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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 16 - 16
1 Feb 2012
Al-Arabi Y Nader M Hamidian-Jahromi A Woods D
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Aims

To determine whether a delay of greater than 6 hrs from injury to initial surgical debridement and the timing of antibiotic administration affect infection rates in open long-bone fractures in a typical district general hospital in the UK.

Methods

In a prospective study, 248 consecutive open long-bone fractures (248 patients) were recruited over a 10-year period between 1996 and 2005. The data were collected in weekly audit meetings. Patients were followed until clinical or radiological union occurred or until a secondary procedure for non-union or infection was performed. The timing of the injury, initial surgical debridement, timing of antibiotic administration, and definitive procedures were all recorded. We also recorded the bone involved and the Gustillo and Anderson (GA) score. Patients who died within 3 months from the injury or who were transferred for definitive treatment were excluded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 157 - 157
1 Feb 2012
Al-Arabi Y Murray J Wyatt M Deo S Satish V
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Aim

To assess the efficacy and ease of use of the Oxford Knee Score (OKS) in soft tissue knee pathology.

Method

In a prospective study, we compared the OKS against the International Knee Documentation Committee 2000 (IKDC) and the Lysholm Scores (Lys). We also assessed the OKS with retrograde (Reversed OKS: 48=worst symptoms, 0=asymptomatic) and antegrade (as currently used in Oxford) numbering. All patients completed 3 questionnaires (OKS, Lys, and IKDC, or RevOKS, Lys, and IKDC) stating which was the simplest from their perspective. We recruited 93 patients from the orthopaedic and physiotherapy clinics. All patients between the ages of 15 and 45 with soft tissue knee derangements, such as ligamentous, and meniscal injuries were included. Exclusions were made in patients with degenerative and/or inflammatory arthritidis. Patients who had sustained bony injuries or underwent bony surgery were also excluded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 1 - 1
1 Feb 2012
Al-Arabi Y Deo S Prada S
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Aims

To devise a simple clinical risk classification system for patients undergoing primary total knee arthroplasty (PTKR) to facilitate risk and cost estimation, and aid pre-operative planning.

Methods

We retrospectively reviewed a series of consecutive PTKRs performed by the senior author. A classification system was devised to take account of principal risk factors in PTKR. Four groups were devised: 1) Non complex PTKR (CP0): no local or systemic complicating factors; 2) CPI: Locally complex: Severe or fixed deformity and/or bone loss, previous bony surgery or trauma, or ligamentous instability; 3) CPII Systemic complicating factors: Medical co-morbidity, steroid or immunosuppressant therapy, High BMI, (equivalent to ASA of III or more); 3) CPIII: Combination of local and systemic complicating factors (CPI+CPII). The patients were grouped accordingly and the following were compared: 1) length of stay, 2) post-operative complications, and 3) early post-discharge follow-up assessment. The complications were divided into local (wound problems, DVT, sepsis) and systemic (cardiopulmonary, metabolic, and systemic thromboembolic) complications.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 497 - 498
1 Oct 2010
Nordin L Al-Arabi Y Deo S Vargas-Prada S
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Introduction: Many papers present results and outcomes of patients undergoing TKR or THR, these are often available to the general population and health care community and health care commissioners. These results are used as a standard to be expected by the interested parties. Patients undergoing lower limb arthroplasty fall into groups that can be broadly divided into standard and complex. Complexity can be further subdivided into local site of surgery problems, general co-morbidity problems or both.

We have come up with a 4-part stratification based on the patient’s primary condition and comorbidities and have evaluated this for a single-surgeon cohort of TKR patients and a multi-surgeon group of THR patients. We present the results and the implications of the findings and highlight the usability of the system.

Methods: Retrospective review of patient’s notes and radiographs recording lenght of stay, early post operative complications, demographic data, medical co-morbidities and local site of surgery issues. This information was used to stratify patients into 4 groups. Complex Primary 0 -standard joint replacement in a fit patient with simple pattern arthritis, Complex Primary I -a fit patient with locally complex arthritis, Complex Primary II -medically unfit patient with simple arthritis and Complex Primary III -medically unfit patient with complex pattern arthritis. We evaluated this for a single-surgeon cohort of TKR patients and a multi-surgeon group of THR patients, a total of 250 patients.

Results: The complication rates between the four groups were analyzed using logistic regression analysis and this revealed a highly significant trend among the four groups (p< 0.0001). Lenght of stay data was analyzed using non-parametric analysis of variance. This revealed a significantly increased lenght of stay in the CI and CII groups compared to the C0 group. Compared to CP0 patients, we found a 3-fold increase in cumulative complication risk in the CPII group, a 4-fold increase in the CPIII group. There were similar trends between CP0 and CPI and between CPI and CPII.

Discussion and Conclusion: This classification system correlates and quantifies increasing primary joint replacement complexity with increasing postoperative complication rates and length of stay. It is of use in stratifying patients for preoperative planning, risk counselling, and surgeon selection. These noted increases mean that this system can identify patient groups likely to incur greater cost during their treatment. It is potentially reproducible and usable for other types of surgery and can be applied to larger patient groups via institutional or national joint registries.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 61 - 61
1 Mar 2009
AL-ARABI Y Mandalia V Williamson D
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Aims:

1) To determine the predictive value of a simple stability test in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation.

2) To determine the effect of cast quality as reflected in the skin cast distance (distance between the cast and the skin in the plane of major displacement or angulation) and the cast index (the inside diameter of the cast in the sagittal plane divided by the inside diameter in the coronal plane) on re-displacement rates in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation.

Methods: This is a prospective study of 57 children aged 4 to 15 with metaphyseal and Salter-Harris II wrist fractures treated with simple manipulation. Under fluoroscopic imaging, a simple stability test involving moving the hand at the wrist in the dorsopalmar, and radioulnar planes was performed following reduction, and x-ray images were saved. We recorded and compared the displacement and angulation on the initial x-rays, during the test, and at one-and 6-week follow-up. We also recorded the skin-cast distance (SCD), and the cast index (CI).

Results: 38 patients had isolated radius fractures and 19 had radius and ulna fractures. Four patients needed remanipulation with K-wire fixation. Multiple regression analysis revealed significant correlation between percentage loss of reduction on testing and subsequent re-displacement (relationship between the two sets of values r = 0.6167, (p< 0.001)). This indicates that instability on testing (seen as a significant percentage loss of reduction) is likely to be associated with some loss of reduction on follow-up. There was a significant relationship between the skin cast distance and the cast index, and loss of reduction on one week follow-up. (p=0.006). Isolated radius fractures had a higher risk of re-displacement than radius and ulna fractures (3.9% and 0.9% respectively; p< 0.05%)

Conclusion: Stable reduction on stability testing in wrist fractures in children immobilised in a good cast (reflected in a low SCD, and CI) is associated with a good outcome. Isolated radius and ulna fractures are more likely to re-displace than radius and ulna fractures. There is a relationship between instability and loss of position at the 1-week follow-up. Potentially unstable fractures can be prevented from slipping by a good cast. A stable fracture on our stability test rarely slips. We therefore feel that stability test is a useful adjunct in decision-making.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 573 - 573
1 Aug 2008
Deo S Al-Arabi Y Vargas-Prada S
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We have previously noted that patients undergoing primary knee arthroplasty can be broadly divided into standard and complex. Complexity can be further subdivided into local site of surgery issues, general co-morbidity problems or both.

On this basis, we devised a simple to apply four-part classification system for patients undergoing primary total knee replacecments (PTKR) to facilitate cumulative risk estimation:

Complex 0 (C0): “Standard” knee replacement in a fit patient with a simple pattern of arthritis.

Complex I (CI): A fit patient with a locally complex arthritis pattern.

Complex II (CII): Medically unfit patient with a simple pattern of arthritis.

Complex III (CIII): Medically unfit patient with a complex arthritis pattern.

When a series of consecutive PTKR’s performed by the senior author was grouped according to our classification, all early postoperative complications and length of stay were evaluated and compared.

Compared to “standard C0 PTKR patients, we found a 3-fold increase in the cumulative complication risk in the CII group (p< 0.001), a 4-fold increase in the CIII group (p< 0.001) and an increased length of stay in the CIII group (p< 0.001). There were similar trends between C0 and other groups.

Further local studies to quantify the cost differentials of treating complex patients and their longer term outcomes and satisfaction are underway.

The senior author would like to discuss with the attending members of this BASK meeting the desirability of adopting such a system regionally or nationally, with the potential benefits for individual patients, surgeons, departments, Trusts and the healthcare system as a whole, and whether minor changes could and should be made to the National Joint Registry forms to accommodate this.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 329 - 329
1 Jul 2008
Al-Arabi Y Deo SD
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We devised a four-part clinical risk classification system for patients undergoing primary total knee arthroplasty (PTKR) to facilitate risk estimation. We retrospectively reviewed a series of consecutive PTKRs performed by the senior author. A classification system was devised to take account of principal risk factors in PTKR (Table 1). The patients were grouped accordingly, and the following were compared:

Length of stay

Postoperative complications

Early post discharge follow-up assessment

Multiple regression analysis was performed. This revealed:

Similar complication rates in the NCP and CPI groups.

3-fold and 4-fold increase in the cumulative risk in the CPII, and CPIII groups respectively (p< 0.001)

Increased length of stay in the CPIII group (p< 0.001).

Conclusion: This classification correlates well with complication rates from surgery, and has a role in stratifying patients for preoperative planning and risk counselling. It is reproducible and can be used for larger patient groups via the National Joint Registry. Our findings also have implications for payment by results and fixed tariffs for PTKR.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 331 - 331
1 Jul 2008
Al-Arabi Y Murray J Wyatt M Satish V Deo S
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Aim: To assess the Oxford Knee Score (OKS) for the assessment of soft tissue knee pathology?

Method: In a prospective study, we compared the OKS against the International Knee Documentation Committee (IKDC 2000) and the Lysholm Scores (Lys). We also assessed the OKS with retrograde and antegrade (as currently used in Oxford) numbering. All patients completed 3 questionnaires stating which was the simplest from their perspective. We recruited 73 patients from the orthopaedic and physiotherapy clinics, meeting the following criteria:

Results: Linear regression analysis revealed no significant difference between all 3 scores (R2=0.7823, P< 0.0001). The OKS correlated best with the IKDC (r=0.7483, Fig1), but less so with the Lys (r=0.3278, Fig2). The reversed OKS did not correlate as well (R2= 0.2603) with either the IKDC (r= −0.2978) or the Lys (r= −0.2586). ANOVA showed the OKS to be significantly easier than Lys to complete (p< 0.0001), but not significantly easier than IKDC (p> 0.05).

Conclusion: The OKS is patient friendly and reliable in assessing soft tissue knee injury. This is particularly useful if the OKS is already in use within a department for measurement of severity of degenerative disease.