barriers to feedback, and may encourage a culture of positive learning from mistakes. ORTHO-ALERT has been continued and expanded across the region. Dedicated roles will be required to maintain this work.

Health-related quality of life in patients with Achilles tendinopathy: Comparison to the general population of the United Kingdom  

T.L. Lewis⁎, G.C.K. Yip, K. Robertson, W.D. Groom, R. Francis, S. Singh, R. Walker, A. Abbasian, A. Latif Guy’s and St Thomas’ NHS Foundation Trust, Maze Pond, London SE1 9RT, United Kingdom  Abstract

Background
There is little evidence available regarding the impact of Achilles Tendinopathy (AT) on health- related quality of life (HRQOL). The primary aim of this study was to quantify the clinical and health-related quality-of-life patient-reported outcome measures for a population presenting with either mid-substance or insertional Achilles tendinopathy.  

Methods
A prospective comparative observational study of consecutive patients with AT presenting for extracorporeal shockwave therapy (ESWT) at a large teaching hospital. The primary outcome was assess- ment of a validated health-related quality of life PROMs (Euroqol EQ-5D-5L) and comparison to 2 general UK population datasets. The secondary outcomes were Visual Analogue Pain Scale (VAS-Pain) and two validated foot-specific patient reported outcome measures (Foot Function Index (FFI) and Victorian Institute of Sports Assessment-Achilles (VISA-A)).  

Results
Between March 2014 and June 2021, 320 consecutive patients (125 male; 195 female) were diag- nosed with AT and referred for a first course of ESWT. EQ-5D-5L PROMs were prospectively collected for 303 of these patients (94.7%). The mean age ( ± standard deviation(SD)) was 52.1 ± 11.4 years. The mean EQ-5D- 5L Index score (mean ± SD) for the AT cohort was 0.783 ± 0.131. Patients less than 55 years with AT had a statistically significantly worse quality of life compared with members of the same age group in the general population. The mean VAS-Pain, FFI, VISA-A clinical outcome scores were 6.0 ± 2.3, 49.5 ± 21.2 and 34.1 ± 14.4 respectively. There was a statistically significant moderate correlation between HRQOL and clinical PROMs (VAS-Pain and FFI vs EQ-5D) however there was no correlation with age.  

Conclusion
This study demonstrates that patients under the age of 55 with AT have a significantly reduced quality of life compared with the general population.  Level of evidence: III   Notes: -    Study conducted entirely in SE Thames by multiple SE Thames SPR -    Published in FAS  Published paper ref: PubMed PMID: 35279393.

THE RADIOGRAPHIC UNION SCORE FOR ULNAR FRACTURES (RUSU) PREDICTS ULNAR SHAFT NONUNION

JM Leow, WM Oliver, KR Bell, SG Molyneux, ND Clement, AD Duckworth

Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, UK

To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU).

Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers.

In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs 7, p<0.001). A ROC curve demonstrated that a RUSU ≤8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤8 (n = 21) were more likely to develop a nonunion (n=16/21) than those with a RUSU ≥9 (n=2/33; OR 49.6, 95% CI 8.6-284.7). Based on a PPV of 76%, if all patients with a RUSU ≤8 underwent fixation at 6-weeks, the number of procedures needed to avoid one nonunion would be 1.3.

The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture.  This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures.

Comparing pinning in situ and capital realignment procedures for severe, stable slipped capital femoral epiphysis: a systematic review.

Grace Kennedy, Jack Pullan, Ahmed El-Bakoury

Background
Slipped Capital Femoral Epiphysis (SCFE) is one of the commonest adolescent conditions requiring orthopaedic intervention.  For severe, stable slips, it is unclear whether pinning in-situ (PIS) or capital realignment procedures (CRP) are superior.

Our primary aim was to compare rates of femoral head avascular necrosis (AVN) following PIS with rates following CRP.  Secondary aims were to consider patient-reported outcome measures (PROMs) and post-operative complications.

Methods
MEDLINE, Embase and Cochrane databases were searched according to an agreed strategy.  Narrative review articles, case reports, letters to the editor and articles not written in English were excluded.   Articles where severe stable cases could not be distinguished from unstable or less severe cases were also excluded.  The risk of bias was assessed using the Newcastle–Ottawa Scale.

Results
Of the 132 citations identified, 127 were excluded following de-duplication and application of the exclusion criteria.  Three observational studies comparing PIS with CRP, and two case series considering CRP alone were identified.  One article was considered fair quality, and four articles were considered poor.

In total, 198 hips from five studies were included (66 PIS, 132 CRP).  AVN was reported in 1.5% following PIS and 10.6% following CRP.  PIS was associated with moderate-good functional outcomes, and CRP with good-high outcomes.  Two comparative studies reported significantly better PROMs following CRP.  Chondrolysis occurred in 3.0% following PIS and 2.4% following CRP.  Femoroacetabular impingement rates were markedly higher following PIS (60.6%) than following CRP (2.3%).  Requirement for reoperation was also greater following PIS (34.5%) than following CRP (13.3%).

Conclusion
There is a trend for PIS to be associated with favourable AVN rates but CRP with favourable PROMs and complication rates.  However, there is insufficient evidence to draw conclusions regarding this, as comparisons are drawn from heterogenous studies that lack information regarding long-term sequalae. Further high-quality research is required.

Conservative treatment of 3- and 4-part proximal humeral fractures: can poor outcomes be predicted?

Background
This study aims to assess radiographic and PROMS data to identify factors leading to poor outcomes following conservative treatment.

Methods & results 
Retrospective local database analysis identified patients sustaining 3 or 4-part proximal humeral fractures. Radiographic and functional outcome measures were collected including Oxford Shoulder Score (OSS), Subjective Shoulder Score (SSV) and VAS pain scores.

We included 104 patients (84F:20M) at mean follow-up of 55 months, with a mean age of 69 at time of injury. Analysis highlighted significant OSS differences in 3 vs 4-part fractures (p=0.027), dominant vs non-dominant side injured (p=0.046), age at injury >65 vs younger (p=0.006), varus coronal neck shaft angle <115 vs 115-155 degree (p=0.002), apex anterior sagittal neck shaft angle >155 vs 115-155 degree (p=0.024), GT displacement >5mm vs less (p=0.001), GT comminution (p=0.02) and medial hinge displacement >3mm or less (p=0.002). Each variable achieved a minimally important clinical difference (MCID) of 5 points.

VAS pain was significant in varus neck shaft angle (p=0.011), GT displacement >5mm (p=0.027), medial hinge displacement >3mm (p=0.045).

SSV varied significantly with 3 vs 4-part fractures (p=0.005), age >65 (p=0.04), varus angulation (p=0.001), apex anterior angulation (p=0.001), GT displacement >5mm (p=0.001), GT comminution (p=0.008), medial hinge displacement >3mm (p<0.001). Each variable showed a MCID of 12.

Conclusion
Patients with a 4-part fracture showed poorer functional outcome on both OSS and SVV. Injury to the dominant side showed poorer clinical outcome than to the non-dominant side. Over age 65 reported poorer clinical outcomes than younger. Varus type fractures, posterior head angulation, GT displacement >5mm, GT comminution and medical hinge >3mm displacement are further predictors of poorer clinical outcomes. These results allow for improved shared decision-making regarding treatment options and patient expectation management.

Does wire fixation for displaced distal radius fractures prevent a loss of reduction?

Plant CE, Ooms A, Cook J, Costa ML

Background
Displaced distal radial fractures are common injuries that can be treated with manipulation and cast application, or with the addition of wire fixation to prevent a loss of reduction.

Objective
This study has been performed to determine whether the addition of wire fixation, provides (1) a greater maintenance of fracture reduction and (2) if this correlates to a clinically relevant difference in functional outcomes.

Methods
Radiological and functional outcomes were assessed for four hundred and four patients recruited to a National Institute for Health Research clinical trial.  Mean differences in the degree of palmar tilt and ulnar variance at time of injury, intra-operatively and 6 weeks post operatively, were compared for patients treated with cast vs wire fixation. A correlation analysis was performed between radiological outcomes at 6 weeks and the patient reported wrist evaluation (PRWE) and EuroQol EQ-5D-5L Index and EQ-VAS recorded at 3, 6 and 12 months.

Results
Cast application resulted in a 4-degree (p<0.001) increase in dorsal angulation at 6 weeks postoperatively in comparison to wire fixation, but no difference in ulnar variance.  No correlation was detected between the radiological and functional outcomes at any of the time points assessed.

Conclusions
Wire fixation provides a greater preservation of fracture reduction, however, this is unlikely to be clinically relevant to the patient.

TITLE
Does it work and is it cost-effective? - Hydrodilatation for Adhesive Capsulitis

AUTHORS
Clara Miller, Emma Poyser, Jonathan Topping, Thomas Key, Ishan Gunatunga, Nicola Vannet

PURPOSE 
Is Hydrodilatation an effective and economical treatment for patients with Adhesive Capsulitis symptoms uncontrolled by primary care management? 

BACKGROUND
Adhesive Capsulitis symptoms are often self-limiting, however, for some patients pain and stiffness can be debilitating and persistent. For severe cases, or when physiotherapy and local steroid injection(s) have not managed symptoms, our local practice is to offer Hydrodilatation treatment. Failing this, patients are often offered a second Hydrodilatation, or more invasive options. Several small studies have reported success with Hydrodilatation, but lack of high level evidence prevented its recommendation by BESS/BOA in the 2015 patient care pathway. Success rates and cost effectiveness of hydrodilatation in our treatment algorithm warranted review.

METHODS
Shoulder Hydrodilatation procedures were identified January 2018 - September 2021 from our electronic Radiology booking system and Practitioner log-book records. Retrospective electronic notes review was conducted and costing information sought from the Finance Department.

RESULTS
451 procedures were identified. After inclusion and exclusion criteria were applied, 365 shoulders in 353 patients were analysed. 307/365 (84%) were successfully treated with one hydrodilatation procedure. Complication rates were low. Treatment failure requiring further procedures were second hydrodilatation 22/58 (38%), steroid injection 12/58 (21%), MUA 7/58 (12%), Arthroscopic Capsulotomy 3/58 (5%) and multiple procedures in 10/58 (17%). A rudimentary cost analysis found Hydrodilatation was significantly less expensive compared to MUA or Arthroscopic Capsulotomy when used in this treatment algorithim, even when including costs of further procedures when required.

CONCLUSION
The data have demonstrated Hydrodilatation is an effective and safe treatment for patients suffering severe symptoms of Adhesive Capsulitis. When used in a step-wise treatment approach, Hydrodilatation avoids the expense and complications associated with surgical management.

Carbon Footprint Reduction In Shoulder Surgery by The Rationalisation of Single-Use Convenience Packs

Authors:
Ryan  Hiller Smith A Chowdhury, H Imran, H Colaco

Hospital:
Hampshire Hospitals Foundation Trust

Introduction
The NHS is responsible for a vast carbon footprint, with annual carbon dioxide emissions estimated at over 20 million tonnes, comparable to the national emissions of Sri Lanka. Operating theatres contribute up to 25% of a hospital’s emissions. We aimed to rationalise the composition of the single-use convenience packs in arthroscopic and open shoulder surgery, to reduce the annual carbon footprint.

Methods
The individual material composition of all items in the single-use shoulder arthroscopy and open shoulder convenience packs was considered. The carbon footprint of each item was calculated by the application of best available cradle-to-grave emission factors. The items in the packs were then rationalised by consensus (of surgeons and scrub team), removing, reducing, or altering unnecessary items. Two new standardised packs were designed, and a predicted annual carbon footprint reduction was calculated.

Results
In the 2022/2023 financial year, 296 arthroscopic and 154 open shoulder procedures were performed. This resulted in the use of 810.7kg of single-use non-recycled plastic. The new rationalised packs will result in an estimated annual carbon footprint reduction of 607.5 kgCO2e.

Conclusion
Through a simple method of single-use convenience pack rationalisation, we can reduce the annual carbon footprint of shoulder surgery by the equivalent of 1,557 miles driven in an average petrol car. This is an underestimate of saving, as the reduction in waste disposal has not been considered. Ongoing work includes expansion to all orthopaedic procedures, assessment of waste disposal and the adoption of sterilisable/sustainable alternatives.

Confidence and Understanding Amongst Trauma and Orthopaedic Consultants and Trainees in Identifying and Managing Child Protection Concerns: Findings from a Deanery Wide Survey

E., Harris and K., Ferguson.

Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF.

Background
The GMC places a duty on all doctors to protect the health and well-being of children and young people. Trauma and Orthopaedic professionals regularly encounter paediatric injuries, of which some may represent abuse or neglect. This study sought to establish the confidence and understanding of Trauma and Orthopaedic consultants and trainees in identifying and managing child protection concerns.

Methods
An anonymous quantitative and qualitative 14-question survey was devised. The survey was conducted using Google Forms in a single Deanery within the United Kingdom and distributed via email to all consultants and trainees.

Results
The survey received 50 responses: 36 consultants and 14 trainees. All consultants and 4 trainees had received formal training in paediatric orthopaedics. 47 (94%) of respondents regarded child protection as ‘very’ or ‘extremely’ important within the context of their clinical practice. 21 (42%) or respondents were ‘confident’ in identifying a child protection concern or non-accidental injury, with a further 23 (46%) ‘very’ or ‘extremely’ confident. Respondents were less confident managing a child protection concern, with 15 (30%) stating they were ‘not’ or ‘not at all’ confident’. Moreover, 19 (34%) and 24 (48%) of respondents respectively did not know how to raise a child protection concern ‘in’ or ‘out of hours’, whilst 37 (74%) did not know how to submit a notification of concern.

Conclusion
The study demonstrated a variable level of confidence and understanding amongst consultants and trainees in identifying and managing child protection concerns. Notably, a significant number were unaware of how to raise a child protection concern or submit a notification of concern.

 Implications
Results have informed the content and delivery of future teaching within the Deanery. Health Board specific support material outlining the appropriate pathway to raise concerns have been developed, including contact details for local child protection and social services. 

Disclosure
None.

Mortality from Tibial Fractures in the Elderly – a retrospective multicentre study

Background

The mortality from tibial fractures in the elderly population is similar to that of a hip fracture. Despite this they are often managed non-operatively. Operative treatment has the benefit of allowing earlier return to weightbearing and reducing complications associated with non-weight bearing in this vulnerable group of patients with co-pathologies and limited functional reserves. Furthermore, compliance with non-weightbearing in this group is poor leading to undesirable outcomes.

Objectives

There is a lack of evidence in the literature comparing mortality outcomes in patients treated operatively with those treated non-operatively. Therefore, our aim was to assess whether there is a difference in mortality between operative and non-operative management of tibial fractures in the elderly population.

Study Design & Methods

A multi-centre study with data collated from Hull Royal Infirmary (major trauma hospital) and Huddersfield Royal Infirmary (district general hospital). Data was collected retrospectively covering a 5-year period between 1st January 2017 to 31st December 2021.
Patients aged 65 and over with a diaphyseal tibial fracture (AO42) were included in the study. Patients with non-acute (>3 weeks), open, periprosthetic, pathological or multiple lower limb fractures were excluded.

Results

A total of 61 patients were identified across both sites, 20 male (32.8 %) and 41 female (67.2%). 37 patients (60.7%) were managed operatively with either an intramedullary nail, circular frame or open reduction and internal fixation. 24 patients (39.3%) were managed non-operatively in an above knee cast. The most commonly quoted reason for non-operative treatment was frailty even though the patient may be fit for an anaesthetic. The rates of mal-union were higher in the non-operative cohort (25%) compared with operative cohort (10.8%). Inpatient stay and time to union were longer in the non-operative group. The 4-month mortality for patients managed operatively was 5.4% (2 of 37 patients) compared with 8.3% (2 of 24 patients) in the non-operative cohort. The 1-year mortality for patients managed operatively remained 5.4% however, it reached 25% (6 of 24 patients) in the non-operative cohort. This was statistically significant.

Discussion

Our data indicates that non-operatively treated tibial fractures have a significantly higher mortality rate. In this population, risks from immobility are high and return to pre-morbid function reduces with increasing non-weightbearing period. The mortality may be reduced if these fractures are managed operatively with an aggressive approach as with hip fractures. We recognise there are certain limitations within our study. Due to relatively small numbers, a subgroup analysis could not be performed and there is a possibility of selection bias being introduced. To address this, we are currently in the process of expanding the study further through working with national and regional collaboratives. Data from several other centres is underway.