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Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_7 | Pages 25 - 25
1 May 2015
Hutchings L Watkinson P Young D Willett K
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Multiple organ failure (MOF) is a major cause of trauma mortality and morbidity. The role of surgical procedures in precipitating MOF remains unclear.

Data on timing and duration of surgery was collated on 491 consecutive patients admitted to a Major Trauma Centre, who survived more than 48 hours and required Intensive Care Unit admission. MOF was defined according to the Denver Post Injury MOF Score, where MOF can occur only later than 48 hours after injury to exclude physiological derangements resulting from inadequate resuscitation.

Overall, 268 patients (54.6%) underwent surgery within 48 hours of injury, with 110 (22.4%) requiring surgery within 6 hours of injury. Total mean intra-operative time (p=0.067) nor the need for an operation within the first 6 (p=0.069) or 48 hours (p=0.124) were associated with MOF development. Multivariate predictive modelling of MOF showed timing and duration of surgery had no significant predictive power for MOF development (Odds Ratio 0.72, 95% CI 0.47–1.10).

Despite previous indication that early surgical intervention can precipitate MOF, current surgical strategy does not appear to impact MOF development.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 178 - 178
1 Jan 2013
Alsousou J Franklin S Thompson M Harrison P Willett K
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Purpose

Platelet-Rich Plasma (PRP), an autologous derivative of whole blood that contains a supraphysiological concentration of platelets and growth factors. Most published studies have investigated the effect of PRP-conditioned media on cell cultures. We are not aware of any study that has investigated whole PRP with its cellular components on human tissue cultures. This study aims to investigate the effect of PRP on cell migration from human Achilles tendon explants, and the subsequent cellular proliferative effects in culture.

Methods

This is an in-vitro study on tendon explants obtained from Achilles tendon rupture patients. The samples were collected in sterile DMEM F12 solution then carefully cut into approximately 1–3mm3 sections. Tendon explants were cultured in three media types: 1. 100% PRP; 2. 50% PRP; and 3. 50% fetal calf serum (FCS). 1 and 2 were made up using DMEM F12 media (standard culture medium). Explants and cells were incubated at 37°c in 5% CO2 for 48 hours.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 230 - 230
1 Jan 2013
Wharton R Zeidler S Gollogly J Willett K
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Aims and methods

We present a review of our use of the Ilizarov apparatus in a non-acute NGO hospital in Cambodia specialising in limb reconstruction. Frames are applied without on table image intensification. A retrospective case-note analysis of Ilizarov apparatus use for all indications was conducted. 53 frames were applied between November 2005 and October 2011. Indications for application were chronic open fracture, osteomyelitis, fracture malunion, infective and non-infective non-union, bone lengthening, primary bone tumour resection, ankle fusion, congenital deformity or pseudarthrosis, chronic hip dislocation, or a combination of the above.

Results

Median delay in presentation was 104 weeks for all indications (range 4–864). Median treatment length was 21 weeks (3–76). The most frequent complication was pin-site infection. This occurred in 18 patients (34%). Return to theatre occurred in 21 patients (40%). Indications were frame adjustment, pin addition or removal, addition of bone graft or re-osteotomy. Failure of union occurred in three patients. These rates are comparable with those published in both Asian and Western literature.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IV | Pages 68 - 68
1 Mar 2012
Willett K Al-Khateeb H Kotnis R Bouamra O Lecky F
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Background

To determine the relative contributions of bilateral versus unilateral femoral shaft fracture plus injuries in other body regions to mortality after injury.

Study design

A retrospective analysis of the prospectively recorded Trauma Registry data (TARN) from 1989 to 2003.


Introduction

Around the knee high-energy fractures/dislocation may present with vascular injuries. Ischaemia time i.e. the time interval from injury to reperfusion surgery is the only variable that the surgeon can influence. It has been traditionally taught that 6-8 hours is revascularisation acceptable. There are only limited case series that have documented the time-dependent lower limb salvage rate (LSR) or the lower limb amputation rate (LAR). We have conducted a meta-analysis to look at LSR and LAR to inform clinical standard setting and for medicolegal purposes.

Methods

Two authors conducted an independent literature search using PubMed, Ovid, and Embase. In addition the past 5 years issues of Journal of Trauma, Injury and Journal of Vascular surgery were manually scrutinised. Papers included those in the English language that discussed limb injuries around the knee, and time to limb salvage or amputation surgery. The Oxman and Guyatt index was used to score each paper.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IV | Pages 54 - 54
1 Mar 2012
Willett K Lambert T Goldacre M
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We summarise findings from surveys of graduates from UK medical schools over 31 years. Serial surveys have been undertaken in 1974, 1977, 1980, 1983, 1993, 1996, 1999, 2000 and 2002. Questionnaires were sent to 33,151 doctors; 24,621 (74.3%) replied. Three years after qualification, 70.8% replied to a second survey; 5-years after qualification, seven cohorts were re-surveyed.

Trauma and orthopaedic surgery was the first choice career for 5.0% (men) and 1.0% (women) 1 year after qualification, and 5.2% (men) and 0.8% (women) at 5 years. Of those with T&O as first choice, 35% who chose it in year one, 56% in year three, and 84% in year five were working in it eventually. Experience as a student or junior, self-appraisal of skills, a particular teacher and enthusiasm for the specialty were the most important influences.

There has been an increase in the percentage of women choosing surgical careers. However, the much higher percentage of men who choose T&O surgery remains striking. The specialty needs to consider whether this matters. Women currently comprise about 60% of the medical school intake in the UK.

This study shows that doctors who ultimately pursued a surgical career made that choice by year 3 (equivalent to ST1) and between 84-92% had settled on the specialty by year 5 (ST3). Career progression for this historical cohort did not require an early commitment and a greater decisiveness may be anticipated in the more expectant system of Modernising Medical Careers.

It is unknown whether recent working time directives will influence career choice. This study defines T&O doctors to be highly motivated by work and not influenced by long working hours or competing domestic demands. This low priority places the specialty at the bottom of comparative tables. A change in work-life balance may directly impact future specialty recruitment.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 101 - 101
1 Feb 2012
David S Kotnis R Ostlere S Willett K
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If the lower re-rupture in operative treated patients was an effect of tendon-end apposition, then patients in whom that could be demonstrated in equinus by ultrasound could be equally well treated non-operatively without the attendant surgical risk.

All patients undergoing ultrasound for a suspected Achilles tendon repair between January 2000-2005 were included. Patients with a residual gap, 5mm or more in equinus; were treated by surgical repair. Those with a gap of less than 5mm were treated non-operatively. We excluded patients with no rupture, partial rupture and musculo-tendinuous junction (MTJ) tears. We recorded the following: clinical findings, ultrasound measurements of tendon gap in neutral and equinus, distance of rupture from distal insertion, the treatment and complications. All patients were followed up to a minimum of 6 months.

156 patients were treated for a clinical Achilles tendon rupture during the study period. We excluded 5 patients with no rupture on ultrasound, 15 with a MTJ tear, 7 with a muscle tear and 4 patients did not follow the protocol. 125 patients comprising 88 males and 37 females were entered into the study. 67 patients were treated operatively (37 open, 30 percutaneous) and 58 non-operatively. There was no significant difference between the 2 groups with respect to age, sex and injury mechanism. Two patients in the non-operative group had a re-rupture (3.4%) compared with 1 (1.5%) in the non-operative group. There were 2 incidences of superficial wound infection and 2 of temporary dorsal foot numbness in the operative. One patient in the non-operative group had a DVT. There was no significant difference for any of the complications between the two groups.

It may be possible to reduce the risk of re-rupture and surgery using dynamic ultrasound to determine which treatment the patient receives.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 104 - 104
1 Feb 2012
Kotnis R Madhu R Al-Mousawi A Barlow N Deo S Worlock P Willett K
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Background

Referral to centres with a pelvic service is standard practice for the management of displaced acetabular fractures.

Hypothesis

The time to surgery: (1) is a predictor of radiological and functional outcome and (2) this varies with the fracture pattern.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 38 - 38
1 Feb 2012
Jain N Willett K
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Quality assurance for training in trauma and orthopaedics was provided by the JCHST through the SAC for Trauma and Orthopaedics. To date there have been written SAC standards; some are compulsory and others advisory and will generate requirements or recommendations to change if unmet on inspection. There has been a major change in the way postgraduate training is monitored and quality assured, with the formation of the PMETB, which now has the combined responsibility for all postgraduate training.

The aims and objectives of our study were to measure the effectiveness of the current quality assurance system for training in Trauma and Orthopaedics, and to determine the reduction in the number of unmet compulsory standards at the end of the visits process and how effectively these requirements were implemented. We also identified the deficiencies in each component of training and determined the current general profile of the quality of training in Trauma and Orthopaedics. The inspection visits, progress and revisit reports were collected from training regions that were visited after the standards were implemented.

In 109 units, in the 3 years studied, the inspection process reduced the overall unmet standards from a mean of 14.8% (10.3-19.2%) to 8.9% (6.5%-12.7%). The number of unmet requirement per unit fell from 4.6 to 2.8 (p<0.05). 27% of units did not improve. Overall 15% of standards were deficient, least in Scottish units and most in Irish units. Currently registrars do 1.4 trauma lists, 2.8 elective lists, 1.3 fracture clinics and 2.1 elective clinics per week. This is the first multi-regional study of a national accreditation process. Quality assurance requires standards setting and rectification. These findings are important for the imminent restructuring by the Postgraduate Medical Education Board.