TORC 2024 Abstracts
Registrar Podium Abstracts
An audit investigating time to MRI and report for patients with suspected Cauda Equina Syndrome
James Paxton, Nathan Campbell, Bryn Jones
Introduction/Background: Cauda equina syndrome (CES) is a time sensitive spinal surgical emergency requiring prompt investigation and management. Delayed diagnosis and treatment can result in severe lifelong disability. As a result, GIRFT published a pathway for investigating suspected CES presentations with scans being completed within 4 hours of request in and out of hours and reports being available within 1 hour later.
Aims: Compare the time taken from scan request to MRI completion and the time taken to publish a report to the standards set by the GIRFT National Suspected CES pathway at the Glasgow Royal Infirmary over a two month period.
Methods: Retrospective collection of time to scan and report for all MRI requests investigating CES at the Glasgow Royal Infirmary between August and September 2023
Results: A total of 68 scans were performed, 17 were requested in hours and 51 requested out of hours. There were 3 MRI scans with radiographic evidence of CES. The average time from request to scan in hours was 2.1 +/- 1.5 hours and the average time out of hours was 23.8 +/- 16.2 hours. The average time from scan to report was 2.5 +/- 1.2 hours. The fastest scan was completed 0.43 hours after request and the fasted report was 0.73 hours. The fasted time from request to report was 1.93 hours.
Discussion/Conclusion: Most suspected CES patients waited longer than the 4 hour target for the completion of an MRI after request. The majority of in hour requests were completed in this time but most out of hour scans were not. Most MRI reports were issued after the target time of 1 hour after the scan. This delay may result in worse outcomes for patients with CES.
Predictors of Rotational Failure in Paediatric Supracondylar Humeral Fractures
W. T. Gardner, P. Davies, D. Campbell, M. Reidy
Background: Lateral-entry wiring (LEW) for displaced supracondylar humeral fractures (SHFs) has been popularised internationally.
Aims: BOAST guidance suggests either LEW or crossed wires; the latter has reported lower risk of loss of fracture reduction –we explore technical reasons why.
Methods: We reviewed 8 years of displaced SHFs in two regional centres. Injuries were grouped using the Gartland Classification, with posterolateral or posteromedial displacement assessment for Gartland 3 injuries. We identified any loss of fracture reduction, and reviewed intra-operative imaging to identify learning points that may contribute to early rotational displacement (ERD).
Results: 345 SHFs were included, between 2012 and 2020. Gartland 2 (n=117) injuries had a 3.42% risk. ERD. Gartland 3 crossed wirings (n=114) had a 6.14% risk of ERD, with those moving all being posterolaterally displaced. Gartland 3, posterolaterally displaced LEW (n=56) had a 35.7% risk of ERD. Gartland 3, posteromedially displaced LEW (n=58) had a 22.4% risk of ERD. All injuries with ERD except 3 had identifiable learning points, the commonest being non-divergence of wires, or wires not passing through both fracture fragments.
Conclusion: LEW requires divergent spread and bicolumnar fixation. Achieving a solid construct through this method appears more challenging than crossed wiring, with rates of ERD 3-5x higher. Low-volume surgeons should adhere to BOAST guidelines and choose a wiring construct that works best in their hands. They can also be reassured that should a loss of position occur, the risk of requirement for revision surgery is extremely low in our study (0.3%), and it is unlikely to affect long term outcomes.
Development of a dedicated paediatric clinic for removal of k-wires
E Tong, D Yadav, E Lindsay, C Donoghue, D Campbell
Background: Removal of K-wires from paediatric patients has traditionally been performed in a general Fracture Clinic, alongside adult patients, causing significant and preventable distress and anxiety to patients and their parents/carers. We therefore devised a dedicated k-wire removal clinic with an aim of improving the quality of care and service we provide our younger patients.
Method: The orthopaedic team liaised with the plaster room, the paediatric, and anaesthetic teams to develop a dedicated K-wire removal clinic in the Children’s Ward. A patient information leaflet was developed for patients and parents/carers and provided at the time of the appointment. A Patient Satisfaction Survey was developed and used to monitor patient/parent/carers feedback of the service. Regular meetings were held within the orthopaedic department on how to improve the service.
Results: Our results have been presented internationally and other departments have been keen to develop similar pathways. The clinic was established in 2022 and to date, 64 patients have attended the clinic. The average age of our patients was 8.4 years. 2 patients had to return the following day for a general anaesthetic (3%). Our clinic therefore has a 97% success rate alongside incredibly positive feedback from patients and their carers.
Discussion: The development of a dedicated K-wire removal clinic has proven to be a welcome improvement in paediatric patient care with multiple benefits including a reduction in risk to patients, an improved patient experience and realistic/informed expectations of their parents and carers.
Improving the Upload Rate of Operation Notes to Electronic Patient Records
Haroon Minhas, T. Sam Greensmith, Tom Harding, Stephen Dalgleish
Introduction: Operation notes are contemporaneous documentation of procedures performed on patients in theatre and are essential for the continuation of care.
Aims: This quality improvement project aims to improve the upload rate of operation notes to electronic patient records.
Methods: This Quality Improvement project uses the PDSA (Plan Do Study Act) cycle method. The primary outcome is improvement of upload rate of operation notes. Firstly, all procedures performed in Orthopaedic trauma theatre over a selected time period were identified from daily trauma lists, then searched on Clinical Portal (electronic patient record) for an operation note. The electronic discharge document was used to verify if a procedure was performed. All patients that underwent a procedure in theatre were included. The first intervention was an email sent to all registrars to reinforce sending operation notes to consultants’ secretaries for upload. The second cycle reviewed a further two-week period following this intervention. The third cycle reviewed a further four-week period after introduction of self-upload of operation notes to electronic patient records from the EKORA system (electronic patient notes).
Results: The first cycle identified 100 procedures between 20/07/20 to 02/08/20, with a 42% upload rate of operation notes. The second cycle between 10/08/20 to 23/08/20, identified 87 procedures and showed an improvement to 83% upload rate. The third cycle between 01/09/24 to 30/09/24 identified 202 procedures, showed an improvement to 96% upload rate.
Conclusion: There has been an improvement between the first, second and third cycle in the upload rate operation notes to clinical portal. This has shown since the implementation of EKORA self-uploading to Clinical Portal, there has been an improved rate of surgeons providing a contemporaneous record of surgery, however, there is still room for improvement. The next intervention will involve reminding all surgeons to upload operation notes to EKORA.
Is MRI Reporting on Spinal Stability after Thoracolumbar Spinal Trauma Adequately Informative?
Ryad Khatib, Eilidh Edminston, Himanshu Shekar
Introduction: The posterior ligamentous complex (PLC) plays a fundamental role in spinal stability, and has four components: facet joint capsule, interspinous ligament, ligamentum flavum, and supraspinous ligament (1). PLC injuries are frequently overlooked, with MRI being the optimal imaging modality for assessment of PLC injury (2). As per the TLICS classification system, PLC integrity is key in assessing fracture instability following trauma, and in decision making for surgical management (3). Thus, precise MRI reporting is required for optimising patient care and outcomes.
Aims: This audit aimed to evaluate current MRI reporting practices on PLC integrity in thoracolumbar trauma within NHS Tayside (NHST).
Methodology: A retrospective assessment was conducted of patients admitted to NHST with thoracic or lumbar spinal trauma between 01/01/2022 and 31/3/2023. Ethical approval was gained. Data was requested from Scottish Trauma Audit Group and deduplicated. Electronic patient records were accessed for patients where NHST was the receiving trauma centre. MRI reports were screened for specific comments on injury to the PLC or its constituents.
Results: 131 patients were admitted to NHST with a thoracic or lumbar spinal injury identified on CT. Of those, 51 patients underwent MRI for evaluation of spinal trauma. 29.4% (n=15) MRI reports specifically commented on the integrity of the PLC or its constituents. The remaining 70.6% (n=36) of reports provided no or unclear comments.
Conclusion: The majority of MRI scans reported in NHST for thoracolumbar spinal trauma did not specifically comment on PLC integrity, despite this being essential to assessing spinal stability and deciding on surgical management. More research is required to assess the impact on patient care and appropriate use of resources. We suggest an intervention, such as a checklist, to standardise and improve the quality of MRI reporting.
A Review of Patients aged 50 years of younger undergoing Knee Arthroplasty: Epidemiology and survivorship
S.R. Morrison, P. Walmsley
Background: The number of total knee replacements (TKR) carried out in the UK increases year on year. Growing evidence exists regarding excellent implant survival in patients aged over 50, but there is a lack of large-scale data regarding survivorship in patients under 50. This data is important to guide surgical decision making, and for patient information.
Aims: Review national data on patients aged 16 – 50 undergoing TKR to assess implant survivorship and to gauge lifetime revision risk.
Methods: Retrospective review of prospectively collected data from the Scottish Arthroplasty Project (SAP) database. Data were collected directly from the database, and those aged 50 years or younger at time of knee arthroplasty were included. These patients were compared to a matched group of patients aged greater than 50 years for comparison. Data were analysed using SPSS.
Results: 3747 patients aged 16 – 50 underwent primary TKR between January 2000 and December 2019. 58.6% of patients were female, and mean age was 45 years. Follow-up period concluded in September 2022, with a mean 10.4 year follow-up. 3042 procedures were for osteoarthritis, and 705 for other cause. 321 cases required revision (92% for aseptic loosening, 8% for infection). Mean time to revision was 64.9 months. Average age at primary of those undergoing revision was 45.9 years with a median of 47 years. In comparison, the patient cohort aged over 50 (116641 patients) had an all-cause revision rate of 3.2%.
Discussion: Survivorship of knee arthroplasties in younger patients remains good at long-term follow-up, with less than 10% risk of all-cause revision at mean 10.4 year follow-up. This is, however, significantly greater than the revision risk for those aged greater than 50. Lifetime risk of revision remains high for younger patients. Consideration should be given to reviewing this patient cohort with regard to PROMs to better highlight the benefits of this intervention.
A second stage audit of the weight bearing status of trauma admissions in NHS Tayside, after implementation of new Standards for documentation
T. Dale MacLaine, L. Garrigan, C. Grierson, J. Paxton, H. Do Lee, S. Dalgleish, J. Littlechild
Introduction: Mobilisation following orthopaedic injury is critical for rehabilitation. Terms such as "partial weight-bearing" or "toe-touch weight-bearing" are frequently used but have variable operational definitions across the multi-disciplinary team, potentially resulting in suboptimal patient care. In August 2024, new British Orthopaedic Association’s Standards for Trauma and Orthopaedics (BOAST) guidelines for terminology on permitted mobilisation following orthopaedic injury were released. These standards introduced clear and precise terminology to remove any ambiguity surrounding weight-bearing instructions. This audit evaluates the consistency of weight-bearing documentation in acute orthopaedic admissions before and after the implementation of the latest BOAST standards at our hospital.
Aim: The aim was to assess whether implementation of these standards led to an improvement in documentation practices.
Methods: Using etrauma, the hospital’s electronic handover system, lists of operative and non-operative patients were generated for July 2024 (pre-BOAST) and August-September 2024 (post-BOAST). Patients’ electronic records were reviewed to assess compliance with BOAST standards. Mann Whitney U tests assessed statistical significance. Additionally, local physiotherapists were surveyed regarding the acceptability of terminology.
Results: There were 227 operative and 41 non-operative patients in July, and 383 operative and 88 non-operative patients in August-September. There was no statistical difference in number of acceptable weight-bearing instructions for both operative patients between July and August-September (58% and 50% respectively, P=0.13) and non-operative patients (37% and 30% respectively, P=0.50). There was no difference in the number of patients with any weight-bearing status documentation between July and August-September for operative patients (71% and 68% respectively, P=0.50) and non-operative patients (63% and 71% respectively, P=0.37).
Conclusion: With no improvement in practice following guideline implementation, alternative interventions are essential. Variability in documentation suggests that established habits and lack of awareness may hinder compliance. Next steps include collaboration with the wider multidisciplinary team to determine locally accepted operational definitions and re-audit following educational interventions.
Unicompartmental Knee Arthroplasty versus Total Knee Arthroplasty - 10 year follow-up and revision data
E Lindsay, JW Lim, G Cousins, D Ridley, B Clift
Background: Unicompartmental knee osteoarthritis can be treated with either Total Knee Arthroplasty (TKA) or Unicompartmental Knee Arthroplasty (UKA) and controversy remains as to which treatment is best. UKA has been reported to offer a variety of advantages but many still see it as a temporary procedure with higher revision rates.
Aims: We aimed to clarify the role of UKA and evaluate the long-term outcomes and revision rates. We retrospectively reviewed the pain, function and total Knee Society Score (KSS) for 602 UKA and 602 TKA in age and gender matched patients.
Method: The total pre-operative KSS scores were not significantly different between UKA and TKA (42.67 Vs 40.54 P=0.021). KSS (pain) was significantly better in the TKA group (44.39 Vs 41.38 P= 0.007) at one year and at five years post-operatively (45.33 Vs 43.12 P=0.004). Performance for UKAs was inferior to TKAs in Kaplan-Meier cumulative survival analysis at 10 years (88.7% Vs 94.6% P<0.001). Over ten years, a total of 115 patients required revision surgery. 79 (13%) patients had a UKA as their primary operation and 36 (6%) had a TKA revision. The main cause for revision surgery in UKA was aseptic loosening (n=34; 43%), followed by osteoarthritis of the contra-lateral compartment (n=16; 20%). TKAs were commonly revised as the result of technical error (11%). Despite the higher revision rate, pre-operative KSS (total) before revision was not significantly different between UKA and TKA (42.94 Vs 42.43 P=0.84).
Discussion: Both UKA and TKA are effective treatment options for unicompartmental knee osteoarthritis, each with their own merits. UKA is associated with fewer complications whereas TKA provides better initial pain relief, is more durable and less likely to require revision. Contrary to the literature, our data also demonstrates that the documented outcomes following revised failed UKA were not inferior to revised failed TKA.