Trauma and orthopaedics

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.

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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.

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.

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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 (2024)

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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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A Systematic Review and Meta-Analysis of the Outcomes of Reconstruction with Vascularised vs Non-Vascularised Bone Graft after Surgical Resection of Primary Malignant and Non-Malignant Bone Tumors (2024)

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Type of publication:
Systematic Review

Author(s):
*Patel, R; McConaghie, G; Khan, M M; Gibson, W; Singh, R; Banerjee, R.

Citation:
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca. 91(3):143-150, 2024.

Abstract:
PURPOSE OF THE STUDY: Vascularised bone grafting (VBG) and non-vascularised bone grafting (NVBG) are crucial biological reconstructive procedures extensively employed in the management of bone tumours. The principal aim of this study is to conduct a comparative analysis of the post-resection outcomes associated with the utilisation of vascularised and non-vascularised bone grafts. MATERIAL AND METHODS: A comprehensive and systematic literature review spanning the years 2013 to 2023 was meticulously executed, utilising prominent online databases including PubMed/Medline, Google Scholar, and Cochrane Library. Inclusion criteria were restricted to comparative articles that specifically addressed outcomes pertaining to defect restoration following bone tumour resection via vascularised and non-vascularised bone grafting techniques. The quality of research methodologies was assessed using the Oxford Quality Scoring System for randomised trials and the Newcastle Ottawa Scale for non-randomised comparative studies. Data analysis was conducted using SPSS version 24. Key outcome measures encompassed the Musculoskeletal Tumour Society Score (MSTS), bone union duration, and the incidence of post-operative complications. RESULTS: This analysis incorporated four clinical publications, enrolling a total of 178 participants (comprising 92 males and 86 females), with 90 patients subjected to VBG and 88 to NVBG procedures. The primary endpoints of interest encompassed MSTS scores and bone union durations. Although no statistically significant distinction was observed in the complication rates between the two cohorts, it is noteworthy that VBG exhibited a markedly superior bone union rate (P<0.001). CONCLUSIONS: Our systematic evaluation revealed that VBG facilitates expedited bone union, thereby contributing to accelerated patient recovery. Notably, complication rates and functional outcomes were comparable between the VBG and NVBG groups. Moreover, the correlation between bone union duration and functional scores following VBG and NVBG merits further investigation.

A Systemic Review of Primary Malignant Long Bone Tumors in Children and Adolescents (2024)

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Type of publication:
Systematic Review

Author(s):
Khan, M; *Patel, R; *Youssef, M; Banerjee, R; Pardiwala, A; Belen, C.

Citation:
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca. 91(2):77-87, 2024.

Abstract:
PURPOSE OF THE STUDY: Managing bone tumours is complex, relying on limited evidence, expert opinions, and retrospective reviews. Multidisciplinary approaches and early diagnosis are crucial for better outcomes, especially in young patients with growing skeletons. The aim of this systemic review and meta-analysis is to give a comprehensive review of common malignant tumors affecting long bones in children and adolescents. MATERIAL AND METHODS: A PubMed/Medline search for "primary malignant long bone tumours in children" initially retrieved 1120 papers, which were subsequently narrowed down to 110 articles based on inclusion and exclusion criteria. These articles were reviewed, focusing on clinical presentation, diagnostic workup, treatment options, surgical planning, and variations in presentation, including rare tumours. The two most commonly reported tumours were osteosarcoma and Ewing sarcoma, leading to the division of studies into five groups. The inclusion criteria encompassed malignancies in patients aged 2-25 years, work-up, imaging, surgical treatment, rare tumour case reports, and surgical management principles, resulting in a heterogeneous group of articles. To enhance categorisation, it was clarified that studies with 10 or more cases were considered retrospective reviews. RESULTS: Reviewing of results thus demonstrate that the two likely tumours in children under consideration were osteosarcoma and Ewing sarcoma. Their presentation findings and clinical features were discussed in detail in the review. It is worth noting here that in case of differential diagnosis this should be the first on the list. DISCUSSION AND CONCLUSIONS: Although focus of literature is more on the two most common tumours. However, rare tumours should be considered as they can mimic these common tumors.

Viscosupplementation with High Molecular Weight Hyaluronic Acid for Hip Osteoarthritis: a Systematic Review and Meta-Analysis of Randomised Control Trials of the Efficacy on Pain, Functional Disability, and the Occurrence of Adverse Events (2024)

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Type of publication:
Systematic Review

Author(s):
*Patel, R; Orfanos, G; Gibson, W; Banks, T; McConaghie, G; Banerjee, R.

Citation:
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca. 91(2):109-119, 2024.

Abstract:
PURPOSE OF THE STUDY: Hip osteoarthritis (OA) has a prevalence of around 6.4% and is the second most commonly affected joint. This review aims to assess the clinical outcomes of intra-articular high molecular weight hyaluronic acid (HMWHA) in the management of hip osteoarthritis. MATERIAL AND METHODS: We conducted a comprehensive search across PubMed, Google Scholar, and the Cochrane Library for randomised trials investigating the effectiveness of high molecular weight hyaluronic acid (HMWHA) in the treatment of hip osteoarthritis. Quality and risk of bias assessments were performed using the Cochrane RoB2 tool. To synthesise the data, we utilised the Standardised Mean Difference (SMD) for assessing pain relief through the Visual Analogue Scale (VAS) and the Lequesne index (LI) for evaluating functional outcomes. Risk Ratio (RR) was calculated to assess the occurrence of complications. RESULTS: A total of four studies involving HMWHA and control groups were included. The standardised mean difference (SMD) for the Visual Analogue Scale (VAS) (SMD -0.056; 95% CI; -0.351, 0.239; p = 0.709) and the Lequesne index (SMD -0.114; 95% CI; -0.524, 0.296; p = 0.585) were not statistically significant. Analysis for complications demonstrated an overall relative risk ratio (RR) of 0.879 (95% CI; 0.527, 1.466; p = 0.622), and was not statistically significant. DISCUSSION AND CONCLUSIONS: Intra-articular HMWHA in hip OA can significantly reduce pain and improve functional recovery when compared with the condition before treatment. However, there is no significant difference between HMWHA, or saline, or other therapeutic treatments. Currently, available evidence indicates that intra-articular HMWHA in hip OA would not increase the risk of adverse events.

Comparison of the Latarjet Procedure With the Modified Putti-Platt Surgery for Recurrent Anterior Shoulder Dislocation With Respect to Functional Outcome (2024)

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Type of publication:
Journal article

Author(s):
Anjum, Ihtisham; Ullah, Ubaid; *Fazli Maula, Aimen; Haroon, Hamza; Ahmad, Yaseen; Hassan, Rao E; Shahid, Kashan; Hussain, Saddam; Haider, Waseem; Ullah, Rizwan

Citation:
Cureus. 16(3):e57270, 2024 Mar.

Abstract:
Introduction Shoulder dislocation is the most common injury encountered in orthopedic outpatient department. The choice of procedure depends on the expertise of surgeons. The objective of this study was to compare the Latarjet procedure with the modified Putti-Platt surgery for recurrent anterior shoulder dislocation in terms of functional outcomes. Materials and methods A quasi-experimental study evaluated 60 patients with recurrent anterior shoulder instability. Patients were assigned to either Latarjet or modified Putti-Platt surgery. Functional outcomes were assessed at six months using the Constant-Murley shoulder score. Results This study encompassed 60 patients (mean age: 23.93+/-5.88 years) undergoing shoulder procedures. Functional outcomes exhibited a majority of 55% excellent, 35% good, 6.7% fair, and 3.3% poor outcomes. No significant differences in functional outcomes were found between the procedures. Conclusion Both procedures may be viable options for recurrent shoulder instability. The choice may depend on patient factors and surgeon preference. Further research is needed to refine techniques and identify ideal candidates.

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