Fewer delays in starting a trauma list can reduce cancellations. A novel system has been previously described where a patient is identified the day before and optimised for theatre. The patient is listed first and designated “Golden Patient”. This project aimed to assess the impact of introducing a “Golden Patient” system on trauma list start times in a district general hospital.

Two months of first case sending and anaesthetic start times were recorded retrospectively (43 cases). The “Golden Patient” system was introduced with a multi-disciplinary implementation group. Target send time of 0830 hours (hrs) and anaesthetic start time of 0900hrs was agreed. First patients on trauma lists were noted in two cycles, two months apart (Cycle 1: 46, Cycle 2: 38).

Prior to implementation: Mean Send Time (MST) of 0855hrs, Mean Anaesthetic Start Time (AST) of 0921hrs.

Cycle 1: MST fell by 9 minutes (p = 0.03) and AST by 11 minutes (p = 0.023). Lists labelled with a “Golden Patient” (47.8%) were sent 14 minutes earlier (p = 0.004) and started 12 minutes earlier (p = 0.02) than those not labelled “Golden”.

Cycle 2: Implementation produced a 13-minute reduction in send times (p = o.oo3) and start times (p = 0.008) overall. “Golden Patient” cases (42.1%) showed an improved MST of 0836hrs and AST of 0902hrs, 10 minutes earlier than those not designated “Golden”.

Implementation of the “Golden Patient” produced a significant improvement in trauma list starts overall. Specifically, “Golden Patients” help to improve efficiency in sending and anaesthetic start times, by up to 19 minutes on average.

Introduction

Neck of femur (NOF) fractures are one of the predominant reasons for hospital admissions in patients >65 year. These fractures are associated with a poor outcome; end to independent living in 60% of patients and a 6 month mortality of 30%. Previous studies have shown show elements of under/mal-nutrition on admission. In addition, their nutritional status shows some deterioration thereafter. The aim of this present study is to examine if the nutritional status of patients with NOF fracture admitted at our institution is associated with a larger post-operative haemoglobin drop. This is compared to an independent living age matched control group from the same geographical area.

We reviewed professional sportsmen who had undertaken Anterior Cruciate Ligament reconstruction to determine their actual and perceived sporting performance and long term outcome. The specific aim was to determine whether the players returned to the same standard of play, following reconstructive surgery. After IRAS approval, a questionnaire survey was distributed to 55 professional players on the Sports Injury Surgery ACL database. 24players returned questionnaires (response rate of 43.6%). Dates of surgery ranged from January 1998-February 2006. The mean elapsed time following surgery was 48 months (range 13-120 months). 12 patients had injured their left knee, 8 their right and 4 both knees. The respondents played rugby league 37% (9), soccer 33.3% (8), rugby union 21% (5) and netball 8.3% (2). 12 respondents were playing in the top leagues in their sports. 15 were regular first team players and 6 were squad players.

62.5% (15) thought they had returned to their previous standard of play, 29% (7) said that they had not and 2 did not know. 71% (17) of respondents thoughts their knee returned to normal however 25% (6) did not. The mean time for RTP was 10 months (5-21 months). Those that returned to the same standard were younger (21yrs) compared to those who did not (25yrs) (P=0.108). 4 players had torn the ACL in the opposite knee or ruptured their reconstruction. Additional meniscal injuries did not influence outcome and at 4 years most players had no or only slight symptoms with sport or activities of daily living. The rupture of the ACL is no longer a career ending injury for the professional sportsman. The majority (62.5%) of players will return to their pre-injury standard of play following reconstruction. The age at injury and additional meniscal injuries were not shown to be significant factors in this series.

A single centre, prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation. Surgical management of all patients followed a protocol of the senior author (PBMT), with regard to technique and fracture reduction. Operations were performed by several different surgeons including the senior author. A definitive fixator was used as a reduction tool in 34 cases, and a separate fracture reduction device was used in 162 patients. Follow-up was in a dedicated external fixator clinic by the senior author until one year post-fracture healing. Fracture healing was determined by fracture stiffness measurements. 196 tibial fractures in 196 patients, average age 29 (range 12-80). 111 right sided and 85 left sided. 166 male and 30 female. 116 fractures due to low energy and 80 due to high energy.

The details of 320 consecutive patients undergoing knee microfracture, with a minimum follow up of 6 months, were taken from the Sports Injury Database at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. All had same phsyiotherapy regime post operatively. Two rounds of postal questionnaires were administered to assess patient satisfaction along with Lysholm, Tegner, VAS for pain and a modified IKDC scores. 196 patients responded (61.25%).

The mean age of our patients was 40.64 years and the mean follow up 37.02 months (range 6–78 months). There were 35 smokers and 161 non-smokers. 64 patients had surgery in the medial compartment, 35 in lateral, 50 in patella-femoral and 47 belonged to the combined category. 93 patients had other surgeries (partial meniscectomies, ACL reconstruction etc) along with microfracture(47.45%).

Seventy two percent of patients were satisfied with their outcome and 18.95% weren’t. 51.43% of smokers were satisfied with their outcome and 76.88% of non smokers (p=0.021). Patients more than 50 years of age were less satisfied (p=0.023) than younger patients. Having concomitant knee surgery, including ACL reconstruction, made no difference to patient satisfaction or functional scores.

The location of the lesion in the knee did not affect patient satisfaction. However, all five post op score levels were statistically different among them. The Lysholm post op scores were significantly better in lateral and PFJ compartments than medial. Lateral and combined groups were significantly better than medial for Tegner post op scores. Lateral and PFJ groups were significantly better than medial for VAS and modified IKDC scores.

Smoking and age significantly affect patient satisfaction after knee microfracture. Having concomitant knee surgeries doesn’t make a difference to either satisfaction or functional outcome. Our results suggest that the medial compartment doesn’t do as well in functional scores as previously thought.

In a novel external fixation system for tibial fractures accurate reduction is achieved with a complex temporary device (Staffordshire Orthopaedic Reduction Machine: STORM) following which the reduced fracture is fixed using a simple titanium bar fixator (IOS). With the fracture reduced, the external fixator screws may be placed in the optimum position. The fixator is designed to allow controlled bending to optimise movement at the fracture site for callus growth. With no need for adjustable elements, the fixator is small and short enough for epicentric placement in the commonest fracture of the middle and distal thirds. Optimum mechanical properties are approached: elastic return is to the reduced position; epicentric placement minimises shear and distraction on weightbearing. Integral healing assessment measures bending stiffness. The device is single-use.

In 40 tibial fractures (closed or grade I compound) the mean healing time was 15 weeks with a healing endpoint of bending stiffness of 15Nm/deg in two orthogonal axes and full weightbearing on fixator removal with no subsequent creep or refracture. Good reduction, defined as less than 5 deg of maximum angulation and less than 3mm of maximum translation, was achieved and maintained. The incidence of pin site complications was extremely low and there were no deep infections.

This new device thus far has had few of the drawbacks commonly associated with external fixation. The infection rate is low, healing time is comparable to other methods and there have been no malunions. We feel our strict adherence to fracture reduction and pin site hygiene are the most important factors in producing these excellent results.

Introduction: We present a prospective comparative study of 200 consecutive patients of closed tibial shaft fractures treated by external fixation using two different fracture reduction methods. Factors affecting fracture healing, including the effect of quality of reduction, was studied.

Methods: The healing time for all these fractures was determined by a combination of clinical, radiological and fracture stiffness measurements. The effect of smoking, AO classification type, associated fractures, initial and final angulation and translation on healing time was evaluated using nonparametric tests and regression analysis.

Results: Healing time was affected most by presence of Compartment syndrome followed by smoking status and final translation at fracture site. Having a compartment syndrome significantly increased fracture healing time (mean 286.7 days versus 139.2 days). There was no difference in healing times between the two different reduction machines. Angulation was found not to affect healing time, but translation did. Both initial and final translation were better using STORM (Staffordshire Orthopaedic Reduction Machine). The amount of axial shortening was also reduced by using STORM.

Conclusion: Healing time is affected by translation at fracture site, which is a factor under the control of the surgeon. The second reduction method using STORM, helps achieve better reduction.

Introduction: The Staffordshire Orthopaedic Reduction Machine (STORM) was developed to assist in the reduction of tibial shaft fractures prior to the application of an external fixator. Its use has now been extended to fractures of the tibial plateau and plafond, where it has been utilised to gain and hold a good reduction prior to the application of various internal and external fixation techniques.

Methods: The STORM was used sterile within the operative field on a standard radiolucent operating table. It was applied with two tensioned 2 mm wires: the distal through the calcaneum; the proximal through the proximal tibia for shaft and pilon fractures, and through the distal femur for plateau fractures.

Controlled traction was applied through these two wires. Torsion was independently corrected and locked. Translation and angulation was corrected using two translation arms each applied to the tibia with a single unicortical screw. The STORM was removed at the end of each operation.

Results: The STORM was used in 241 cases.

Pilon (n=42): bridging hinge 23 (t [mean operation time in minutes]=102.9), percutaneous plate 10 (t=131.4), ring fixator 5 (t=140), screws and fibula plate 3 (t=77), other 2.

Discussion: The STORM is a safe device for reliable reduction of tibial plateau, shaft and pilon fractures which allows good access for internal or external fixation. No significant complications attributable to the use of the current design of the STORM were encountered.

Introduction: In a new external fixation system for tibial fractures, accurate reduction was achieved with a complex temporary device, the Staffordshire Orthopaedic Reduction Machine (STORM) following which the fracture was fixed using a simple titanium bar fixator (IOS). The fixator was designed to allow controlled bending to optimise movement at the fracture site for callus growth. Ideal mechanical properties are approached: elastic return is to the reduced position; epicentric placement minimises shear and distraction on weightbearing. Integral healing assessment measures bending stiffness. The device is single-use.

Methods: Closed or grade I compound unstable tibial shaft fractures in 38 patients were externally fixed using the STORM in the operating theatre to reduce the fracture prior to application of an IOS fixator. Immediate full weight-bearing was encouraged. Bending characteristics of the fixator allowed 1 mm of axial movement for 20 kg loading. Fixator removal time was determined by fracture stiffness measurements against which the integral IOS stiffness measurement was compared.

Results: Mean healing time was 18.1 weeks, shortest time 9.5 weeks. The healing endpoint was fixator removal at a bending stiffness of 15 Nm/deg in two orthogonal axes. There was no subsequent creep or re-fracture. Good reduction, defined as less than 3 deg of maximum angulation and less than 3 mm of maximum translation, was achieved and maintained.

Discussion: The IOS/STORM system allows safe and effective treatment of tibial shaft fractures. With the fracture reduced, the external fixator screws can be placed in optimum positions. Good reductions were achieved and maintained. The IOS bending characteristics appear to approach the optimum for callus growth. The simple integral fracture stiffness measurement method has been validated against more complex devices.

Single centre prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation.

Methods: Surgical management of all patients followed protocol of senior author (PBMT), with regard to technique and fracture reduction.

Operations performed by several different surgeons including senior author.

Definitive fixator used as a reduction tool in 34 cases, fracture reduction device used in 162 patients – ST.O.R.M

Followed up in a dedicated external fixator clinic by the senior author until one year post fracture healing.

Fracture healing was determined by fracture stiffness measurements.

Results: 196 tibial fractures in 196 patients, average age 29 (range 12–80).

111 right sided and 85 left sided.

166 male and 30 female.

116 fractures due to low energy and 80 due to high energy.

Mechanism of injury: football 75, fall 52, RTA 49, direct blow 7, assault 4, rugby 3, crush 2, dancing 2, bowling 1, roller skating 1.

33 patients had an additional 74 injuries: 35 fractures (3 open), 7 compartment syndromes, 3 dislocations, 7 head injuries, 16 chest injuries, 9 soft tissue injuries.

According to AO classification system: 33 A1, 47 A2, 42 A3, 15 B1, 46 B2, 7 B3.

Time to # healing was 19 weeks on average (range 9–87)

X ray data: 15 patients had deformity > 5 degrees in the coronal plane and 1 of these also had deformity > 10 degrees in the saggital plane.

One patient underwent osteotomy for correction of malunion.

85 patients had a total of 279 pin site infections requiring Abx (6 with 14 pin infections requiring iv abx), and 33 pins were removed due to persistent infection. 15 patients had 32 ring sequestra which settled with debridement under GA.

7 fixators removed early due to pin site infection.

1 established osteomyelitis-lautenbach.

7 refractures, all healed(5 with pop, 2 with further fixator)

Non-union: 5 hypertrophic, 2 atrophic-all healed with further external fixation.

Malunion: 1

Conclusion: Our results show that external fixation of closed tibial fractures is a viable alternative to other treatment methods with regard to healing time and angular deformity.

Our study also uses a well validated end point to define fracture healing and does not rely on the difficulty of defining healing on clinical or radiological grounds which is known to be unreliable. This is the first time this highly repeatable methodology has been used for such fractures.

A prospective study of 196 closed tibial diaphyseal fractures treated by a monolateral external fixator is presented.

The patients were managed by a group of Surgeons including the senior author (PBMT), a definitive fixator being used in 34 patients, and a fracture reduction device in 162 patients. All the patients were followed up in an external fixator clinic by the senior author, and follow up continued for 1 year after the fractures had healed. Fracture healing was determined clinically.

There were 196 tibial fractures, with an average age of 29 years (range 12–80 years). 111 Fractures involved the right tibia, and 85 the left. There were 166 males and 30 females. 116 Fractures were deemed due to a low energy accident, and 80 due to a high energy injury. The most common mechanism of injury was football (75), a fall (52), a road vehicle accident (49), direct trauma (7), assault (4), and rugby (3). According to the AO classification system 33 were A1 fractures, 47 A2, 42 A3, 15 B1, 46 B2, and 7 B3. Time to fracture healing was 19 weeks on average (with a range from 9–87 weeks).

15 Fractures united with a deformity of more than 5⁰ in the coronal plane. One patient required a corrective osteotomy for a mal-united fracture. There were 279 pin track infections that required antibiotic treatment in 85 patients. 33 Pins had to be removed due to persistent infection. Of these patients 15 developed 32 ring sequestrae, but infection was settled by debridement under GA. 7 External fixators had to be removed early because of pin site infection. One patient developed a full blown osteomyelitis, which was treated with the Lautenbach irrigation and settled. There were 7 re-fractures, but all healed after further treatment. 5 Were treated in a POP cast and 2 were re-treated with another external fixator. There were 7 non-unions, but all eventually healed with further treatment with an external fixator.

The authors conclude that treating a closed tibial fracture with an external fixator is a viable alternative method of treatment.

Aims: To show that the treatment of buckle fractures in children in a soft bandage, rather than a plaster cast, is an effective and safe method of treatment. Methods: In order to determine the difference between the two groups it was decided to compare the range of movement at three weeks. Power calculations were performed. This gave a required sample size of 23 for each group. The project was submitted for ethical approval in July 1999. Patients enter the trial after parents agree and sign the consent form. Allocation to either plaster or bandage is random and parents draw previously sealed envelopes themselves. Patients are seen each week and measurements taken of their range of movement. Results: Thirty seven patients have completed the study. 17 have been allocated to bandage the rest to cast. Those in bandage show an excellent range of movement at the þrst week with no reported problems on their questionnaires. One patient has transferred from bandage to plaster at the request of the parents. Conclusion: Results suggest a positive result for treatment in bandage with no reported adverse effects and, a highly desirable result for the patient. We would hope to suggest a change in treatment policy for such fractures.

We set out to determine whether modification of ward facilities and working practices can prevent MRSA infection on an elective Orthopaedic ward, and whether these changes are cost effective.

Following a cluster of 3 cases of acute, deep MRSA infections in arthroplasty patients in early 1999, a review of elective orthopaedic facilities was carried out. The problems identified on the elective Orthopaedic ward were:

inadequate toilet/washing facilities

The following changes were made:

Ward

reduction of beds from 36 to original complement of 30

Staff

regular MRSA screening of all staff

Practices

all patients must have a negative MRSA screen before admission

There has been only one further case of MRSA wound infection in the 1300 major cases that have been through the ward in the last 3 years. This patient spent the first 48 hours post-operatively on the ITU, where MRSA colonisation was widespread.

We performed a cost analysis exercise on the request of our Microbiology department, as they felt that the routine swabbing of so many patients was not cost effective.

We analysed the year 2000 in which 1783 patients were screened for MRSA at a total cost of £24,962 (£14.00 per screen).

A literature search gave us the estimated cost of an MRSA infected arthroplasty being in the order of £31,568, which compares favourably with the total yearly cost of our screening program.

With appropriate facilities and modification of working practices, MRSA infection can be controlled on an elective Orthopaedic ward.

The total yearly cost of our screening programme is less than the potential cost of a single MRSA infected arthroplasty.

The changes made to our working practice and the introduction of our screening programme have been found to be both clinically and cost effective.