Aims

There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures.

Aim

This study quantified changes in the microbiology of osteomyelitis in a single specialist centre within the UK. The rate of infection with multi-drug-resistant (MDR) bacteria was measured over a ten year period in 388 patients.

Background

Both surgeon and hospital volume influence patient outcomes following revision knee arthroplasty.

The NW Advancing Quality programme is a regional one aimed at improving the delivery of evidence based care. Hip and knee replacement has been one of 5 clinical areas. Over a 3 year period performance at all 24 NW trusts has been measured. For hip and knee replacement patients the evidence based care has been delivery of antibiotic and thromboembolic prophylaxis. Robust data has been collected on the choice and timeliness of prophylaxis and readmission rates for each trust. The programme included financial and reputational (public reporting) rewards for top performing units. Sharing of data and collaborative working has been put in place to improve overall performance

Over the 3 years of the programme data has been collected on 47,825 patients. Across the region delivery of the measures has improved from 88 to 96%. Patients achieving all measures and avoiding readmission has improved from 64 to 85%. There has been reduced variation in performance. The biggest improvement in performance has occurred in the initially poorer perfoming trusts (year 1 range 54–97%, year 3 range 86–99%). All cause readmission within 28 days of discharge has fallen from 9 to 7%.

The progamme has demonstrated that it is possible to improve delivery of evidence based care and clinical outcomes on a regional basis. It has evolved from a stand alone programme to continue as a regional CQUIN. The programme has had wider benefits. Units report a change of culture producing improved delivery of other protocols. The collaboraive working has created a multidisciplinary network with improvement initiatives widened to include comparing PROMS data, Enhanced Recovery and Shared Decision Making. Challenges have included obtaining consensus regarding the initial and now soon to be introduced updated thromboembolic measures

A retrospective review of 51 consecutive patients undergoing fixation of Scaphoid fractures by two surgeons in a single institution was conducted. Twenty-four patients were treated with a Herbert screw and twenty-seven with an Acutrak screw. This included six patients who underwent acute fixation, three in each group. The remaining cases were for the treatment of non-union and delayed union.

There were no significant differences between the two groups in terms of age, side of injury, and mechanism of injury. Fractures were classified as proximal, middle and distal thirds of the Scaphoid and there was no significant difference between the groups regarding the types of fractures treated. The only significant difference between the groups was the time from injury to fixation when considering the cases of delayed union and non union which was greater in the Herbert screw group (7.5 months vs 4 months p=<0.05).

There was no significant difference in outcome between the two methods of fixation. Union rates for all cases were 79% for Herbert screws and 81% for Acutrak screws and 82% and 83% respectively when only considering the delayed union/non-union procedures. There was no difference in terms of time to union, further surgery or clinical outcome between the two groups. The Acutrak screw required removal in five patients and the Herbert screw in two due to symptoms from screw prominence. This was not statistically significant.

In conclusion there is no significant difference in surgical outcome between these two methods of fixation for Scaphoid fractures. The authors feel that this supports the view that biological factors are more important than the method of fixation in obtaining union of Scaphoid fractures.

Background: Recognising the need for orthogeriatric input for fractured neck of femur patients, as evident from recent studies, has been established fact for some time now. Although, most studies suggest a healthcare model involving an orthogeriatric service of some degree, usually a visiting physician or a post-operative rehabilitation setup, we highlight an innovative strategy involving a dedicated in-house orthogeriatric team providing a high-level of care based in a stabilisation unit. Since the realisation back in 2004 that the Relative Risk for Mortality in patients with fractured neck of femurs was 164.6, CI (130.5–204.8) compared to the expected level of 100, a series of changes were introduced to combat this.

Methods: Within the orthopaedic department a trauma stabilisation unit (TSU) was setup with a dedicated orthogeriatric service and the early warning score (EWS) system was implemented. This was used to identify patients requiring higher levels of care and thus transfer to TSU.

Results: The 2007 Relative Risk for Mortality for hip fractures stands at 92.4, CI (66–125.9) suggesting a reduction of 44% in mortality. Furthermore, there has been no significant change in age, co-morbidity or delay to surgery over this period.

Discussion: The presence of an orthogeriatric service which dedicates itself to patient optimisation pre-operatively and post-operative recovery has immensely improved the outlook on this frail population. The increase level of nursing care with a ratio of 1:2 and implementation of the EWS system again adds to improved patient care and outcome. Thus we strongly advocate that the development of such a care model within trauma & orthopaedics is essential in improving the service our patients receive.

The AO, Frykman, Mayo and Fernandez classification system for distal radius fractures were evaluated for interobserver reliability and intraobserver reproducibility using plain radiographs. Five orthopaedic consultants, five orthopaedic registras and five orthopaedic senior house officers classified 20 sets of distal radius fractures on two seperate occasions. There were 2400 induvidual observations. Kappa statistics were used to establish a relative level of agreement between observers for the two readings and between seperate readings by the same observer. Our results for intraobserver reproducibility showed Fernandez Kappa value of 0.49, Frykman 0.47, Mayo 0.45 and AO 0.33. A 0.4 result shows good consistecy accorcing to well reconised staistical boundries and is significant. That is reproducibility happened at a level greater than by chance. Interobserver Kappa values were poor in all classification systems. We also sought to look at varibles within grade of surgeon and developed Kappa values for these also.