Trauma and orthopaedics

Fear of reinjury after acute Achilles tendon rupture is related to poorer recovery and lower physical activity postinjury (2024)

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Type of publication:

Journal article

Author(s):

Larsson, Elin; LeGreves, Agnes; Brorsson, Annelie; Eliasson, Pernilla; Johansson, Christer; *Carmont, Michael R; Nilsson Helander, Katarina.

Citation:

Journal of Experimental Orthopaedics. 11(4):e70077, 2024 Oct.

Abstract:

Purpose: The aim of this study was to investigate how fear of reinjury to the Achilles tendon affects return to previous levels of physical activity and self-reported Achilles tendon Total Rupture Score (ATRS) outcomes.

Methods: Data were collected from a large cohort of patients treated for an acute Achilles tendon rupture at Sahlgrenska University Hospital Molndal between 2015 and 2020. The ATRS and additional questions concerning fear of reinjury, treatment modality, satisfaction of treatment and recovery were analyzed 1-6 years postinjury. Analysis was performed to determine the impact of fear of reinjury on patient-reported recovery and physical activity.

Results: Of a total of 856 eligible patients, 550 (64%) answered the self-reported questionnaire and participated in the follow-up. Of the participants, 425 (77%) were men and 125 (23%) were women. ATRS, recovery in percentage, satisfaction of treatment, recovery on a 5-point scale and physical activity level post- versus preinjury were significantly related to fear of reinjury (p < 0.001). Of the nonsurgically treated patients, 59% reported fear of reinjury compared to 48% of the surgically treated patients (p = 0.024) Patients that reported fear of reinjury had a 15-point lower median ATRS score than those who did not (p < 0.001).

Conclusion: More than half of patients who have suffered an Achilles tendon rupture are afraid of reinjuring their tendon. Patients who reported fear of reinjury exhibited a significantly lower ATRS score. This indicates the importance of addressing psychological aspects in the treatment after this injury.

Level of Evidence: Level II.

Link to full-text [open access - no password required]

Percivall Pott (1713-1788): Father of Orthopaedics and Pioneer of Occupational Medicine (2024)

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Type of publication:

Journal article

Author(s):

*Forster, Seth.

Citation:

Cureus. 16(10):e70608, 2024 Oct.

Abstract:

Percivall Pott was an eighteenth-century English surgeon best known for three eponymous diseases: Pott's fracture, Pott's puffy tumour and Pott's disease of the spine. He wrote extensively, with treatises covering a wide range of surgical subjects, including cataracts, cranial trauma, hernias
and neurology. Pott's practice came at a time when surgery was being transformed from the work of barbers into a scientific study. His publications had a wide-reaching impact, influencing contemporary practice and setting out building blocks for the work of those who came after him. This article aims to explore the life and career of Percivall Pott, looking in particular at his influence on the subjects of orthopaedics and occupational medicine.

UK Foot and Ankle Thromboembolism (UK-FATE) (2024)

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Type of publication:

Journal article

Author(s):

Mangwani, Jitendra; Houchen-Wolloff, Linzy; Malhotra, Karan; Booth, Sarah; Smith, Aiden; Teece, Lucy; Mason, Lyndon W; Shaikh, Rabia; Alfred, Wilam; Okhifun, Imobhio; Cinar, Ece; Bua, Nelson; Vemulapalli, Krishna; Acharya, Ashok; Gadd, Richard; Money-Taylor, John; Kantharaju, Rohit; Bhosale, Abhijit; Bahri, Suchita; Broadbent, Rosie; Drummond, Isabella; Jones, Neil; Shah, Savan; Ravindrarjah, Thuwarahan; Yasen, Zaid; Singh, Kunjshri; Al-Habs, Ruqaiya; Jeyaseelan, Lucky; Habbiba, Abdullah; Walker, Thomas; Dewhurst, Maximilian; Glasgow, Nisha; Eze, Dominic; Carter, Gary; Rajan, Praveen; Patil, Vijay; Amer, Omer; Malik, Kalim; Pavanerathan, Pranavan; Mallick, Arijit; Seferiadis, Ilias; Currall, Verity; Sadasivan, Preetha; Kumar, Sunil; Sanjani, Shahrukh R; Ciaccio, Maria; Ayyaswamy, Brijesh; Prasad, Pradeepsyam; Anand, Mr; Sunilraj, Dr; Lane, Suzanne; Prathap, Swetha; Kankate, Raghubir; Aktselis, Ioannis; Davda, Kinner; Vijapur, Arvind; Tayyem, Mohammed; Chau, Jackie; Azhar, Muhammad S; Sturdee, Simon; Hussain, Halima; Sonde, Sarah; Luqman, Muhammad Q; Farooq, Rahy; Wells, Gareth; Shenolikar, Aneil; Simons, Michiel; Hodgson, Paul; Thomas, Rhys; Stevens, Sam; Elhassan, Yahya; Adeniyi, Adebowale; Aspinall, Will; Joseph, Vinay; Day, Miriam; Tong, Aureola; Joyner, Claire; Alzaranky, Muhammed; Elhassan, Osman; Chhantyal, Kishor; Arora, Abhishek; Abiddin, Zain; Kucharski, Robert; Ahmad, Irfan; Zeb, Junaid; Ishaq, Usman; Thomas, Jija; Jain, Kowshik; Deol, Rupinderbir; Faroug, Rad; Johal, Karan; Mordecai, Simon; Argyropouos, Miltiadis; Chawla, Amit; Ibrahim, Mohamed; Pereira, Marta; Barr, Lynne; Julies, Elda; Hill, Francesca; Kapoor, Smriti; Bailey, James; Mukhopadhyay, Ishani; Rana, Sarina; Tarig, Hamza; Qualaghassi, Mahdi; Seewoonarian, Sheena; Rose, Barry; Crate, Georgina; Abbott, Sarah; Fenner, Christopher; Geleit, Ryan; Yousaf, Sohail; Akram, Nimra; Al-Hubeshy, Zahra; Patel, Bhavi; Hussein, Mohamed; Clark, Callum; Giddie, Jasdeep; Dega, Raman; Dasari, Kishore; Nandhara, Gurbinder; Kumar, Pritesh; Gupta, Prateek; Poole, Hope; Zace, Pamela; Alvi, Farhan; Jacob, Jagan; Reddy, Raji; Sateesh, Vaishnav; Gledhill, Andrea; Craven, James; Cichero, Matt; Yates, Ben; Newton, Ayla; Grice, John; Fawcett, Nicholas; Fraig, Hossam; Hamad, Farouk; Marsland, Daniel; Elliot, Robin; Ghani, Yaser; Chandrashekhar, Suresh; Millan, Ravi K; Clark, Andrew; Rahman, Kashed; Sykes, Mark; Little, Zoe; Saleem, Jawaad; Jolly, Lewis; Jain, Aman; Qadri, Ansar; Rymaruk, Sophy; Kulkarni, Avadhut; Garabadi, Mohanrao; Akhtar, Meraj; Hossain, Munier; Yunus, Shamael; Saleem, Maleeha; Fong, Joanna; Islam, Amirul; Nusir, Ben; Chapman, James; Holmes, David; Mamoowala, Neville; Almond, Kieran; Wright, Claire; Caruana, Ethan; Watson, Thomas; Allison, Georgia; Pillai, Anand; Madhi, Imad; Alsalihy, Mazin; Elamin, Khadija; Yip, Chee Rong; Tew, Lucy; Dahiya, Rohan; Goff, Thomas; Bagshaw, Oliver; Slade, Henry; Andrzejowski, Paul; Gomati, Ayoub; Drake, Chris; Hind, Jamie; Morgan, Rebecca; Khalaf, Ahmed; Ditta, Adeel; Ramasamy, Arul; McIntyre, Joshua; Blacklock, Calum; Middleton, Scott; Clayton, Robert; Hrycaiczuk, Alex; Thornhill, Christopher; Jeyakumar, Gowsikan; Vaithilingam, Delani; Potter, Kate; Jamal/Pete Chan, Bilal; Mohamed, Muyed; Fraser, Debbie; Elhalawany, Ahmed; Beastall, James; Cousins, Gerard; Nunag, Perrico; Loveday, David; Bawa, Akshdeep; Gilmore, Rebecca; Schankat, Kerstin; Walls, Andrew; Corin, Nicole; Robinson, Peter; Hepple, Steve; Harries, William; Riddick, Andrew; Winson, Ian; Marsh, Luke; Bashir, Muhammad A; Saini, Jigyasa; Atkinson, Henry; Limaye, Rajiv; Johnson-Lynn, Sarah; Sethi, Mohit; Flanagan, George; Uddin, Akram; Reilly, Ian; Martin, Rebecca; Pujol-Nichol, Andrea; Carroll, Natalie; Boucher, Alexander; Alward, Mustafa; Myint, Yuland; Butler, Katherine; Kendal, Adrian; Bugeja, Mark; Mooteeram, Justin; Saedi, Farid; Koc, Togay; Morcos, Zeid; Robertson, Gregory; Holmes, Natal; Tribe, Howard; Pearkes, Tim; Soliman, Ahmed; Prasanna, Anil; Teoh, Kar; Kamat, Sanil; Bajracharya, Abhijit; Reeves, James; Ngwayi, Mbori; Imtiaz, Galal; Blackmore, Noah; Lau, Benjamin; Naik, Arjun; Tung, Eleanor; Murhekar, Siddhartha; Ray, Robbie; Lyle, Shirley; Makwana, Nilesh; Kaisi, Kahlan A; Al-Musabi, Musab; Dean, Mike; Hughes, Adrian; Shuttlewood, Kimberley; Welck, Matthew; Patel, Shelain; Sykes, Adam; Thibbaiah, Mahesh M; Hadi, Hosain; Haldar, Anil; Ardakani, Amir G; Jani, Priyanka; Kutuzov, Vladislav; Gibbons, James; Trussler, Daniel; Hawley, Eve; Akhtar, Sabeen; Rajgor, Harshadkumar D; Budair, Basil; Prem, Hari; Mckenzie, James; Thurston, Daniel; O'Sullivan, Michael; Elmajee, Mohammed; Pond, Erika; *Zahra, Wajiha; *Heaver, Catriona; Igbagiri, Kueni; Gaukroger, Andrew; Solan, Matthew; Peacock, Christian; Fan, Ka S; Barton, Tristan; Robinson, Derek; Graham, Selina; Zeolla, Julian; Everett, Samuel; Iqbal, Mohammad; Gourbault, Lysander; Singh, Shashwat; Tang, Cary; Tarhini, Mariam; Khan, Shahrukh; Balasubramanian, Satishkumar; Lever, Caroline; Bansod, Vaibhav; Iyengar, Kartik; Wadood, Abdul; McMillan, Lara; Toh, Eugene; Masunda, Stanley; Federer, Simon; Ahmad, Faheem; Lashin, Ahmed; Kaddah, Ahmed; Oladeji, Emmanuel; Dawe, Ed; Nolan, Ciaran; El-Bayouk, Khalil; Dhukaram, Vivek; Chapman, Anna; Beddard, Laura; Thomas, Alex; Garg, Vipul; Taylor, Heath; Kelsall, Nikki; Roslee, Charline; Akram, Nimra; Lowdon, Hamish; Kamel-Sherif, Ahmed; Jones, Anette; Best, Alistair; Zabaglo, Mate; Sayani, Junaid; Kyaw, Olive; Khin, Chan; Ali, Ramla; Shaik, Yousufuddin; Hossain, Natasha; Valente, Lucia; Ajis, Adam; Guha, Abhijit; Pereira, Melwyn; Ayoub, Atif; Paraoan, Vlad; Hali, Nayeem; Baird, Charles; Kugan, Raj; Abdallatif, Ahmad; Blomfield, Mark; Jackson, Gillian; Craven, James; Malhotra, Anubhav; Toner, Aileen; Render, Luke; Ashley, Connor; Limb, Richard; Smith, Robert; Hughes, Luke; Matthews, Hannah; Shiers-Gelalis, Fleur; Ting, Jason; Place, Stuart; Budgen, Adam; Stanley, James; Jowett, Charlie.

Citation:

Bone & Joint Journal. 106-B(11):1249-1256, 2024 Nov 01.

Abstract:
Aims: Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE. Methods: This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE. Results: A total of 13,569 patients were included from 68 sites. Overall, 11,363 patients were available for analysis: 44.79% were elective (n = 5,090), 42.16% were trauma excluding TA ruptures (n = 4,791), 3.50% were acute diabetic procedures (n = 398), 2.44% were TA ruptures undergoing surgery (n = 277), and 7.10% were TA ruptures treated nonoperatively (n = 807). In total, 11 chemical anticoagulants were recorded, with the most common agent being low-molecular-weight heparin (n = 6,303; 56.79%). A total of 32.71% received no chemical prophylaxis. There were 99 cases of VTE (incidence 0.87% (95% CI 0.71 to 1.06)). VTE-related mortality was 0.03% (95% CI 0.005 to 0.080). Univariable analysis showed that increased age and American Society of Anesthesiologists (ASA) grade had higher odds of VTE, as did having previous cancer, stroke, or history of VTE. On multivariable analysis, the strongest predictors for VTE were the type of foot and ankle procedure and ASA grade. Conclusion: The 90-day incidence of symptomatic VTE and mortality related to VTE is low in foot and ankle surgery and TA management. There was notable variability in the chemical prophylaxis used. The significant risk factors associated with 90-day symptomatic VTE were TA rupture and high ASA grade.

Enhancing Junior Doctors' Preparedness and Satisfaction in Trauma and Orthopaedics: A Quality Improvement Project With the Development of a Comprehensive Guidebook (2024)

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Type of publication:

Journal article

Author(s):

Mohammed, Ghulam Dastagir Faisal; *Younis, Zubair; Amin, Jebran; Mansoor, Zaina; Lingnau, Leonie; Jesudason, Edwin P.

Citation:

Cureus. 16(9):e70061, 2024 Sep.

Abstract:

BACKGROUND: Junior doctors often feel underprepared for their trauma and orthopaedics (T&O) rotation due to limited exposure during medical school and inadequate support. This project aimed to enhance junior doctors' preparedness and satisfaction during their T&O rotation by developing a comprehensive guidebook that addresses key orthopaedic knowledge and logistical challenges. METHODS: A quality improvement project (QIP) was conducted at Ysbyty Gwynedd Hospital. Initial surveys identified factors contributing to poor experiences during the trauma and orthopaedics rotation, including limited knowledge of orthopaedic emergencies and a lack of useful reference resources. A guidebook was developed and refined through multiple plan-do-study-act (PDSA) cycles. The guidebook covered topics such as orthopaedic emergencies, common injuries, referral pathways, and hospital logistics, presented in an accessible flowchart format. RESULTS: The primary objective of achieving 75% satisfaction among junior doctors was successfully met, with satisfaction increasing from four (40%) to eight (80%) doctors in the most recent survey. Secondary outcomes included a marked improvement in the understanding of quality improvement projects, rising from three (30%) to eight (80%) doctors. Orthopaedic knowledge also saw a significant enhancement, increasing from four (40%) to nine (90%) doctors. Confidence in handling night on-call duties improved dramatically, with all 10 doctors (100%) reporting increased confidence, compared to four (40%) doctors initially. Additionally, seven doctors (70%) expressed a greater interest in pursuing a career in orthopaedic surgery. CONCLUSION: The comprehensive guidebook significantly improved junior doctors' preparedness and satisfaction during their T&O rotation. While the guidebook is a valuable resource, ongoing mentorship and hands-on experience remain essential for long-term success. Replication of this project across other departments and hospitals is recommended to assess its broader applicability and impact.

Link to full-text [open access - no password required]

A literature review assessing the perioperative efficacy and safety of tranexamic acid in elective total hip and knee arthroplasty in UK practice (2024)

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Type of publication:

Journal article

Author(s):

*Patel R.; Golding S.; Nandra R.; Banerjee R.;

Citation:

Journal of perioperative practice. (pp 17504589241278478), 2024. Date of Publication: 20 Sep 2024 [epub ahead of print]

Abstract:

Hip and knee arthroplasty are frequently associated with significant blood loss, often necessitating blood transfusions. A variety of methods are employed to minimise blood loss and consequently mitigate the necessity for transfusions. This review explores the incidence of blood loss in hip and knee arthroplasty alongside perioperative strategies aimed at its reduction in UK practice. Given the increasing prevalence of tranexamic acid utilisation, we systematically examine the extant literature concerning its application in patients undergoing hip and knee arthroplasty. Our analysis discerns a prevailing consensus within published studies favouring the implementation of tranexamic acid as a safe and efficacious measure for reducing blood loss during hip and knee arthroplasty procedures.

Does tranexamic acid really matter in reducing blood loss? A critical evaluation of its efficacy in orthognathic surgery through a comprehensive systematic review and meta-analysis (2024)

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Type of publication:

Systematic Review

Author(s):

Mortada H.; Hussain S.A.; Liyanage D.D.; Zou Y.; Subbiah P.; *George J.; Mansour H.R.K.; Khajuria A.

Citation:

British Journal of Oral and Maxillofacial Surgery. (no pagination), 2024. Date of Publication: 2024. [epub ahead of print]

Abstract:

Tranexamic acid (TXA) is acknowledged for reducing blood loss and transfusion requirements in various surgical specialties, yet its role in orthognathic procedures is less defined. Our study seeks to fill this knowledge gap by reviewing the available data and summarising the efficacy and clinical outcomes of TXA in orthognathic surgery. We performed a systematic review and meta-analysis, searching five databases for studies until 16 April, 2023. Our key outcome measures were intraoperative blood loss, postoperative bleeding, and transfusion rate. Previous weaknesses in systematic review and meta-analyses (SRMA) were identified using Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2). The risk of bias was evaluated with the RoB-2 tool. A total of 15 studies were included, involving a combined total of 1060 patients. Compared with the control, the TXA group demonstrated significant reductions in intraoperative blood loss (mean difference -135.60 mL; p < 0.00001; 95% CI, -177.51 to -93.70 mL), Hb level drop (mean difference: 2.67 [-0.63, 5.98]), and improved surgical field visibility [p < 0.00001. (MD -0.99) (CI -1.11 to -0.86)]. No significant differences were observed in postoperative haematocrit levels (mean difference: -0.42 [-2.19, 1.35]; p = 0.003; I<sup>2</sup> = 75%), operation duration (p = 0.21), or duration of hospital stay (p = 0.63) between TXA and control groups. In orthognathic surgery, TXA effectively minimises blood loss, demonstrating both safety and efficiency. Well-designed, larger studies and comparisons with other haemostatic agents could solidify TXA evidence.

Lateral femoral wall thickness in trochanteric hip fractures: a systematic review (2024)

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Type of publication:
Systematic Review

Author(s):
*Selim, Amr; Ponugoti, Nikhil; Daoub, Ahmed; Johnson-Lynn, Sarah; *Rhee, Shin Jae.

Citation:
Hip International. 2024 Aug 26.[epub ahead of print]

Abstract:
BACKGROUND: Thin lateral femoral wall has been investigated as a sign of instability in trochanteric hip fractures, necessitating lateral wall reconstruction or the use of a cephalomedullary nail (CMN). Various cut-off values have been proposed to guide implant choice. This review aims to determine the clinical significance of the lateral femoral wall thickness (LWT) in trochanteric hip fractures and identify an optimal cut-off value for increased risk of lateral wall (LW) fracture when using Dynamic Hip Screw (DHS). METHODS: A comprehensive search was conducted in databases including Medline, Embase, and the Cochrane library up to July 2023. A predefined strategy was employed, with 5 eligible studies critically appraised using the methodological index for non-randomized studies (MINORS) criteria. Outcomes assessed encompassed the standardised mean difference (SMD) of LWT between the LW fracture and non LW fracture groups, aggregate LWT mean in LW fracture group, and the relation between AO/OTA fracture type with LW fracture utilising the chi-square test. RESULTS: Among 481 patients from 5 studies, 112 experienced LW fractures, while 369 did not postoperatively. Analysis indicated a significantly lower LWT in the LW fracture group (SMD -1.13, I2 = 41.3%, p = 0.146). The mean LWT in the LW fracture group was 18.2 mm, with a 95% confidence interval of 17.29-19.10 mm. CONCLUSIONS: A preoperative thin lateral femoral wall is a critical predictor of fixation failure and suboptimal functional outcomes when using a DHS. Thorough evaluation of pre- and intraoperative x-rays is essential. CMN is recommended over DHS in cases with LWT measurements <19 mm.

Identification and optimisation of perioperative factors for patients with von Willebrand disease undergoing elective total hip and knee (2024)

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Type of publication:
Journal article

Author(s):
*Patel, Ravi; Golding, Steven; Nandra, Rajpal; Banerjee, Robin

Citation:
Journal of Perioperative Practice. 2024 Aug 12. [epub ahead of print]

Abstract:
Von Willebrand disease stands as the most prevalent bleeding disorder seen in both medical and surgical practice. Due to recurrent bleeding episodes within the joints, many patients endure arthropathy, leading to substantial pain and restricted function. Total joint arthroplasty emerges as a final option for managing such cases. Nevertheless, the existence of von Willebrand disease presents several challenges in this regard. This review aims to explore the perioperative strategies tailored for patients with von Willebrand disease undergoing elective total joint arthroplasty.

The option of transosseous distal suture placement during minimally invasive Achilles tendon repair for high-risk patients can improve outcomes, however does not prevent re-rupture (2024)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Nilsson-Helander, Katarina; Carling, Malin.

Citation:
BMC Musculoskeletal Disorders. 25(1):610, 2024 Aug 01.

Abstract:
PURPOSE: Achilles tendon ruptures (ATRs) close to the insertion, in high-level athletes, and in patients at high risk of re-rupture, may be better suited to operative repair. Minimally Invasive Repair (MIR) of the Achilles tendon has excellent outcome and low complication rates. Traditionally MIR has showed lower repair strength, failing due to suture pull-out from the distal tendon stump. The aim of this study was to describe the outcome of ATR patients who received transosseous distal suture placement using a standard technique as a reference. METHODS: Following ATR, patients were evaluated for pre-injury activity level, body weight, location of the tear and size of the distal Achilles tendon stump. Patients considered to be at high-risk of re-rupture: Tegner level >= 8, body weight >= 105Kg and distal ATR, received transosseous (TO) distal suture placement (n = 20) rather than the usual transtendinous (TT) technique (n = 55). Patient reported outcome measures and functional evaluation was performed at 12 months following repair. RESULTS: At 12 months follow up both methods resulted in good median (IQR) Achilles tendon Total Rupture Score TO 83.8 (74-88.3) vs. TT 90 (79-94), low increased relative Achilles Tendon Resting Angle TO -3.5 (3.6) vs. TT -3.5 (3.3) and mean (SD) Single leg Heel-Rise Height Index TO 88.2% (9.9) vs. TT 85.6% (9.9) (n.s.). There were 4 re-ruptures in the high-risk group and 2 in the group receiving TT distal suture placement. All but one of these were traumatic in nature. The mode of failure following TO distal suture placement was proximal suture pull out. CONCLUSIONS: To distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients can lead to results equivalent to those in lower-risk patients treated with a standard TT MIR technique, except for the re-rupture rate which remained higher. There may be factors that have greater influence on outcome other than suture placement following ATR.

Link to full-text [open access - no password required]

Dedicated anticoagulation management protocols in fragility femoral fracture care - a source of significant variance and limited effectiveness in improving time to surgery: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

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Type of publication:
Journal article

Author(s):
Farhan-Alanie M.M.; Dixon J.; Irvine S.; Walker R.; Eardley W.G.P.; Smith M.; Yoong A.; Lim J.W.; Yousef O.; McDonald S.; Chileshe C.; Ramus C.; Clements C.; Barrett L.; Rockall O.; Geetala R.; Islam S.U.; Nasar A.; Almond K.; Hassan L.F.Y.; Brand R.B.; Yawar B.; Gilmore C.; McAuley D.; Khan W.; Subramanian P.; Ahluwalia A.; Ozbek L.; Awasthi P.; Sheikh H.; Barkley S.; Ardolino T.; Denning A.; Thiruchandran G.; Fraig H.; Salim O.; Iqbal R.; Guy S.; Hogg J.; Bagshaw O.; Asmar S.; Mitchell S.; Quek F.; Fletcher J.; French J.; Graham S.; Sloper P.; Sadique H.; Matera V.; Sohail Z.; Leong J.W.; Issa F.; Greasley L.; Marsden S.; Parry L.; Mannan S.; Zaheen H.; Moriarty P.; Manning W.; Morris T.; Brockbanks C.; Ward P.; Pearce K.; McMenemy L.; Mahmoud M.; Kieffer W.; Lal A.; Collis J.; Chandrasekaran K.; Foxall-Smith M.; Raad M.; Kempshall P.; Cheuk J.; Leckey S.; Gupta R.; Engelke D.; Kemp M.; Venkatesan A.; Hussain A.; Simons M.; Raghavendra R.M.; Rohra S.; Deo S.; Vasarhelyi F.; Thelwall C.; Cullen K.; Al-Obaidi B.; Fell A.; Thaumeen A.; Dadabhoy M.; Ali M.; Ijaz S.; Lin D.; Khan B.; Alsonbaty M.; Lebe M.; Millan R.K.; Imam S.; Theobald E.; Cormack J.; Sharoff L.; Eardley W.; Jeyapalan R.; Alcock L.; Clayton J.; Bates N.; Mahmoud Y.; Osborne A.; Ralhan S.; Carpenter C.; Ahmad M.; Ravi S.M.; Konbaz T.; Lloyd T.; Sheikh N.; Swealem A.; Soroya E.; Rayan F.; Ward T.; Vasireddy A.; Clarke E.; Sikdar O.; Smart Y.W.; Windley J.; Ilagan B.; Brophy E.; Joseph S.; Lowery K.; Jamjoom A.; Ismayl G.; Aujla R.; Sambhwani S.; Ramasamy A.; Khalaf A.; Ponugoti N.; Teng W.H.; Masud S.; Otoibhili E.; Clarkson M.; Nafea M.; Sarhan M.; Hanna S.; Kelly A.; Curtis A.; Gourbault L.; Tarhini M.; Platt N.; Fleming T.; Pemmaraju G.; Choudri M.J.; Burahee A.; Hassan L.; Hamid L.; Loveday D.; Edres K.; Schankat K.; Granger L.; Goodbun M.; Parikh S.; Johnson-Lynn S.; Griffiths A.; Rai A.; Chandler H.; Guiot L.; Appleyard T.; Robinson K.; Fong A.; Watts A.; Stedman T.; Walton V.; Inman D.; Liaw F.; Hadfield J.; McGovern J.; Baldock T.; White J.; Seah M.; Jacob N.; Ali Z.H.; Goff T.; Sanalla A.; Gomati A.; Nordin L.; Hassan E.; Ramadan O.; Teoh K.H.; Baskaran D.; Ngwayi J.; Abbakr L.; Blackmore N.; Mansukhani S.; Guryel E.; Harper A.; Cashman E.; Brooker J.; Pack L.; Regan N.; *Wagner W.; *Selim A.; *Archer D.; *McConaghie G.; *Patel R.; *Gibson W.; Pasapula C.S.; Youssef H.; Aziz M.A.; Subhash S.; Banaszkiewicz P.; Elzawahry A.; Neo C.; Wei N.; Bhaskaran A.; Sharma A.; Factor D.; Shahin F.; Shields D.; Ferreira C.D.F.; Jeyakumar G.; Liao Q.; Sinnerton R.; Ashwood N.; Sarhan I.; Ker A.; Phelan S.; Paxton J.; McAuley J.; Moulton L.; Mohamed A.; Dias A.; Ho B.; Francis D.; Miller S.; Phillips J.; Jones R.; Arthur C.; Oag E.; Thutoetsile K.; Bell K.; Milne K.; Whitefield R.; Patel K.; Singh A.; Morris G.; Parkinson D.; Patil A.; Hamid H.; Syam K.; *Singh R.; *Menon D.; *Crooks S.; Borland S.; Rohman A.; Nicholson A.; Smith B.; Hafiz N.; Kolhe S.; Waites M.; Piper D.; Westacott D.; Grimshaw J.; Bott A.; Berry A.; Battle J.; Flannery O.; Iyengar K.P.; Thakur A.W.; Yousef M.; Bansod V.; El-nahas W.; Dawe E.; Oladeji E.; Federer S.; Trompeter A.; Pritchard A.; Shurovi B.; Jordan C.; Little M.; Sivaloganathan S.; Shaunak S.; Watters H.; Luck J.; Zbaeda M.; Frasquet-Garcia A.; Warner C.; Telford J.; Rooney J.; Attwood J.; Wilson F.; Panagiotopoulos A.; Keane C.; Scott H.; Mazel R.; Maggs J.; Skinner E.; McMunn F.; Lau J.; Ravikumar K.; Thakker D.; Gill M.; McCarthy P.; Fossey G.; Shah S.; McAlinden G.; McGoldrick P.; O'Brien S.; Patil S.; Millington A.; Umar H.; Sehdev S.; Dyer-Hill T.; Yu Kwan T.; Tanagho A.; Hagnasir A.; White T.; Bano C.; Kissin E.; Ghani R.; Thomas P.S.W.; McMullan M.; Walmsley M.; Elgendy M.; Winstanley R.; Round J.; Baxter M.; Thompson E.; Hogan K.; Youssef K.; Fetouh S.; Hopper G.P.; Simpson C.; Warren C.; Waugh D.; Nair G.; Ballantyne A.; Blacklock C.; O'Connell C.; Toland G.; McIntyre J.; Ross L.; Badge R.; Loganathan D.; Turner I.; Ball M.; Maqsood S.; Deierl K.; Beer A.; Tan A.C.W.; Mackinnon T.; Gade V.; Gill J.; Yu San K.; Archunan M.W.; Shaikh M.; Ugbah O.; Uwaoma S.; Pillai A.; Nath U.; Rohan

Citation:
Injury. 55(8) (no pagination), 2024. Article Number: 111686. Date of Publication: August 2024. [epub ahead of print]

Abstract:
Introduction: Approximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery. Method(s): Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged >=60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery. Result(s): Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54-0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75-3.57, p=0.219). Conclusion(s): Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.

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