Chaired by Mr Andy Wainwright
09:45-11:05
Presentations from our clinical trainees who, despite no dedicated time for research, have been involved in clinical trials and developing new patient pathways. Themes this year include:
At the end of the day, there will be live voting and prizes for the best presentations.
Presentations will last six minutes, with time for questions after every third candidate.
This study assessed the clinical course of military personnel with shoulder instability. We assessed the pattern of labral tears suffered; the reliability of pre-operative diagnostic methods (arthrogram vs. clinical examination) and; finally, assessed their outcomes both in terms of satisfaction, pain, and return to full deployment.
Retrospective demographic and clinical data was collected for patients listed for arthroscopic stabilisation between September 2016 and January 2019. For service evaluation, patient-reported outcome measures (PROMS) data and occupational outcome data were gathered.
41 patients were treated surgically. 24.4% had an isolated anterior tear, 41.5% had complex 2-zone or pan-labral tears on arthroscopy. Clinical examination showed higher sensitivity, accuracy and negative predictive value for labral tear patterns compared to MRA. Mean pre-op OSIS score was 18.58 (SE ±1.67), and mean post-op score was 41.5 (SE ± 1.13). 82.14% returned to full deployment during the study period and 85% had returned to sport.
Complex labral tear patterns are common in military personnel with shoulder instability and clinical examination appears to be more effective than imaging at predicting injury pattern. Patients respond well to arthroscopic stabilisation with good rates of return to work and sport, regardless of chronicity of injury.
Incidence of VTE in the paediatric population is significantly lower than in adults. Those that sustained a VTE are more likely to have adverse outcomes including recurrent thrombosis, post thrombotic syndrome and sudden death. There is a bimodal age distribution; infants <2 years old and adolescents (especially females). The aims of our study are to assess clinical experience, beliefs, attitudes and concerns related to VTE risk assessment and prescribing in paediatric patients.
Online survey distributed to all doctors within a single Trauma Department. Retrospective audit of paediatric T&O patients over a 12month period; 6 months before and 6 after introduction of new VTE prophylaxis Guidelines.
100% believed VTE in paediatric orthopaedic patients was ‘Unlikely’ or ‘Very unlikely’. 13% had encountered at least one patient with a DVT during clinical practice. Majority reported they did not routinely prescribe chemical VTE in paediatrics. 188 children were identified, 37% had a VTE risk assessment (39% before introduction of guideline), and 9% had VTE prophylaxis prescribed (5% before). BMI, age, FMHx, COCP, reduced mobility, total anaesthetic time, and severity of illness/trauma were all considered extremely important predisposing risk factors for VTE in paediatric orthopaedic patients.
Clinical experience of encountering paediatric VTE is low. Severe Trauma and Burns are perceived as an extremely important potential risk for VTE in paediatric patients. While VTE is rare in paediatric trauma patients the impact and morbidity is significant. Greater awareness is needed and risk assessments should be considered.
To compare pre-referral microbiology and previous bone excision in long bone osteomyelitis with intra-operative microbiology from a specialist centre.
The inclusion criteria for this prospective observational cohort study were; (i) aged ≥18 years, (ii) received surgery for long bone osteomyelitis and (iii) met diagnostic criteria for long bone osteomyelitis. Patient demographics, referral microbiology and previous surgical history were collected. Antimicrobial options were classified using the BACH classification. Cultures and susceptibility of pre-referral microbiology were compared to the intra-operative sampling results.
79 patients met inclusion criteria. 39 (49.4%) patients had information available at referral regarding microbiology. Microbiology information at referral fully matched microbiology samples taken at operation in 8 cases (20.5%). Fifteen of the 39 patients (38.5%) had a different species isolated at surgery compared to referral microbiology. The remaining 16 patients (41.0%) had a culture-negative osteomyelitis on surgical sampling. 35 patients were classified as A1 (44.3%), 15 as A2 (18.9%) and 29 as Ax (36.7%). Patients who had received previous excision of osteomyelitis before referral (n=32, 40.5%) had an increased odds ratio (OR) of having microbiology with limited antimicrobial options (OR: 3.8, 95% CI 1.2 – 11.2, P=0.023, Fisher’s exact test).
Patients are frequently referred with limited microbiological information. Pre-referral microbiology in long bone osteomyelitis correlated with intra-operative samples taken at our centre in less than one quarter of cases. Pre-referral microbiology data should be used with caution for planning treatment in osteomyelitis. Previous surgery for osteomyelitis was associated with microbiology culture with limited antimicrobial treatment options.
The COVID-19 pandemic has caused mass disruption to all aspects of society, with elective orthopaedics not spared. The pandemic has potential to cause a tsunami of health burden in the community if elective services are not resumed to pre-pandemic levels of activity. A previous study in our department demonstrated that elective orthopaedic surgery can be safely resumed in the independent sector at a time when COVID-19 is prevalent in the community. This study reviewed the resumption of elective services in a higher risk patient cohort and the return to operating at the National Health Service (NHS) site.
A strategy of phased relaxation of clinical co-morbidity criteria was followed. Patients from the orthopaedic waiting list were selected according to these criteria and observed recommended preoperative isolation protocols. Operations were undertaken in the independent sector under the COVID-19 contract and the NHS site. Patients were assessed from all phases in the resumption of services. In-hospital and postoperative complications with specific enquiry as to the development of COVID-19 symptoms or need and outcome for COVID-19 testing at 14 days and six weeks was recorded.
263 patients were included in this study, of which 155 were female. The mean age of patients was 52.45. The mean BMI of all patients was 29.1 kg/m2. 124 patients were ASA grade 1, 117 ASA grade 2 and 22 ASA grade 3. 167 patients underwent a major operation with total hip replacement being the most common operation. There were no in-hospital complications. No patients had a positive test result or symptoms of COVID-19 in the six-week post-operative period.
In summary, we demonstrated that elective orthopaedic surgery can be safely undertaken via a green pathway in a higher risk patient cohort when COVID-19 is prevalent in the community.
To assess the ability of the JS-BACH classification of bone infection to predict clinical and patient-reported outcomes in prosthetic joint infection(PJI).
Patients who received surgery for suspected PJI at two tertiary UK centres between 2010 and 2015 were classified into ‘uncomplicated’, ‘complex’ or ‘limited options’ by two clinicians blinded to outcome. Any discrepancies adjudicated by a third reviewer. Patients were assessed for recurrence since the index operation and status of the joint. A Cox proportional-hazard model assessed significant predictors of recurrence following the index procedure. Patient-reported outcomes included the EuroQol EQ-5D-3L index score and the EQ-visual analogue score(VAS) at 0, 14, 42, 120 and 365 days following the index operation.
220 patients were included with a median time to final follow-up of 4.7years. Controlling for type of index procedure and site of infection, Cox proportional-hazards ratio of recurrence when classified as complex versus uncomplicated was 25.2(95% CI 3.45 – 183.7,p<0.001) and having limited options verses uncomplicated was 59.0 (95% CI 7.93 – 439.1, p<0.001). None of the patients who were classified as ‘uncomplicated’ PJI(0/52) had received either amputation, joint fusion, excision arthroplasty, chronic suppressive anti-biotics, had died from sepsis secondary to PJI or were awaiting treatment for an active infection at final follow-up. This compared to 21.3%(27⁄127) of patients classified as ‘complex’ PJI and 65.9%(27⁄41) of patients classified as ‘limited options’. Compared to the age-matched population, patients with ‘uncomplicated’ PJI reported similar EQ-index scores(age-matched population: 0.782, ‘uncomplicated’: 0.730, SD 0.326) and EQ-VAS(age-matched: 77.9, ‘uncomplicated’ PJI: 79.4, SD 20.9). This was significantly higher when compared to patients classified as ‘complex’(EQ-index: 0.515 SD 0.323, p<0.012; EQ-VAS: 68.4 SD 19.4, p=0.042) and ‘limited options’(EQ-index: 0.333 SD 0.383, p<0.001; EQ-VAS: 60.2, SD 23.1, p=0.005, ANOVA with Tukey post-hoc comparison).
JS-BACH classification is a significant predictor of clinical outcome and quality of life following surgery for PJI.
Methoxyflurane is a historic vaporised anaesthetic agent. It has undergone a renaissance using a smaller dose in a handheld ‘Penthrox’ device. There is minimal literature regarding its use in common orthopaedic presentation management. We describe the demographics, injuries and outcomes for 97 injuries managed with Penthrox at our centre. Patient demographics and procedure types were recorded for patients receiving Penthrox. Success was defined as fracture manipulation into safe position, joint enlocation or completion of other planned event. Time to procedure and admission rates were recorded. There were 101 Penthrox doses given to 89 patients over 97 unique episodes over 2 months without serious complication. Native elbow dislocations were reduced on 4⁄4 patients. Native shoulder dislocations were reduced in 11⁄17 patients. Prosthetic total hip arthroplasty dislocations were reduced in 3⁄10 patients. All 54 fractures were managed successfully with Penthrox. Success and discharge were quicker when Penthrox was used as an adjunct for treatment. We have shown that Penthrox is safe and can be used for common emergent trauma scenarios in A&E. It has lessened time to procedure that would otherwise require general anaesthesia and has facilitated earlier discharges. Protocolisation of injuries can highlight where Penthrox may be of benefit going forward.
Cerebral palsy (CP) can result in progressive hip migration. The Cerebral Palsy Integrated Pathway (CPIP) includes routine surveillance pelvic radiographs to assess migration. Images should be of acceptable quality to justify radiation exposure. The aim of this audit was to determine the adequacy of pelvic anteroposterior radiographs for hip surveillance performed at the Nuffield Orthopaedic Centre (NOC).
50 radiographs were assessed (inclusion criteria: imaging performed at NOC, within preceding year; frankly dislocated or operated hips were excluded). Child age and gross motor function classification system (GMCFS) were recorded. Adequacy was assessed against 4 criteria: (1) femoral shaft abduction/adduction; (2) pelvic rotation; (3) femoral rotation and (4) pelvic inclination. Measures were made bilaterally where applicable. Performance target set at 95% for each criterion.
Mean age of cohort 9.7yrs (SD4.0, min 2.3, max 17.3) with GMCFS 1-5 of 2⁄5, 10⁄50, 19⁄50, 10⁄50 and 9⁄50 respectively. Only criterion 2 achieved the performance target (96%, 48⁄50 radiographs). Criterion 1 achieved an 86% pass rate, criterion 3 49% and criterion 4 60%. Only 4⁄50 radiographs passed all criteria.
Excessive hip abduction/adduction can result in unreliable hip migration assessment. 14% of the cohort were sub-optimally positioned and therefore subjected to radiation producing suboptimal images. Pelvic rotation was appropriately accounted for during positioning during imaging, but pelvic inclination and femoral rotation were not. However, these have limited impact on migration assessment. Outcomes of the audit were feedback to radiology team on importance of positioning and CPIP clinical guidelines, and to re-audit in 6 months.
With continually increasing pressure faced by the NHS, day cause surgery may reduce this burden. This review aims to compare the outcomes for day case shoulder replacement with a similar matched cohort of patients receiving standard in patient care.
Seventy-three patients (mean age 68 years) had 82 shoulder arthroplasty procedures. Forty-six shoulder replacements (35 hemiarthroplasty, 11 totals) were undertaken in a dedicated stand-alone day-case unit and 36 (21 hemiarthroplasty and 15 total) were undertaken as in-patient cases. Constant and Oxford Shoulder Scores were collected prospectively for patients undergoing day case shoulder replacement compared to inpatient care blinded to the operative surgeon and followed up for a minimum of a year.
There was no significant difference between the outcomes of shoulder arthroplasty performed in the day case or in-patient. Day cases complications included a rotator cuff tear after a year and an early shoulder dislocation. Inpatient complications included shoulder instability, a rotator cuff tear, nerve damage and one a periprosthetic fracture. Operation time was statistically shorter for day cases by 25.1 minutes (95% CI - 36.5 to -13.7; d = -0.95, 95% CI -1.42 to 0.48). Estimated marginal means (EMM) revealed lower post-surgery oxford pain scores in day cases (EMM = 3.25, 95% CI 2.35, 4.16) compared with inpatients (EMM = 4.65, 95% CI 3.64 to 5.67).
Day case shoulder replacement is safe with comparable outcomes to routine inpatient care for patients up to ASA 3 classification with high satisfaction and excellent functional outcomes.
The Coronavirus disease (COVID-19) pandemic has contributed to over 5 million deaths worldwide. Hospitals responded by expanding services to accommodate the forecasted rise in COVID-19-related admissions. We describe the effects these changes had on management of orthopaedic trauma and patient outcomes at a district general hospital in Southern England.
Data were extrapolated retrospectively from two separate six-week periods in 2019 and 2020 (1st April - 13th May) using electronic records of patients referred to the orthopaedic team. Soft tissue injuries were included where a confirmed diagnosis was made with radiological evidence. Patients were excluded if no orthopaedic intervention was required. Data were compared between the two time periods.
There were fewer attendances to hospital in 2020 compared with 2019 (178 vs 328), but time from presentation to surgery significantly increased in 2020 (2.94 days vs 4.91 days, p=0.009). There were fewer operative complications in 2020 (36⁄145 vs 11⁄88, p<0.001). However, ordinal logistic regression analysis found a significantly greater complication severity in 2020 including death (p=0.039). Complication severity was unrelated to COVID-19 status.
Restructuring of orthopaedic services in response to the COVID-19 pandemic has been associated with significant delays to surgery and higher post- operative complication severity. Our results demonstrated the need to fast-track emergency operative orthopaedic services in UK district general hospitals
Ankle fusion is a successful operative treatment for end stage ankle arthritis. This could be done open or arthroscopically and evidence suggests that arthroscopic ankle fusions have better outcomes. In addition to the operative technique other patient-factors can influence complication rates. The most significant complication of ankle fusion is a non-union. To better understand the risk factors related to this we undertook a retrospective investigation of primary arthroscopic ankle fusions.
We reviewed all arthroscopic ankle fusions conducted at our institution over a 10-year period with a minimum of 6-month follow-up. Patients excluded if they had simultaneous fusion of neighbouring joints. The primary outcome variable was radiographic union. Other operative complications were analysed as secondary outcomes. Two hundred and eighty-four arthroscopic ankle fusions in 271 patients were performed over the study period and met the inclusion/exclusion eligibility criteria.
The overall non-union rate was 7.7 %. Logistic regression analysis found that non-union was more than 14 times more likely to occur after previous triple fusion. Current smoking, increasing age, obesity (BMI>30), surgical grade (trainee vs consultant) or the degree of weightbearing status post operatively were not significant risk factors of non-union. The leading cause of reoperation was the removal of metal (18%).
This is the largest case series of arthroscopic ankle fusions in the literature and the first to demonstrate that patients who had an arthroscopic ankle fusion done after previous triple fusion have unacceptably high non-union rates and in such cases an ankle replacement may be recommended.