We propose that ASEPSIS provides the most accurate and reproducible results and also provides more information with the grading of wound infection. The overall rate of orthopaedic wound infection using the ASEPSIS method is 3%. If all hospitals used this scoring method, more accurate comparisons of infection rates could be made.
A centralized wait list management system (WLMS) for TKR, THR and knee arthroscopy was developed to collect accurate data on parameters of patients’ wait for surgery. A priority metric rating patient priority was implemented. Data from hospital enterprise systems related to aspects of patients’ wait for surgery was collected and imported. Patients’ functional status was significantly worse than population norms, they were adversely affected while waiting and are unsatisfied with their access to surgery. Traffic ratios (ratio of booked to completed surgeries) exceed the maximum value for a stable wait list and the waits for surgery exceed national and international recommendations for maximum wait-times. To develop and implement a WLMS for TKR, THR and knee arthroscopy to enable the accurate and efficient collection of data on size of list, rate of list growth, rate surgeries are performed, health and functional status of patients, and surgeon rated priority. Patients are adversely affected while waiting and are unsatisfied with the length of their wait. Traffic ratios exceed the maximum value for a stable waitlist. The priority metric has face validity for rating patient acuity. SF36 and WOMAC scores were three to four standard deviations worse than the population norm, over 50% of patients felt wait time would negatively affect outcome, 80% felt waits should be twelve months or less, and over 50% were unsatisfied with access to surgery. VAS scores were normally distributed with good face validity. Wait times are one hundred and thirty to three hundred days for arthroplasty and ninety to four hundred days for arthroscopy. Traffic ratios are 0.9 for arthroplasty and 1.5 for arthroscopy. Prospective outcomes with respect to the wait list will allow determination of minimum acceptable wait times from administrative, surgeon and patient perspectives. Accurate and reliable collection of wait list data provides a sound basis for future decision-making. Surgery bookings were centralized. A priority metric based on a visual analog scale (VAS) with a single question asking the surgeon to rate the patient priority was implemented. A cross-sectional postal survey was conducted. Data from hospital enterprise systems related to aspects of patients’ wait for surgery was collected and imported into the WLMS.
A centralized wait list management system (WLMS) for TKR, THR and knee arthroscopy was developed to collect accurate data on parameters of patients’ wait for surgery. A priority metric rating patient priority was implemented. Data from hospital enterprise systems related to aspects of patients’ wait for surgery was collected and imported. Patients’ functional status was significantly worse than population norms, they were adversely affected while waiting and are unsatisfied with their access to surgery. Traffic ratios (ratio of booked to completed surgeries) exceed the maximum value for a stable wait list and the waits for surgery exceed national and international recommendations for maximum wait-times. To develop and implement a WLMS for TKR, THR and knee arthroscopy to enable the accurate and efficient collection of data on size of list, rate of list growth, rate surgeries are performed, health and functional status of patients, and surgeon rated priority. Patients are adversely affected while waiting and are unsatisfied with the length of their wait. Traffic ratios exceed the maximum value for a stable waitlist. The priority metric has face validity for rating patient acuity. SF36 and WOMAC scores were three to four standard deviations worse than the population norm, over 50% of patients felt wait time would negatively affect outcome, 80% felt waits should be twelve months or less, and over 50% were unsatisfied with access to surgery. VAS scores were normally distributed with good face validity. Wait times are one hundred and thirty to three hundred days for arthroplasty and ninety to four hundred days for arthroscopy. Traffic ratios are 0.9 for arthroplasty and 1.5 for arthroscopy. Prospective outcomes with respect to the wait list will allow determination of minimum acceptable wait times from administrative, surgeon and patient perspectives. Accurate and reliable collection of wait list data provides a sound basis for future decision-making. Surgery bookings were centralized. A priority metric based on a visual analog scale (VAS) with a single question asking the surgeon to rate the patient priority was implemented. A cross-sectional postal survey was conducted. Data from hospital enterprise systems related to aspects of patients’ wait for surgery was collected and imported into the WLMS.
Ankle fractures are common injuries and commonly require operative stabilisation. The aim of treatment should be anatomical reduction as this will lead to good long-term results. Non-anatomically reduced fractures will lead to a poor functional outcome and development of osteoarthritis. Our aim was to determine whether revision of non-anatomical fixations within 12 months of initial surgery improved outcome. We present eight cases of non-anatomical ankle fixations that were revised by the senior author over a 4-year period. There were 4 females and 4 males. The mean age was 45.6 years at review (range 28–63) and the mean time from initial fixation to revision was 5.25 months (range 2–11). Mean time at review was 26.6 months (range 7–45). Clinical scoring for functional outcome was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) rating system for the ankle and hindfoot. Mean AOFAS score prior to revision was 40 (range 19–69) and the mean score at review was 80 (range 54–100). All patients reported benefit in terms of function from the revision procedure. The aim of initial surgery is for anatomical reduction of the ankle joint. Should suboptimal fixation be encountered within 12 months of the initial surgery, we feel revision surgery is justified.
Despite the literature reporting a high complication rate tension band wiring remains a common technique for the fixation of olecranon fractures. In our unit 44 patients who underwent tension band wiring of olecranon fractures between May 1998 and May 2002 were reviewed specifically with regards factors that might be responsible for a poor outcome. The patient’s age at the time of injury, mode of injury and fracture configuration were recorded. In addition the adequacy of reduction was assessed and the position of the k-wires (parallel/non-parrallel, anterior cortex fixing/intramedullary) length of wire beyond the fracture line and number of circlage wire twists noted. All patients had a minimum follow-up of 12 months. 22 patients (50%) had complications following the index procedure of which 8 had wire back out, 7 had pain and discomfort requiring removal of the metalwork and 4 had wound infections. Fixation of the radius occurred in 1 patient and 2 patients developed a non-union. In all further surgery was needed in 18 patients (41%). No common features were identified in patients developing complications and in particular no statistical difference was found when k-wire position (P=0.35) length of k-wire beyond the fracture line (P=0.34) and number of circlage wire twists (P=0.33) were analysed. Using Kaplan-Meier analysis the patients who required wire removal were likely to undergo their surgery within 6 months of fracture fixation. The high complication rate begs the question: Is this an appropriate modern method of fracture fixation?
The purpose of this study was to design a clinically useful classification for distal humeral fractures that would provide guidance to the surgeon with regard to surgical approach and operative management. This classification was assessed using the original radiographs from a study comparing distal humeral fracture classifications previously undertaken in Oxford, and validated using the exact methodology of that study. Nine independent assessors (3 orthopaedic consultants, 3 orthopaedic registrars and 3 musculoskeletal radiologists) were asked to classify 33 sets of radiographs on two separate occasions using the Riseborough and Radin, Jupiter and Mehne, and AO classifications as well as the new classification system. The assessors were unaware of the origin of the new system as this had been given a fictitious name. Using the Kappa statistic, the level of inter-observer and intra-observer agreement was determined and interpreted using the Landis and Koch criteria. Amongst all observers, the new classification is both a substantially reliable (k=0.664) and reproducible (k=0.732) classification system. The new classification achieved superior inter- and intra-observer agreement compared to the other three classification systems with a low proportion of unclassifiable fractures comparable to the AO method (3.7%). In reproducing materials and methodology from an independent study, we have been able to validate this new fracture classification system. Used in conjunction with a management algorithm, we believe the new classification aids the surgical decision-making process for these complex fractures.
An inability to extend the hallux following trauma is most often observed after direct laceration to the Extensor Hallucis Longus [EHL]. Primary repair, subsequent splinting and appropriate rehabilitation best deal with this type of injury. Damage to either the EHL muscle belly or the motor nerve to EHL are uncommon causes of the dropped hallux and present difficult reconstructive problems. Damage to the motor nerve branch to EHL in isolation is an uncommon problem and as far as we are aware surgery to address this pathology has not previously been described in the literature. This problem can occur after a penetrating injury, high tibial osteotomy or intramedullary nailing of a fractured tibia. We describe the operative procedure, technique and outcome in two cases of extensor hallucis longus to extensor digitorum communis (EDC) transfer to overcome this problem. A longitudinal skin incision is made just lateral to the tibia in the distal anterior part of the leg. The extensor retinaculum is divided and the EHL tendon identified and divided just distal to the EHL musculotendinous junction. The extensor digitorum communis (EDC) is then identified and the proximal stump of EHL woven into the EDC. A Pulvertaft weave technique is used and secured with 3/0 Ethibond suture. The appropriate amount of tension is placed on the repair by simulating weight bearing on the foot, ensuring the great toe remains in the neutral position. The extensor retinaculum is then repaired with 2/0 Vicryl and the skin closed with interrupted nylon sutures. The wound is infiltrated with 0.5% Marcaine to aid postoperative pain relief. A protected active motion rehabilitation program follows the surgery. We have used this technique in two cases, both have regained active extension of the hallux.
The Scarf osteotomy has proven to be an effective intervention in the correction of various degrees of hallux valgus deformity. Outcome compares favourably with other bunion surgeries such as the distal or proximal Chevron or crescentic osteotomy. The Scarf osteotomy is a more extensive surgical procedure than other techniques and the technically demanding nature of the procedure requires experience to master. This paper describes peri-operative complications during our early experience of Scarf osteotomy for hallux valgus. A case note review was carried out for the first 100 Scarf osteotomy procedures completed by the senior author. There were six patients (6%) with peri-operative complications. Four of these were intra-operative complications including a split of the first metatarsal in three cases, and a shearing of the K wire in one case, and there were two cases of post-operative stress fracture. These complications should be considered by those beginning to master the Scarf osteotomy procedure and by surgeons teaching surgical trainees.
This study was designed to assess the standard of orthopaedic training of Senior House Officers in the U.K. and to determine the optimum time that should be spent in these posts before registrar training. Two MCQ papers were constructed. One for the pre test and one for the post test. Questions covered all aspects of orthopaedics and trauma including operative surgery. The paper was firstly tested on controls including medical students, house officers, registrars of various grades and consultants. There was no statistical difference in the results for the two papers within the groups indicating that pre and post test papers were of similar standard. In addition the average scores in the tests increased proportionately to the experience and grade of the control. 129 SHOs from 25 hospitals in 10 different regions were tested by MCQ examination at the beginning of their 6-month post. They were again tested at the end of the job. The differences in score were compared. This difference was then correlated with the experience and career intention of the SHO. There was no statistical difference between pre and post test results in all groups of SHOs in the study (student t test). The best improvement in scores during this six month period were seen in SHOs of 1–1.5 years orthopaedic experience. SHOs of more than 3 years experience demonstrated the smallest improvement in their score. There was a net loss of seven trainees with a career intention of orthopaedics to other disciplines. In the vast majority of Senior House Officer posts in this country, very little seems to be learnt during a six-month attachment. This is especially so for those who are doing orthopaedics for the first time as well as very experienced SHOs.
Meticulous haemostasis not only improves the operative field facilitating spinal surgery, but also diminishes chances of post-operative neurological complications from a compressive haematoma. Since being introduced in the 1940’s, implantable haemostats have proven a useful adjunct in achieving haemostasis with relatively few complications. However, their use in spaces bounded by bony architecture can lead to compressive effects on neurological structures. We present three cases of post-operative cauda equina syndrome – two cases following surgery for lumbar disc herniation and one case following surgery for lumbar canal stenosis. In each case, implantable haemostats were utilised to control haemorrhage for complications during the surgery. All three patients underwent urgent exploration, which revealed cauda equina compression from clot organised around the haemostat. Neurological recovery was variable. We recommend careful attention to intra-operative haemostasis. Although haemostats can assist in achieving haemostasis, we caution against leaving them in situ.
