Aims

During the COVID-19 pandemic, drilling has been classified as an aerosol-generating procedure. However, there is limited evidence on the effects of bone drilling on splatter generation. Our aim was to quantify the effect of drilling on splatter generation within the orthopaedic operative setting.

Hospital Episode Statistics [HES] are often used by hospital managers and politicians as a reflection of departmental workload. The accuracy of these data is often questioned. We aimed to ascertain the reliability of this database for trauma admissions.

Between 2002 and 2003, all admissions were recorded by doctors using a separate departmental database. Data were collected during the daily trauma meetings and compared with the HES returns for the same period. 2496 patients were recorded in the trauma admissions database. Overall, 36.4% of the patients were either not recorded by the HES database or wrongly coded in terms of type of admissions or diagnosis.

HES data for all 2496 records was analysed by type of admissions and speciality.4.2% of trauma patients were incorrectly classified as elective or day cases. 2.9% of trauma patients admitted to hospital were not recorded in the HES data as orthopaedic admission.

The accuracy of HES diagnosis coding was tested on 300 records randomly selected by a statistical package. HES recorded the wrong diagnosis in 29.3% of cases. A significant number of trauma cases were not counted in the HES data. This may have significant implications for trauma funding.

HES data does not accurately record diagnosis and therefore can not be used as a research tool for specific injuries. Data recording practice should be changed to improve HES data accuracy.

Osteoporosis is an increasing problem due to increasing age and inactivity. Distal radial fractures are often the first symptom of this disease. Medical treatment can reduce the risk of further fractures (including hip fractures with the associated mortality and morbidity).

To develop a method for accurate assessment of bone density from routine wrist radiographs:

Various bone substitutes were tested until one was found that gave reasonable density matches with fresh bone over a limited X-ray kV range;

Wrist and radius thickness were measured from the radiograph. This was combined with the optical density of the distal radius (relative to the bone substitute) to calculate a value for the bone density. The patients subsequently underwent a DEXA scan of the contralateral (uninjured) wrist. [The X-ray calculated bone density and the DEXA density compare well. (R> 0.5]

Conclusion: This technique gives reasonably accurate results. It is not yet ready for clinical practice. A larger study is required to improve the accuracy of this technique, perhaps comparing results with lumbar spine DEXA.

Aim: To quantify changes in epidemiology, in-patient treatment and outcome of hip fracture patients over seven-year period. This data has provided a baseline of our local changes and provided information for local planning of health care provision for these patients, in terms of improved care pathways, treatment protocols, management with geriatricians, provision for discharge in the future.

Subjects and methodology: Retrospective randomised analysis of in-patient charts of patients with hip fractures admitted to a large 650-bed Acute District General Hospital in 1996 compared with 2003. The following data is gathered: Epidemiological data, baseline test data for anaemia and renal function, time to surgery from admission, post-operative complications, time to discharge from ward and functional outcome. During this time interval we introduced a number of changes to our system of care such as: more junior doctors on the wards, more access to emergency operating time, better post-operative monitoring and care, and a move to a new hospital.

Results: In 1996, the total number of admissions over 6 months was 144 compared to 160 in 2003 for the same time period. The mean age has increased from 83 years compared to 85 years in 2003. Median mental test score declined from 9 in 1996 to 6 in 2003. The mean co-morbidities rose from 1.7 in 1996 to 2.8 in 2003. 11% of patients were medically unfit for surgery in 1996 compared to 30% in 2003 resulting in delay in time to theatre. 33% of patients were admitted from nursing homes in 2003 compared to 22% in 1996. The mortality rate was 12% in 1996 compared to 18% in 2003.

Conclusion: This study demonstrates that deteriorating pre-operative status in terms of age, ASA, mental test score and co-morbidities seems to have negated any of the system changes we introduced to improve our service. Some of our results are at variance with some national trends, highlighting the importance of undertaking this type of study locally. In our situation this was all the more surprising, given that demographically we have a relatively young population in Swindon compared to the national statistics. Performance and National League table results must take into account these demographic variances.

Background Hospital Episode Statistics (HES) is often used by hospital managers and politicians as a reflection of departmental workload. The accuracy of this data is often questioned. We aimed to ascertain the reliability of this database for trauma admissions.

Method Between August 2002 and July 2003, all admissions were recorded by doctors using a separate departmental database. Data was collected during the daily trauma meetings. This data was compared with the HES return for the same period.

Results 2496 patients were recorded in the trauma admissions database. Overall, 36.4% of the patients were either not recorded by the HES database or wrongly coded in terms of type of admissions or diagnosis.

HES data for all 2496 records was analysed by type of admissions and speciality.

4.2% of trauma patients were incorrectly classified as elective or day cases.

2.9% of trauma patients admitted to hospital were not recorded in the HES data as orthopaedics admission.

The accuracy of HES diagnosis coding was tested on 300 records randomly selected by a statistical package.

HES recorded the wrong diagnosis in 29.3% of cases.

Conclusion A significant number of trauma cases were not counted in the HES data. This may have significant implications for trauma funding.

HES data does not accurately record diagnoses and therefore can not be used as a research tool for specific injuries.

Data recording practice should be changed to improve HES data accuracy.

Purpose: To evaluate the feasibility and short term outcomes of bilateral medial unicompartmental replacement, undertaken with the patient positioned to allow simultaneous procedures in a safe and appropriate fashion.

Methods: The use of the minimally invasive approach for implantation of the Oxford unicompartmental replacement (Biomet, UK) has become increasingly popular over the past few years, though this requires a specific knee positioning for optimal implantation to allow the leg to remain dependant and a full range of flexion.

We describe a previously unreported method of positioning to allow bilateral procedures.

Fifteen patients have undergone bilateral medial unicompartmental replacements (ie 30 knees), using the minimally invasive approach, with our appropriate positioning technique.

Early results in terms of complications, post-operative radiographs and Oxford knee score were noted. A comparison with groups of an age and sex-matched bilateral total knee replacement group and a group of single unicompartmental knees was also undertaken.

Results: The mode of patient positioning for the bilateral procedure is described

There were no noted complications in the operative or early post-operative periods. Review of the radiographs demonstrates 4 minimally malpositioned implants with no symptomatic correlation. In early follow, from 6 months to 2 years, there has been 1 moderate result, with a patient requiring an MUA for 1 knee. 12 of 15 patients report good or excellent post-operative results in both knees. Three patients report problems with 1 knee only. The age matched group of bilateral total knee replacements had longer hospital stays, greater blood transfusion requirements and minor post-operative complications. There were a similar number of radiographic abnormalities and 1 re-operation in the single unicompartmental group.

Conclusion: It is possible to safely undertake bilateral simultaneous Oxford unicompartmental knee replacements using a minimally invasive technique using our described method, with obvious benefits for patients with symmetrical knee arthrosis. (299 words)

Introduction: Although knee athroplasty is a very successful operation, British knee surgeons have a wide variation in their methods of patient management. Aims: To determine current knee practice within the United Kingdom. Material and Methods: A postal survey was conducted of all members of the British Association of Knee Surgery. They were asked about pre-operative assessment, type of prosthesis used, antibiotic prophylaxis, DVT prophylaxis, bilateral arthroplasty, preferred anaesthetic, urinary catheter, patella replacement, autologous blood transfusion, mobilisation, duration of hospital stay and patient follow up. Results: 71% (221) members replied. The results and implications will be presented in full at the presentation. Some of the more interesting findings included: 18% did not have a pre-admission clinic, 18% use thromboprophylaxis for medicolegal reasons only (do not believe it works), 19% never replace the patella, 48% perform unicondlyar arthroplasty, 41% follow up patients indefinitely, one discharges patients at 6 weeks, 77% perform bilateral arthroplasty. Discussion and Conclusion: Comparison with a 1996 study of UK knee practice shows that most techniques are unchanged although slightly more surgeons routinely use an uncemented implant. (4.8% 1996, 12% 2001). There remains a wide variation in UK practice. The authors would be grateful if colleagues from other countries would contact them so that comparable studies of practice could be performed in their countries. This data may be used to compare international attitudes to knee arthroplasty.

Introduction: Osteoporosis is an increasing problem due to increasing age and inactivity. Distal radial fractures are often the first symptom of this disease. Medical treatment can reduce the risk of further fractures (including hip fractures with the associated mortality and morbidity). Aims: To develop a method for accurate assessment of bone density from routine wrist radiographs. Material and Methods: 1. Various bone substitutes were tested until one was found that gave reasonable density matches with fresh bone over a limited X-ray kV range. 2. Patients with distal radius fractures had the bone substitute placed beside the wrist being X-rayed. Wrist and radius thickness were measured from the radiograph. This was combined with the optical density of the distal radius (relative to the bone substitute) to calculate a value for the bone density. The patients subsequently underwent a DEXA scan of the contralateral (uninjured) wrist. Results: 20 patients. The X-ray calculated bone density and the DEXA density compare well. (R> 0.5)Discussion and Conclusion: This technique gives reasonably accurate results. It is not yet ready for clinical practice. A larger study is required to improve the accuracy of this technique, perhaps comparing results with lumbar spine DEXA.

NHS Patients can wait up to 15 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?

In a prospective study, 105 patients listed for elective lumbar spine surgery at a district general hospital If the MRI scan is over 6 months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted.

44% Discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled.

14% discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI.

Changes seen include disc resolution, prolapse at a new level, progressive modic changes and compression at other levels.

We do not support the fact that patients may have to wait upto 18 months before having elective spinal surgery. However, we found that significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient that had been listed for fusion alone got better.

Due to changes seen on the second MRI scan, 1 in 6 operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

Objective: NHS Patients can wait up to 18 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?

Design: A Prospective study.

Subjects: 105 patients listed for elective lumbar spine surgery at a district general hospital

Outcome Measures: If the MRI scan is over six months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted.

Results: Forty-four percent discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled. Fourteen percent discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI. Changes seen include disc resolution, pro-lapse at a new level, progressive modic changes and compression at different levels.

Conclusions: We do not support the fact that patients may have to wait up to 18 months before having elective spinal surgery. However, a significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient who had been listed for fusion alone got better. Due to changes seen on the second MRI scan, one in six operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

Introduction: Knee arthroscopy is one of the most commonly performed orthopaedic procedures. All orthopaedic surgeons have heard anecdotal stories of thermal injury and drape combustion, yet a literature search has failed to find any papers reviewing the nature of such risks.

Materials and methods: A thermocouple attached to a laptop computer was used to record the temperature at the arthroscope tip, the light cable end and the light source generator. All potentially flammable materials commonly used during arthroscopic surgery (various disposable drapes, cotton drapes, gowns, paper towels and swabs), were placed at measured distances from a) the light cable end and b) the arthroscope tip.

Results: The arthroscope tip reached a maximum temperature of 41.90° in 200 seconds. The light cable tip reached 80° at 100 seconds and a maximum temperature of 110°C in 342 seconds. The light source generator reached a temperature of 153°C. All materials tested (except cotton swabs) underwent signs of combustion. The disposable drapes burnt most rapidly. None of the materials considered had any evidence of thermal damage when placed at distances of 2.5 cm beyond the light cable and 0.5 cm beyond the arthroscope tip. Combustion was most rapid at a distance of 5mm from the instruments.

Most surgeons consider the arthroscope tip or light cable end to be the site most likely to induce combustion. Fuel, heat and oxygen are required to produce combustion. Direct contact with the tip results in greater exposure to heat but lower oxygen availability. The fasted combustion occurred at 5mm due to higher oxygen availability despite a lower temperature.

Conclusions and Recommendations:

Disposable drapes will burn with the light cable and the arthroscope tip.