TORC 2024 Abstracts
Registrar Poster Abstracts
Patient Experience surrounding the Trauma Operating List at Royal United Hospitals (RUH), Bath NHS Foundation Trust
E Dominguez, R Whitham
Introduction: Cases on the Orthopaedic Trauma Operating List (TOL) can be postponed due to clinical priority and resource availability. However, between February and March 2024, 5 cases at the RUH were postponed due to miscommunication with patients.
Aims: We aimed to evaluate patients’ experiences and understanding of being listed on the TOL, and assess the usefulness of a ‘Trauma Patient Information Leaflet’ (TPIL) in improving this.
Methods: Responses from a patient survey distributed to patients added to the TOL between 21 April and 19 May 2024 were collected (Cycle 1). Patients lacking capacity to consent for a procedure were excluded. On 20 June 2024, TPIL was introduced to clinical areas and distributed by the on call Orthopaedic team to new patients being listed to TOL. The same survey was re-distributed between 17th June and 21st July 2024 (Cycle 2).
Results: Twenty-one (21) patients responded to the survey in Cycle 1 whilst 15 responded in Cycle 2. Four (27%) patients in Cycle 2 recalled receiving a TPIL. 6% less patients in Cycle 2 reported they ‘definitely’ understood how the TOL worked. 30% more patients in Cycle 2 reported waiting longer than expected for their operation. 20% less patients in Cycle 2 felt enough information we provided to them whilst waiting.
Conclusion: Based on free-text responses, verbal advice by the first assessing influences outweighs written advice on patient expectation. The TPIL has great potential as a tool to establish consistency of information provided by the Orthopaedic and/or Emergency team particularly around projected waiting times for daycase patients, of which there were 28% more responders of in Cycle 2. However, significant improvement can still be made on TPIL’s dissemination and use.
Scottish Open Fractures of the Tibia (SOFT) National Collaboration: The Tayside Report
E. Fraser, C. Sreenan, G. Love, K. Lindsay
Introduction: Open tibial fractures have an incidence of 17/100,000 and bring a variety of issues to the orthopaedic team. Management can often be complex and as such has endured considerable evolution in recent times. A combined orthoplastic approach is vital and the British Orthopaedic Association guidance amplifies this. As part of the Scottish Open Fractures of Tibias Project, we retrospectively reviewed Tayside data for these injuries.
Aims: The primary aim was to assess the different approaches used nationally to produce Scottish guidance for these injures. The secondary aims were to look at BOAST adherence, complications and post-operative infection.
Methods: All patients with an open tibia fracture between 01/06/2021 and 31/05/2023 were identified using electronic Scottish Trauma Audit Group data and historical trauma lists. Demographics, the patient journey and adherence to the BOAST guidelines were reviewed. Important data points appointed nationally were also evaluated. Local Caldicott approval was granted.
Results: 42 patients were included – all were fixed primarily. There was equal distribution of injury energy and on average it took 15 hours to get to theatre. 70% of patients were treated with intramedullary nailing. There were no frames used definitively. In terms of wound management – VAC dressings were rare, as was plastic surgeon involvement. Coverage was mainly primary closure, with 3 free-flaps included. Unemployment was the most significant socio-economic factor found. Consistent with literature, infected cases were higher grade injuries. However, there was considerable variation in pathogens, antibiotic usage, duration and timing.
Conclusion: The Tayside approach has been evaluated and BOAST guidance is well adhered to. Infection rate was 14% – although lower volume, this is lower than other centres. We hope to improve antibiotic timing and usage alongside plastic surgery communication. National collaboration and recommendations from the full Scottish dataset will enhance the local pathway; improving patient journey and outcomes.
An Initial Exploration of Scottish Surgical Trainee Views on International Study Leave
D.Waugh, M. Johnston
Introduction / Background: All resident doctors in training are contractually entitled to study leave, though there is wide regional variation in access to study budget across UK training programmes. Surgeons face an average personal cost of mandatory CCT requirement ranging from £20,000 and £26,000 (1). Clinicians undertaking international work have reported increased clinical skills, involvement in research and service development activity upon return to the UK, demonstrating value of international experience in training (2).
Aims: To determine rates at which surgical trainees have used international leave, future intentions, personal costs and views.
Methods: A combined free text and option survey was developed and published in Microsoft Office Forms. This was publicised across Scotland. Preliminary analysis was conducted following data collection from 1 October 2024 - 7 October 2024.
Results: In total, 69 responses were obtained from surgical trainees. Overall, 57% of respondents (N=40) had utilised international study leave, with 87% (N=60) reporting future intention to utilise. Study budget was inadequate to support training or aspiration in 99% (N=68), with trainees reporting personal spend of up to £5000. Concern regarding removal of international leave was expressed by 99% (N=68) respondents, with a variety of free text responses highlighting support.
Discussion / Conclusion: To our knowledge, this is the first study to explore surgical trainee views on international study leave in Scotland. There is overwhelming support for international study leave. The majority of trainees enjoy collaboration with international peers and feel their research benefits. There is potential to reduce stress, burnout and improve recruitment and retention. This survey should provide meaningful insight to trainee opinions on international study leave both in Scotland and the UK as a whole, helping to shape national policy and future workforce planning.
Retrospective review of Total Hip Replacement peri-prosthetic fractures over a ten year period in a single centre
S.R.Morrison, A. MacInnes
Background: CPT stems are collarless, polished, cemented, double-taper hip stems that have been in use for over 30 years. Recent National Joint Registry data highlighted a 1.4% rate of peri-prosthetic fracture (PPF) in the CPT stem – greater than twice the risk of PPF in any other stem.
Aims: Review local 10 year data of PPF involving the CPT stem, and identify apparent risk factors for fracture, and attempt to quantify the impact of this.
Methods: Retrospective cohort study analysing patients who underwent a primary total hip replacement (THR) using a CPT stem in Tayside over a 10 year period with maximum 10 year follow-up. Patients were identified as having a PPF through the audit service and these patients were reviewed. Data was collected from electronic notes and Carestream PACS for radiographic data.
Results: 5401 primary THRs were carried out, with 59 PPFs. Mean follow-up period was 5.8 years. 57.6% were female, and the mean age at time of primary operation was 71.1 years. The mean time from primary operation to PPF was 742.5 days. This gave a CPT PPF rate of 1.09%. 88% of PPFs were Vancouver type B fractures (of these 58% were B1, 31% B2, and 11% B3). 63% of the PPFs were involving extended or extra-extended necks. The general rate of stem malpositioning was 49.2% in the PPF cohort.
Discussion: Our rate of PPF locally using the CPT stem was lower than reported in national registry data, however, still remained above rates for other stems in use. Lower stem sizes appeared more likely to be involved in periprosthetic fractures, and stem malpositioning was significantly more common in the PPF population than generally.
Revision Knee Arthroplasty Practice in NHS Lanarkshire - A Review of BOA Guidance
D. Waugh, A. Haddock, A. Abbas
Introduction: Revision Toal Knee Arthroplasty (RTKR) is a complex surgical issue with high cost and potential for complication. While NHS England recently restructured revision pathways, Scotland has not been part of this process. Challenge meeting British Orthopaedic Association (BOA) standards in Scotland has been highlighted, particularly with relation to surgeon and centre volumes, funding and geography (1), subsequently receiving national attention (2).
Aims: To determine local volumes of revision knee arthroplasty and compliance with BOA Standards.
Methods: Following clinical audit proposal, a retrospective audit was conducted reviewing local arthroplasty records for patients at University Hospital Hairmyres (UHH) held by Specialist Nursing Staff.
Results: A total of 21 patients underwent RTKA between 04/06/2021 and 04/09/2023, representing 3% of knee arthroplasty case burden locally (N=743). Revision indications included: aseptic loosening (43%, N=9), infection (29%, N=6), component mal-position (14%, N=3), meniscal dislocation (5%, n=1), bearing post fracture with polyethylene wear (5%, N=1) and medial collateral ligament instability (5% N=1). Procedures were carried out under 5 consultants with variable operative numbers (mean = 5, median=4, mode=4, range 1-12). Of these, 29% (N=6) were dual consultant procedures. Of the recommended pre-operative investigations, 10% (N=2) had all recommended XR imaging and 71% (N=15) had both ESR and CRP testing. Intra-operative biopsy was undertaken as recommended in 75% of cases. Recommended MDT structure was not in place.
Conclusion: Numerous challenges are faced with RTKA, similar to other units in Scotland. Developing a standardised MDT could improve compliance with BOA standards. Measures to increase operative numbers such as a “buddy” system could be explored to facilitate dual consultant operating.
Clinical Outcomes of Avon Patellofemoral Joint Replacement in Younger Patients
Louis Hainsworth, Shady, Hermena, Benedict J A Lankester
Introduction: Isolated patellofemoral osteoarthritis (PFOA) accounts for approximately 10% of all knee osteoarthritis cases. While a substantial proportion of individuals with this condition may not require surgical intervention, those with severe symptoms can benefit from patellofemoral joint arthroplasty (PFA). PFA has been shown to be an effective surgical solution for managing PFOA, particularly in cases where conservative treatments have failed. However, the National Joint Registry (NJR) has reported higher revision rates for PFA compared to total knee arthroplasty (TKA), with a notable discrepancy observed in younger patients. Males under 55 years exhibit a 13.3% failure rate at 5 years, while females in the same age group show a failure rate of 9.6%. This elevated revision rate in younger patients raises concerns about the long-term durability of PFA in this population. To date, no comprehensive case series has been published examining the outcomes of younger patients undergoing PFA. Therefore, the purpose of this study is to report the medium-term outcomes of an onlay-design PFA in patients under 55 years of age, conducted at a non-design center.
Methods: Patients younger than 55 years at the time of their PFA surgery were identified from a cohort treated by a single surgeon. The primary outcome measure was the all-cause revision rate, which was evaluated using clinical notes, imaging review, and NJR data cross-referencing. The Avon patellofemoral prosthesis was used in all cases.
Results: A total of 50 PFA procedures were performed in 46 patients, consisting of 41 females and 5 males (mean age 48.8 years, range 35–54), with 4 bilateral cases. Surgeries were conducted between 2010 and 2022. The mean follow-up duration was 6.1 years (range: 12 months to 13.2 years). Only one revision surgery was recorded, which occurred 3 years postoperatively due to progressive osteoarthritis.
Conclusions: The findings suggest that PFA using an onlay-design prosthesis can achieve low revision rates in the medium term, particularly in carefully selected younger patients. These results highlight the potential durability of this approach in a younger demographic, providing a viable surgical option for symptomatic PFOA.
Evaluation of the Role of the Acute Medical Registrar in Orthopaedics
A.M. Jennings, S. Dalgleish, C. Baines
Introduction: This project hoped to evaluate a new role, encompassing an in-hours registrar physician being based on the orthopaedic wards for advice, patient reviews, and patient journey optimisation.
Aim: This service aimed to provide input for all patients who required them outwith the already established ortho-geriatric service.
Method: The success of this role was assessed through feedback questionnaires, as well as through the auditing of functional indicators such as the burden on the on-call orthopaedic registrar and other departments for advice from junior doctors, plus the number of medical emergencies.
Results: The survey received a total of 42 responses from various staff roles. All respondents thought the role had improved patient care or the functioning of the department. Respondents thought the role primarily enhanced patient care and safety and led to increased support for junior doctors and nursing staff. Data showed a 44% reduction in medical emergency calls since the role began. Total calls outwith the department for medical support reduced by 100% in hours and 50% out of hours when analysed over 22 days. Over a 14 day period, calls to the on-call orthopaedic registrar also reduced by 100% in hours, with no significant difference out of hours.
Conclusion: This role has improved patient care and safety and allowed faster medical support with reduced impact on orthopaedic and general medical services. Feedback has been very positive from all staff. The major limitation is lack of 24 hour support. Next steps will include expanding the role, as well as introduction of framework for professional development.
Developing a Novel Virtual Reality System for Orthopaedic Pre-Operative Trauma Planning
Mr Dominic Waugh, Mr David Howie, Mr Owen Bailey, Mr Rahul Bhattacharyya, Chloe Schiphorst, Lyle Boylan
Introduction: Virtual Reality (VR) in orthopaedic surgery has demonstrated positive training impact (1), with potential to improve a variety of patient outcomes (2). While using patient-specific geometrical models has been described, there is little published on VR as a pre-operative tool. To our knowledge, we are first in developing a low cost, high fidelity VR system using “Medicalholodeck” software allowing visualisation of stereoscopic 3D patient images with specific surgical implants in the same virtual space. Here, we present early user data on implementation.
Aims: Demonstrate face and content validity of a novel VR system with generation of a net promotor score (NPS).
Methods: Following development, hardware / software acquisition and initial testing, a local user guide was developed for use. Participants reviewed a patient CT scan using standard PACS systems before use of the VR system. Immediate qualitative and quantitive data was collected and analysed using microsoft excel.
Results: Responses (N=24) were obtained from a variety of grades (medical student to consultant) evaluating differing fracture patterns. All users stated the VR system matched PACS CT closely. Participants were asked to rate subjective understanding of fracture pattern using likert scales pre and post use. A Wilcoxon signed-rank test indicated there was significant difference (p = <0.05, W = 115.5, z = -4.0145) between understanding of fracture pattern before and after use of VR. Users reported the VR system was helpful in planning fixation with a change of operative plan in 87% (N=21). An overall NPS of +71 was obtained, with 75% being active “promotors”.
Conclusion: After early positive results of this novel technology’s perceived usefulness by the clinical team, we have demonstrated initial face and content validity. We seek to review the benefit to describing injury to patients and validate accuracy of true implant templating using a DICOM/3D object file (.STL) model.
Post Operative Weight-bearing Terminology and Instructions in Foot & Ankle Surgery - A Retrospective Audit
Mr Dominic Waugh, Mr Niall Teahan, Dr Amy Haddock, Mr Amit Putti
Introduction / Background: Ankle fractures are one of the commonest fractures operated on in the UK, with BOA guidance suggesting “most” should be able to bear weight as tolerated post fixation (1). However, there is variation in patient weight bearing status post operatively, with evidence suggesting early weight bearing is clinically non-inferior (2). The BOA have recently published guidance pertaining to mobilisation and weight bearing after orthopaedic surgery, with recommendations on terminology and instructions (3).
Aims: To retrospectively review operation notes for foot and ankle orthopaedic patients and determine if they would be compliant with updated BOAST standards.
Methods: Patients were identified by reviewing operative cases performed between 10/06/2024 and 09/08/2024 through local eTrauma systems. Operation notes were interrogated locally and results analysed in Microsoft Excel.
Results: In total, 31 cases were identified. While all cases discussed weight bearing status in some form, 87% (N=27) used terminology compliant with new standards. There were variable terms used, with 35% (N=11) using a mixture of compliant / non-compliant terms and 13% (N=4) using noncompliant terms. Duration of weight bearing was specified in 90% (N=28). Clinical justification was justified in 16% (N=5), with 52% (N=16) detailing use of specific aids.
Discussion / Conclusion: While the majority of cases used only terminology compliant with published standards for practice, a third used a mixture of terminology. A minority included justification for clinical decision making. Surgeons should be aware of the new BOAST guidance and include this in post operative notes. We intend to run a short quality improvement project as surgeons become familiar with this new guidance.
Early versus delayed mobilisation for non-surgically treated proximal humerus fractures: a systematic review and meta-analysis of randomised trials
Haroon Minhas, Stephanie Bagni, Neal Millar, Dimitris Challoumas
Background: Proximal humerus fractures (PHFs) are among the commonest bony injuries, most of which can be managed non-surgically.
Aim: The aim of our systematic review and meta-analysis was to compare the effectiveness and safety of early versus delayed mobilisation in conservatively treated PHFs.
Methods: A literature search was performed in multiple databases in February 2023 aiming to identify all randomised controlled trials (RCTs) comparing early versus delayed (conventional) mobilisation as part of the non-surgical management of PHFs. Primary outcomes were patient-reported function and pain at short-term (3 months), mid-term (6 months) and long-term (12 months) follow up, and secondary outcomes included secondary fracture displacement and total complications. Meta-analyses produced mean differences (MDs) or standardised MDs (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes, with 95% confidence intervals (CI). Certainty of evidence was assessed using the GRADE tool. Recommendations for clinical practice were given only based on results of high or moderate certainty of evidence.
Results: Six (6) RCTs were included that compared early mobilisation (EM; within one week from injury) to delayed mobilisation (DM; after 3 or 4 weeks of immobilisation). There were no differences in patient-reported function (combined or Constant score) or pain between the EM and DM groups at any follow up time points except for a significant difference in combined function scores favouring EM [SMD 0.4 CI (0.1,0.7), P=0.006]. There were no significant differences in the incidence of secondary fracture displacement and total complications in the two groups [OR 3.5 CI (0.7,18.2), P>0.05, and OR 1.2 CI (0.5,2.9), P>0.05, respectively]. All results were based on moderate or high strength of evidence.
Discussion: We recommend commencement of early rehabilitation for non-surgically managed PHFs after a short period of immobilisation for no more than one week, which should be prescribed purely for comfort.