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Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_19 | Pages 9 - 9
1 Nov 2017
Bucknall V Phillip V Wright C Malik M Ballantyne A
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‘Primum non nocere’ is one of the most well known moral principles associated with the medical profession. Often, in our bid to maintain and improve quality of life, we neglect to recognise those patients who are in fact nearing the end of theirs. Thus, our aim was to ascertain if we are recognising the ‘dying’ orthopaedic patient and whether key elements of management in accordance with SIGN are being addressed.

All hip-fracture deaths occurring at a District General Hospital over a 4-year period (2012–2015) were included. Paper and electronic notes were used to record patient demographics, days from admission to death, diagnosis of ‘dying’ and discussions regarding DNACPR and ceiling of care. Total numbers of investigations undertaken during the week prior to death were noted.

89 hip-fracture deaths occurred between 2012–2015, of which 57 were female with a mean age at death of 84 years. The number of days post-admission to death was 17.5 (range 0–109). 45 patients had a new DNACPR recorded and 13 were longstanding. 43 patients (48.3%) were diagnosed as dying at a mean of 7.2 days following admission, 31 of whom (72.1%) had ceiling of care discussed. Of this cohort, 32 had futile investigations during their last week of life and astoundingly 10 on the day of death.

Although some effort is being made to recognise the ‘dying’ orthopaedic patient, further work is needed to establish a clear ceiling of care pathway, which maintains and respects patient comfort and dignity during their last days of life.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_18 | Pages 1 - 1
1 Nov 2017
Bucknall V Rutherford D Macdonald D Shalaby H McKinley J Breusch S
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Patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma have been recently established. However, little is known regarding what patient factors affect these outcomes. This is the first and largest prospective study to determine which patient factors influence surgical outcome following Morton's neuroma excision.

Over a seven-year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Patient demographics were recorded in addition to co-morbidities, deprivation, associated neuroma excision and other forefoot surgery.

Obesity, deprivation and revision surgery proved to statistically worsen MOXFQ outcomes post-operatively (p=0.005, p=0.002 and p=0.004 respectively). Deprivation significantly worsened the mental component of the SF12 (p=0.043) and depression the physical component (p=0.026). No difference in outcome was identified for age, sex, time from diagnosis to surgery, multiple neuroma excision and other forefoot surgeries. 23.5percnt; of deprived patients were dissatisfied with their surgery compared to 7percnt; of the remaining cohort.

Patient reported outcomes following resection of symptomatic Morton's neuroma are shown to be less favourable in those patients who display characteristics of obesity, depression, deprivation and in those who undertake revision neuroma resection. Surgery can be safely delayed, as time to surgery from diagnosis bears no impact on clinical outcome.


The Bone & Joint Journal
Vol. 98-B, Issue 10 | Pages 1376 - 1381
1 Oct 2016
Bucknall V Rutherford D MacDonald D Shalaby H McKinley J Breusch SJ

Aims

This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton’s neuroma.

Patients and Methods

Between May 2006 and April 2013, we prospectively studied 99 consecutive patients (111 feet) who were to undergo excision of a Morton’s neuroma. There were 78 women and 21 men with a mean age at the time of surgery of 56 years (22 to 78). Patients completed the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF-12) and a supplementary patient satisfaction survey three months pre-operatively and six months post-operatively.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_12 | Pages 12 - 12
1 Jun 2016
Bucknall V Davidson E Chesney D Clayton R Short N Brenkel I
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Alcohol-based cutaneous disinfectant use is well established in the surgical environment. However, during scrubbing, volatile alcohols are inspired into the pulmonary system. With the recent reduction in the national drink driving limit, even low levels of detected breath alcohol can have legal implications. This study aimed to determine the extent to which passive inhalation of alcohol-based surgical hand disinfectant affects estimated percentage blood alcohol concentration (%BAC) on breathalyser testing.

Over a one week period (September 2015), 24 theatre team members (13 surgeons, 6 scrub staff and 5 anaesthetists) were prospectively recruited. The mean cohort age was 43.7 years (50% female). Participants were instructed to scrub for 90 seconds with an alcohol-based hand disinfectant comprising of the active ingredients (per 100g): propan-1-ol 30.0g, propan-2-ol 45.0g and mecetroniumetilsulphate 0.2g. Estimated %BAC was recorded immediately before and after scrubbing, and every five minutes thereafter until levels returned to 0.00%BAC. Results ≥ 0.05%BAC were deemed above the Scottish legal driving limit.

All participants exceeded the 0.05%BAC threshold on immediate post scrub testing. The mean peak %BAC was 0.12% (± 0.05) with a maximum BAC documented at ≥0.20% in four subjects. In all participants, the %BAC descended to zero over a period ranging from 10–30 minutes with a mean time to zero of 16.7 (± 4.8) minutes.

Following the use of alcohol-based surgical hand disinfectant, estimated blood alcohol concentrations detected on breath sampling can rise up to four times the Scottish driving limit which may have legal and professional ramifications.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_14 | Pages 27 - 27
1 Dec 2015
Bucknall V Rutherford D Macdonald D Shalaby H McKinley J Breusch S
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Current knowledge regarding outcomes following surgical treatment of Morton's neuroma remains incomplete. This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma.

Over a seven year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively.

Statistically significant differences were found between the mean pre- and post-operative MOXFQ and physical component of the SF-12 (p< 0.05). No difference in outcome was identified in patients in whom multiple neuromas were operated compared to single site surgery. However, revision surgery proved to statistically worsen MOXFQ outcomes post-operatively p< 0.004. Overall satisfaction was reported as excellent (49%) or good (29%) by the majority of patients but 10% were dissatisfied with poor (8%) or very poor (2%) results expressed. Only 64% were pain free at the time of follow-up and 8% of patients MOXFQ scores worsened.

These findings illustrate that overall, patient reported outcomes following resection of symptomatic Morton's neuroma are acceptable but may not be as favourable as earlier studies suggest. Caution should be taken when considering revision surgery which has shown to be a poor prognostic indicator. Contrary to current knowledge, multiple site surgery can be safely undertaken.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_17 | Pages 3 - 3
1 Dec 2015
Bucknall V Rutherford D Macdonald D Shalaby H McKinley J Breusch S
Full Access

Current knowledge regarding outcomes following surgical treatment of Morton's neuroma remains incomplete. This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma.

Over a seven year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively.

Statistically significant differences were found between the mean pre- and post-operative MOXFQ and physical component of the SF-12 (p<0.05). No difference in outcome was identified in patients in whom multiple neuromas were operated compared to single site surgery. However, revision surgery proved to statistically worsen MOXFQ outcomes post-operatively p<0.004. Overall satisfaction was reported as excellent (49%) or good (29%) by the majority of patients but 10% were dissatisfied with poor (8%) or very poor (2%) results expressed. Only 64% were pain free at the time of follow-up and 8% of patients MOXFQ scores worsened.

These findings illustrate that overall, patient reported outcomes following resection of symptomatic Morton's neuroma are acceptable but may not be as favourable as earlier studies suggest. Caution should be taken when considering revision surgery which has shown to be a poor prognostic indicator. Contrary to current knowledge, multiple site surgery can be safely undertaken.


The Bone & Joint Journal
Vol. 96-B, Issue 10 | Pages 1370 - 1377
1 Oct 2014
Connelly CL Bucknall V Jenkins PJ Court-Brown CM McQueen MM Biant LC

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients’ social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome.

Cite this article: Bone Joint J 2014;96-B:1370–7.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_25 | Pages 6 - 6
1 May 2013
Bucknall V Connelly C McQueen MM Court-Brown CM Biant L
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Open or closed fracture of the tibial shaft is a common injury. There is no long-term outcome data of patients after tibial shaft fracture utilising modern treatment methods. This study assessed pain and function of 1509 consecutive patients with a tibial shaft fracture at 12–22 years following injury. Secondary outcomes included: effect on employment, effect of social deprivation, necessity for hardware removal and comparative morbidity following fasciotomy.

Prospective study of 1509 consecutive adult patients with a tibial shaft fracture (1990–1999) at a high-volume trauma unit. 1034 were male, and the mean age at injury was 40 years. Fractures were classified according to AO, and open fractures graded after Gustillo and Anderson. Time to fracture union, complication rate, hardware removal and incidence of anterior knee pain were recorded. Employment and assessment of social deprivation were detailed. Function was assessed at 12 to 22 years post injury using the Short Musculoskeletal Functional Assessment and Short Form 12 questionnaires.

87% of fractures united without further intervention. Social deprivation was associated with higher incidence of fracture and poorer functional and economic outcomes. 11.5% patients underwent fasciotomy which correlated with poorer long-term outcome. Tibial shaft fracture had high mortality in the elderly. At long-term follow-up 25% of patients have anterior knee pain and 20% ankle discomfort after IM nailing.

This is the largest and longest study assessing functional and economic outcomes of tibial shaft fracture. This is the first paper to describe ankle pain following tibial IM nailing at long-term follow-up.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 549 - 549
1 Nov 2011
Bucknall V McBryde C Revell M Pynsent P
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Introduction: The Oxford hip score (OHS) instrument is used to assess pain and disability before and after hip arthroplasty and may be used as a standard for auditing pre and post-operative patients. It has been suggested that patients with a low pre-operative hip score (< 25th percentile) should be carefully assessed before surgical management is employed. This study aimed to determine the factors that influence a surgeon’s decision to undertake hip arthroplasty in patients with a low pre-operative hip score.

Methods: All patients who underwent hip arthroplasty over a two month period (n=121) were included. Of these, four pre-operative OHS questionnaires were missing. The remaining (117) were validated and those scoring below the published 25th percentile (58.3%) were selected (n=35), termed the ‘low-group’. Individual OHS responses scored 0–4 were examined (0 = no impairment and 4 = worst impairment) and the proportional differences between the responses for this group and the remaining 75% were investigated. The pre-operative radiographic Tönnis stage of osteoarthritis was determined.

Results: The median cohort OHS was 68.8% (IQR = 50–79%). Of the questions that scored highly, 59% were purely pain related, 14% function and 27% both. 66% of patients experienced moderate/severe pain and 31% suffered night pain. The ‘low-group’ never scored 4 (worst impairment) on questions concerning washing, transport, shopping, stairs and work. However, 57% scored 4 on questions encompassing a pain component. In all questions except donning socks and walking, the proportion of 4 in the ‘low-group’ was significantly different to the remainder of the cohort. Tönnis grade 3 (osteophytes and advanced loss of joint space) osteoarthritis predominated (49%).

Conclusion: Arthroplasty in patients with low pre-operative OHS is influenced mainly by pain affecting quality of life. Half of these patients also have advanced features of osteoarthritis on radiographic assessment despite the low scores.