BTS Programme 2015

BRITISH

CIETY SO

AUMA TR

www.bts-org.co.uk

Contents Page 3

Welcome from the BTS President – AD Patel

Page 4-5

Sponsors Profiles

Page 7

Keynote Speaker Profiles

Pages 8-14

Conference Programme

Pages 15-16

Poster Presentations by Day

Pages 17-50

Wednesday Oral Presentation Abstracts

Pages 51-82

Thursday Oral Presentation Abstracts

Pages 83-108

Wednesday Poster Presentation Abstracts

A whole day on the 3rd November is dedicated to External Fixation with lectures and hand on workshops – kindly supported by DePuy Synthes Trauma – this is an ideal opportunity to get to grips with external fixation. Places are limited so you are advised to register as soon as possible to avoid any disappointment.

Pages 109-130

Thursday Poster Presentation Abstracts

An excellent programme for the meeting has been organised and a great deal of work has gone into setting the meeting up and especially in such a beautiful location.

Pages 131-133

Notes Pages

I look forward to seeing you all to debate and discuss the management of trauma.

Message from the BTS President , AD Patel - 09.10.15 Dear Colleagues, I am looking forward to seeing you all in Stoke on the 3 rd, 4th and 5th November for the 25th annual meeting of the British Trauma Society.

It was in Stoke, in a hotel which incidentally is still standing, where the first annual meeting took place 25 years ago. Rather nostalgically, the programme for that meeting will be available to view at this year’s meeting. You will notice that we started as a multi-disciplinary meeting and we remain the same to this day.

In addition to the meeting there are a number of vacancies on the Executive Board and we are welcoming nominations in time for the AGM on Wednesday 4th November at 6pm. I am envisaging a lively annual general meeting which all members are welcome to attend. This should make you thirsty for the local brew!

For those that are thinking of attending do not hesitate, and for those attending, look forward to a great time.

See you in Stoke!

Mr AD Patel FRCS President of the British Trauma Society

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BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

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Heraeus Medical is one of the leading companies in the field of bone cement and biomaterials for elective ortopaedic and trauma surgery. As a result, the company makes an essential contribution by improving the surgical outcome in bone and joint surgery leading to an improvement in the patients health-related quality of life.

EXHIBITING SPONSORS BTS 2015 gratefully acknowledges the contribution that the sponsors below have made to make this event possible.

With over 25 years' experience and an unrivalled dedication to quality, the products we research, engineer and manufacture are at the forefront of calcium technology. Our innovative products range from bone grafts to matrices that elute supra-MIC levels of antibiotics at the site of infection.

Furthermore, this may lead to a reduction in healthcare costs. Heraeus Medical mainly focuses on biomaterials for orthopaedic surgery.

The key product PALACOS, is regarded as the Gold Standard amongst bone cements, with a history of clinical efficacy spanning five decades.

We are proud to be driving improved outcomes across a wide range of clinical applications, in musculoskeletal infection, trauma, spine and sports injuries, for surgeons and patients alike

METAPHYSIS LLP (incorporating Intelligent Orthopaedics) METAPHYSIS was incorporated in 2013 to develop a new concept in orthopaedic trauma in cooperation with a number of other European institutions. We are based in Keele village. In July 2015 METAPHYSIS acquired the Intelligent Orthopaedics’ products.

Founded in 1927 and headquartered in Warsaw, Indiana, USA, Zimmer Biomet is a global leader in musculoskeletal healthcare. We design, manufacture and market orthopaedic reconstructive products; sports medicine, biologics, extremities and trauma products; spine, bone healing, craniomaxillofacial and thoracic products; dental implants; and related surgical products.

However, the story started in the early 1990’s when Professor Peter Thomas FRCS (Consultant Orthopaedic Surgeon) and Professor Peter Ogrodnik commenced a research project on the healing of long bone fractures and as a result Intelligent Orthopaedics was formed to take the product innovations to market. Currently two products are marketed with others to follow shortly.

We collaborate with healthcare professionals around the globe to advance the pace of innovation. Our products and solutions help treat patients suffering from disorders of, or injuries to, bones, joints or supporting soft tissues. Together with healthcare professionals, we help millions of people live better lives.

STORM and IOS were first marketed in 2005 and has customers in the USA, Europe, Middle East and Australia as well as the UK. If you are interested in hearing about the next major developments in orthopaedic trauma please come to our stand and have a look!

We have operations in more than 25 countries around the world and sell products in more than 100 countries. For more information, visit www.zimmerbiomet.com, or follow Zimmer Biomet on Twitter at www.twitter.com/zimmer.

With more than 20 years of innovation and 1,700 installations worldwide, Sectra is a world-leading provider of IT systems and services for orthopaedics, radiology and other image-intensive departments.

Marquardt medical UK ltd Innovation, quality and service are decisive criteria for excellence in medical engineering. In our daily work as specialists for osteosynthesis and spinal devices we are dedicated to provide the medical sector with high-quality products for human medical care. From development to production to in-house storage: Visit our stand to find out more about our new innovations in orthoapedic trauma surgery . www.marquardt-uk.com email- info@marquardt-uk.co.uk

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BTS - 25th Annual Scientific Meeting

Sectra offers a complete set of highly efficient preoperative planning tools both for 2D and 3D images.

The latter are especially valuable for planning complex trauma cases. Sectra’s solution enables orthopaedic surgeons to increase precision in planning and advance preparation for various scenarios, thereby avoiding stress, saving time and minimizing risk during surgery.

BTS - 25th Annual Scientific Meeting

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BRITISH TRAUMA SOCIETY ANNUAL SCIENTIC MEETING

Keynote Speakers

FLOOR PLAN

Exhibition Stands 1.

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Fiona Lecky MB Ch B, FRCS, DA, MSc, PhD, FCEM

Zimmer Biomet Biocomposites Heraeus Marquardt Medical UK Metaphysis Sectra AB BTS Membership British Orthopaedic Society

Mark Loeffler Consultant in Trauma and Orthopaedics

Fiona Lecky is Clinical Professor and Honorary Consultant in Emergency Medicine (EM) at ScHARR and Salford Royal NHS Foundation Trust. Fiona's role also includes that of Research Director of the Trauma Audit and Research Network and Chief Investigator of the Head Injury Transportation straight to Neurosurgery Trial (HITS-NS) (HTA funded). She has also recently started Chairing the 2012 NICE Head Injury Guideline Development Group. Fiona trained both as an undergraduate and Emergency Physician in the North West. During the latter period she received a Wellcome Fellowship in Clinical Epidemiology which enables her to look at clinical and biochemical markers of shock in major injury for her PhD. Fiona is also the Clinical Lead of the Injuries and Critical Care research group, art of the Vascular Specialty Group within the Greater Manchester Comprehensive Research Network.

Mark Loeffler qualified from the London Hospital Medical College. Basic surgical training was at Addenbrookes and Whipps Cross Hospitals; higher surgical training was at the Royal London Hospital, Royal National Orthopaedic Hospital, Colchester and Black Notley Hospitals and Auckland New Zealand. He was appointed as a Consultant in Trauma and Orthopaedic Surgery at Colchester general hospital, specialising in Trauma, Knee and hip surgery. He has been clinical lead of the Orthopaedic department and Director of the surgical division at Colchester. He has a keen interest in teaching and is Orthopaedic undergraduate tutor and middle grade educational supervisor. In 2014 he was awarded best trainer on the Royal London Hospital registrar rotation.

He is actively involved in Orthopaedic research and has published papers in many areas of trauma and Orthopaedic surgery. He enjoys his large family, sailboat racing, tennis and playing in a pub rock band.

I did a Welsh orthopaedic training rotation and was part of a limb reconstruction fellowship in Oxford. Research and clinical interests are complex lower limb trauma, bone infection, non-union, malunion and fractures with bone loss.

Deepa Bose MBBS, FRCS, FRCS (Tr & Orth)

Peter Thomas has been a Consultant Orthopaedic and Trauma Surgeon at the University Hospital of North Midlands since July 1989 and a Visiting Professor of Orthopaedic Engineering at Staffordshire University since June 2007. Peter has a special interest in treating lower limb trauma.

Exhibition Professor Peter B M Thomas MB,BS, FRCS(Eng), FRCS(Ed)

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BTS - 25th Annual Scientific Meeting

Most of Peter’s research efforts have been concentrated on studying the effects of movement on the healing bone, particularly the potential of external fixation. In collaboration with engineer Professor Peter Ogrodnik, he has developed new medical devices and moved them from basic research and pilot studies within his own clinic to launch them as commercially supplied devices to the NHS. Firstly the Staffordshire Orthopaedic Reduction Machine (STORM™), and secondly, he has helped develop and test a new type of external fixator for tibial fractures, the IOS™ fixator. Peter and the team were finalists for the Royal Academy of Engineering MacRobert Award and won the Lord Stafford Award for Innovation. He has been involved with various charitable organisations, joining medical relief teams across the world. Peter is currently the clinical lead of a team working on some exciting new developments that will take orthopaedic devices in to the 21st century and that will harness the power of the internet to change the on-going management of fractures.

BTS - 25th Annual Scientific Meeting

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BTSBTS 2015 Programme – 4th– and 5th November 2015 2015 Programme 4th and 5th November 2015 th Keele Hall, Keele University.

Keele Hall,Programme Keele University.

BTS 2015 – 4 and 5th November 2015 Keele Hall, Keele University.

Wednesday 4th November 2015 Wednesday 4th November 2015 th 08:30 10:00 ANDAND REFRESHMENTS Wednesday November 2015 08:30 - 10:004 REGISTRATION REGISTRATION REFRESHMENTS 10:00 – 10:15 Welcome by the BTS President – AD– Patel 08:30 –- 10:00 REGISTRATION REFRESHMENTS 10:00 10:15 Welcome by theAND BTS President AD Patel Ballroom Ballroom 10:20 – 10:55 ORAL PRESENTATIONS 10:00 – 10:55 10:15 Welcome by the BTS President – AD Patel Ballroom 10:20 ORAL PRESENTATIONS Ballroom Session 1 1 Session 10:20 – 10:55 ORAL PRESENTATIONS Ballroom 5 x 55 Minute Presentations, followed by 10 x 5 Minute Presentations, followed by 10 Session 1 ‘Audit of a of Fracture Clinic service using the British minutes discussion timetime ‘Audit a Fracture Clinic service using the British minutes discussion 5 x 5 Minute Presentations, followed by 10 Orthopaedic Association Standard for Trauma Orthopaedic Association for Trauma ‘Audit of a Fracture ClinicStandard service using the British minutes discussion time Guidance (BOAST 7) in a Level One Trauma

‘A snap shot audit of Orthopaedic Trauma at a Major Trauma Centre’ Edward John Nevins, Jonathan Yates, Matthew Richard Gaines, Cronan Christopher Kerin

11:30 – 11:45

REFRESHMENTS

Exhibition Area

11:45 – 12:15

ORAL PRESENTATIONS Session 3

Ballroom

‘Have post pelvic binder films become obsolete in the face of Trauma CT?’ David Wood, Rathan Jayapalan, Clara Tetty, Jonathan Mcgregor-Riley

Guidance (BOAST 7) in a Level One for Trauma Orthopaedic Association Standard Trauma Centre’ Centre’ Guidance (BOAST 7) in a Cronan Level One Trauma Henry Slade, Jonathan Yates, Kerin, Simon Henry Centre’Slade, Jonathan Yates, Cronan Kerin, Simon Scott.

Scott.

Henry Slade, Jonathan Yates, Cronan Kerin, Simon Scott.

‘Venous Thrombo-Embolism (VTE) Prophylaxis in in ‘Venous Thrombo-Embolism (VTE) Prophylaxis UK neurosurgical trauma: Is there a national UK neurosurgical trauma: Is there a national ‘Venous Thrombo-Embolism (VTE) Prophylaxis in consensus?’ consensus?’

UK neurosurgical trauma: Is Iqbal, there a national Alexander Bolt,Bolt, BilalBilal Khan, Faisal Alastair Alexander Khan, Faisal Iqbal, Alastair consensus?’

Marsh.

Marsh.

Alexander Bolt, Bilal Khan, Faisal Iqbal, Alastair

‘Pelvic Pressure Changes after a fracture: A pilot cadaveric study assessing the effect of pelvic binders and limb bandaging’ Rhys Morris, Andew Loftus, Anna Lygas, Rozina Mahmood, Ian Pallister

Marsh. outcomes in Low Energy Open Ankle ‘Treatment ‘Treatment outcomes in Low Energy Open Ankle Fractures in the Elderly’ Fractures in outcomes the Elderly’ ‘Treatment in Low Energy Open Ankle Asanka Wijendra, Rupali Awe, George Asanka Wijendra, Rupali Awe, George Fractures in the Elderly’ Grammatopolous, Michael Lamyman, Gregoris Grammatopolous, Michael Lamyman, Asanka Wijendra, Rupali Awe, GeorgeGregoris Kambouroglou.

Kambouroglou.

Grammatopolous, Michael Lamyman, Gregoris Kambouroglou.

‘The‘The CostCost of Time: Major Trauma Centre of Time: Major Trauma Centre Repatriation’ Repatriation’ ‘The Cost of Time: Major Trauma Centre Christopher Bano, Joanna Bovis, Tereza Malacova, Christopher Bano, Joanna Bovis, Tereza Malacova, Repatriation’ Kumar Kunasingam, Adel Tavakkolizedah Kumar Kunasingam, Adel Tavakkolizedah Christopher Bano, Joanna Bovis, Tereza Malacova, Kumar Kunasingam, Adelfor Tavakkolizedah ‘Current practice of consent trauma surgery: ‘Current practice of consent for trauma surgery: A time for change?’

A time forpractice change?’

‘Current of consent for trauma surgery: Steven Churchill, Cezary Kocialkowski, Ladan Steven Churchill, Cezary Kocialkowski, Ladan A timeAnand for change?’

Hajipour, Pillai Hajipour, Anand Pillai Steven Churchill, Cezary Kocialkowski, Ladan Hajipour, Anand Pillai

11:00 – 11:30 PRESENTATIONS 11:00 – 11:30 ORAL ORAL PRESENTATIONS Session 2 2 Session 11:00 – 11:30 ORAL PRESENTATIONS Session 2

Ballroom Ballroom Ballroom

‘Surgical fixation of Rib improves 4 x 54 Minute Presentations, followed by 10 ‘Surgical fixation of Fractures Rib Fractures improves x 5 Minute Presentations, followed by 10 outcomes in major trauma patients withwith thoracic discussion timetime outcomes in major trauma patients thoracicminutes minutes discussion ‘Surgical fixation of Rib Fractures improves 4 x 5 Minute Presentations, followed by 10 injury: A comparative study at a UK Major injury: A comparative studypatients at a UK Major outcomes in(MTC)’ major trauma with thoracic minutes discussion time Trauma Centre Trauma (MTC)’ study at a UK Major injury:Gerakopoulos, ACentre comparative Efstratios Leonie Walker, David Efstratios Gerakopoulos, Leonie Walker, David Trauma Centre (MTC)’ Melling, Simon Scott, Sharon ScottScott Melling, Scott, Sharon EfstratiosSimon Gerakopoulos, Leonie Walker, David Melling, Simon Scott, Sharon Scott how to ‘The‘The Glasgow Coma Scale: Do we Glasgow Coma Scale: Do know we know how to assess?’ assess?’

‘The Glasgow ComaMussa, Scale: Euan Do weStirling, know how to JohnJohn Jeffrey, Mohamed Jeffrey, Mohamed Mussa, Euan Stirling, assess?’

Ihsaan Al-Hadad, Jason Auld,Auld, Simon WestWest Ihsaan Al-Hadad, Jason Simon John Jeffrey, Mohamed Mussa, Euan Stirling, Ihsaan Al-Hadad, Jasonand Auld, Simon West ‘Management of Femoral Tibial Shaft ‘Management of Femoral and Tibial Shaft Fractures in patients with multiple injuries: Fractures in patients with multiple injuries: ‘Management of Femoral and Tibial Shaft Experience of a of Major Trauma Centre’ Experience a Major Trauma Centre’ Fractures in patients with multiple injuries: Hossam Fraig, Daniel Marsland, Amir Qureshi, Hossam Fraig, Amir Qureshi, Experience of aDaniel MajorMarsland, Trauma Centre’ NickNick Hancock Hancock Hossam Fraig, Daniel Marsland, Amir Qureshi, Nick Hancock

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4 X 5 Minute Presentations, followed by 10 minutes discussion time

‘The management of adult motorcyclists and pillion passengers with isolated open lower limb fractures in England, 2007 – 2014: A study using data from the TARN database’ Aurelie Hay-David, Thomas Stacey, Ian Pallister, TARN Research Committee ‘Head injuries and Warfarin: When are patients safe to be discharged?’

Aranghan Lingham, Yashashwi Sinha, Saleem Riaz ‘20 Years of Traumatic Brain Injury in the NHS – same treatments but different patients – are we moving forward?’ - Fiona Lecky

12:15 – 13:00

KEYNOTE LECTURE Ballroom

13:00 – 14:00

LUNCH

Exhibition Area

14:05 – 14:40

ORAL PRESENTATIONS Session 4

Ballroom

‘Follow-up of 810 Consecutive Titanium Hydroxyapatite coated uncemented stem hemiarthroplasties’ Syed Nawaz, Sophie Wrigley, Young-Seok Cho, Andrew Keightley, Arshad Khaleel

5 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘The effect of education on Tip-Apex distance in dynamic hip screw neck of femur fracture fixation’ Agniesh Dutta, Parag Raval ‘Warfarin reversal in Neck of Femur Fractures – current failings and future strategies’ John E Lawrence, Daniel Fountain, Andrew Carrothers, Duncan Cundall-Curry ‘Relationship of Vitamin D with bone mineral density, fracture type and social deprivation in neck of femur patients’ Emma Formoy, Ekemini Ekpo, Timothy Thomas, Cezary Kocialkowski, Anand Pillai

BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

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‘Medium to long term follow up of a consecutive series of 604 Exeter Trauma Stem Hemiarthroplasties’ Shruti Raut, Martyn Parker

14:45 – 15:15

ORAL PRESENTATIONS Session 5 ‘Outcome of Ilizarov frame treatment in the elderly. The Chertsey Experience’ Robert Boyd, Verona Beckles, Arshad Khaleel, Ankit Desai

16:30 – 17:00

KEYNOTE - Ballroom

‘Fixing Tibias!’– Professor Peter Thomas

17:00 – 17:35

ORAL PRESENTATIONS Session 7

Ballroom

‘Patient compliance with Venous Thromboembolism Prophylaxis in trauma and orthopaedic patients’ John R Blackwell, Parag Raval, John P Quigley, Amit Patel, Donald J McBride

5 x 5 minute presentations followed by 10 minutes discussion time

Ballroom

4 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘Venous Thromboembolism in the trauma and orthopaedic population’ John R Blackwell, Parag Raval, John P Quigley, Amit Patel, Donald J McBride

‘Results of the management of open tibial shaft fracture with segmental defect using the masquelet technique’ Munier Hossain, Rhys Morris, Alun Evans, I Pallister

‘VTE Prophylaxis in patients with ankle fractures’ Akmal Turaev, Sahan Fernando, A Fadulelmola, Radwane Faroug, R. Smith, J. Davenport

‘Use of poller screws with intramedullary nailing to increase fracture stability and gain interfragmentary compression’ Duncan Cundall-Curry, John E Lawrence, Daniel M Fountain, Matija Krkovic

‘Multi Centre audit of fracture neck of femur’ Ahmed Fadulelmola, A Turaev, A Abishek, K Sigamoney, A Chitre ‘Predictors of return to pre-morbid level of mobility and residence after hip fracture: A retrospective cohort study’ Benjamin D Chatterton, O Salar, PN Baker, C Hutchinson, CER Meyer, OL Thomas, DJ Ford

‘Results of the modified papineau technique for management of post-traumatic chronic osteomyelitis or open fracture with large soft tissue defect’ Munier Hossain, Ian Pallister

15:20 – 15:45 15:50 – 16:30

REFRESHMENTS ORAL PRESENTATIONS Session 6 ‘The virtual fracture clinic: innovation to optimise efficiency within trauma systems’ Zaamin Hussain, Niel Kang ‘Way forward to efficient fracture clinic’ Faiz R Hashmi, Jafri Mansoor, Ike Nwachukwu

18:00 -19:00

BTS AGM

Exhibition Area Ballroom

5 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘The assessment and management of Displaced Supracondylar Fractures of the humerus in children. An audit of BOAST Guideline 11 in a District General Hospital’ Edward Jenner, Mark Jinks, Farhan Syed, Hope Poole, Faiz Hashmi ‘Repeat radiographs following cast application in children with forearm fractures – An unnecessary evil?’

Rhodri Gwyn, Juliette Lewis, Abdul Gaffar Duddhinwala ‘Compliance with NICE Guidelines for VTE prophylaxis for non-surgically treated lower limb injuries with plaster casts’ Rohit Singhal, Callum Thomson, Ronan Banim

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BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

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Thursday 5th November 2015 08:30 – 09:30 REGISTRATION AND REFRESHMENTS 09:30 – 10:00 ORAL PRESENTATIONS Session 1 ‘A 7-year prospective epidemiological study of acute elbow admissions to a trauma unit’ Alexander Bolt, Siddartha Govilkar, John Blackwell, Stuart Hay

‘Refracture rates in paediatric forearm fractures: Is prolonged immobilisation the answer?’

Christie Brennan, Mark McMullan, Mukesh Madhavan, Philip Henman

Ballroom

‘Innovative use of single incision internal fixation lateral third clavicle fractures augmented with fiberwire.’

Rajpal Nandra, Simon McLean, Daniel Thurston, Socrates Kalogrianitis

4 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘A new nail with a locking blade for the complex proximal humeral fractures’ Faiz R Hashmi, Professor Dr Edgar Mayr, Klinikum Augsburg

‘Ultrasound guided interscalene brachial plexus blocks in shoulder surgery’ Kelly Jones, Prakash Jayakumar, Sonali Polakhare, Amratlal Patel

‘Alternative tension band technique for olecranon fractures: a Biomechanical study’ Sanjit Singh, Jan Kuiper, Abol Behzadian, T Madhusudhan, Amit Sinha ‘Elastic Titanium Nailing for Metacarpal Fractures – Our Results’ Ankit Desai, John Afolayan, William Winterbee, Kevin Newman

10:05 – 10:40

ORAL PRESENTATIONS Session 2

Ballroom

‘The use of intra-articular dye to assess injury to & reduction of the syndesmosis – the ‘Chertsey’ Test’ Robert Boyd, Zuhair Nawaz, Arshad Khaleel

4 x 5 Minute Presentations, followed by 10 minutes discussion time.

12:20 – 13:00

KEYNOTE LECTURE - Ballroom

‘Path to the Paralympics’ – Mark Loeffler

13:00 – 14:00 14:05 – 14:30

LUNCH ORAL PRESENTATIONS Session 4

Exhibition Area Ballroom

‘Fractured neck of femurs are clinical commissioning groups spoiling your figures’ Martin Sharrock, Ronnie Davies, Philomena Smith, Martyn Lovell

4 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘Compliance of Hemocue usage among hip fracture patients: A retrospective study’ Shazali Sulieman, William Eardley, Paul Baker ‘Internal Fixation of intracapsular neck of femur fractures – two hole dynamic hip screws or cannulated hip screws’ Simon Woods, Ivan Vidakovic, Alloush AlMothenna, Reza Mayahi

‘Sensitivity of magnetic resonance imaging in detecting soft tissue injuries of the knee’ Jonathan Yates, Tom Jamieson, William Bosswell, Cronan Kerin

‘Predicting the length of lag and locking screws from the length of gamma nails: a retrospective case series study’ Rhys Morris, Ian Pallister

‘Motocross biking for competition and for recreation : - A prospective analysis of four hundred and twenty three (423) injured riders’ Rohit Singh, AK Hamad, SM Hay

14:35 – 15:10

‘Ankle syndesmosis fixation, variation in practice and protocol for a trainee led, regional, multi centre randomised controlled trial’ Steve Borland, Patrick Williams

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10:40 – 11:00 11:00 -11:45

REFRESHMENTS KEYNOTE LECTURE – Ballroom

Exhibition Area

11:50 – 12:15

ORAL PRESENTATIONS Session 3

Ballroom

‘A district general hospitals’ experience of distal bicep repairs; a ten year analysis’ Paul Brewer, Noman Saghir, Daniel Winson, Hany Ismaiel

4 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘Infected non-unions - how I manage them in 2015’ – Deepa Bose

BTS - 25th Annual Scientific Meeting

ORAL PRESENTATIONS Session 5 ‘Predicting intra-operative periprosthetic fracture during uncemented hemiarthroplasty for intracapsular neck of femur fractures’ Harpal Uppal, Anil Dhadwal, Chris Downam, Ben Dean, Partha Bose, Adnan Saitha

Ballroom

5 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘Periprosthetic lower limb fractures; 10 years experience’ Rhodri Gwyn, Sanjit Singh, Ashok Mukherjee ‘Comparative outcome of isolated hip fractures and hip fractures in patients with simultaneous upper limb injury’ Atanu Bhattacharjee, Razi Bashir, Ibrahim Malek, Asad Syed

BTS - 25th Annual Scientific Meeting

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POSTER PRESENTATIONS - Wednesday 4th November

‘Does laminar flow ventilation reduce infection rate? An observational study of trauma in England’ Elizabeth Pinder, A Bottle, P Aylin, M Loeffler ‘Adequacy of hip fracture radiographs in emergency department and it’s implications’ Al-Mothenna Alloush, Tamas Kobezda, Michael Mokawem, Najarajan MuthuKumar

15:15 – 15:30

REFRESHMENTS

Exhibition Area

15:30 – 16:05

ORAL PRESENTATIONS Session 6

Ballroom

‘Epidemiology of acetabular fractures in the North West of England’ Suran De Almeida, Pratima Khincha, Bishoy Youssef, N Birkett, E R Street, A D Clayson, Nikhil Shah, Henry Wynn Jones

5 x 5 Minute Presentations, followed by 10 minutes discussion time.

‘A biomechanical study to determine the optimum method of fixation for distal tibial fractures’ Ashwin Unnithan, Zhaochen Shan, Camilla Halewood, Arshad Khaleel, Professor Andrew Amis

16:15

POSTER NUMBER

POSTER TITLE

MAIN AUTHOR AND CO AUTHORS

1 2

‘Analysis of post-operative thromboprophylaxis instructions at a major trauma centre: A closer look at the operation note’ ‘Mortality arising from diabetic neck of femur fracture patients’

Leslie Ing, Saif Sait, Kirsty Drewm Kumar Kunasingam Onn Shaun Thein, Emma Hirons, Kishore Dasari

3

‘Femoral and tibial nailing in 2014, is follow up necessary?’

4

8

‘A UHSM Audit: How many trauma calls are potentially avoidable?’

‘The role of CT scanning in humeral head fractures’ ‘Improving the care and safe movement of patients with pelvis fractures by developing a local guideline at a Level 1 Major Trauma Centre’ ‘Incidental findings on whole body computerised tomographic scanning in a tertiary trauma centre’ ‘Fracture clinic service efficiency’

Andrew Swali, Martyn Lovell, Oluwatomisin Ashiru Rory Grinsall, Martyn Lovell, Ronnie Davies

9

‘Antibiotic prophylaxis for hip fracture surgery’

10

‘Correlation between Forearm to Distal Interphalangeal joint of little finger and femoral nail length’ ‘The management of segmental tibial shaft fractures: A systematic review’ ‘Arthroscopy for lateral epicondylitis: Does pre-operative MRI scanning accurately predict the findings at arthroscopy?’

‘Distal femoral oblique fracture in a young male soldier: An unusual presentation’ ‘LER in diagnosing acute prosthetic joint infection’

5 6 7

11 12

‘Bilateral spontaneous bisphosphonate insufficiency fractures of the proximal tibia and unilateral distal femur: A case report and recommendation’ Zaid Al-Wattar, Kasetti Ravikumar

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‘Dedicated anaesthetic teams for trauma – optimising fracture neck of femur patient care and the additional benefit to improved best practice tariff (BPT) – a district general hospital (DGH) experience’ Sushil Manohar, Atul Malik, Syeda Naqvi, Martin Beard, Subhash Sivasubramanium, Ram Ponnuru, Pragnesh Raj, Aun Shaun Thein

15

14

17

‘Autologous Chondrocyte Implantation with bone cylinder graft in osteochondral defects in knee’ ‘Femoral head histology in hip fracture surgery: To send or not to send?’

‘Should we remove bullets from the spinal cord?’

18

‘Attendance at fracture clinics’

‘The outcome after operative and non-operative management of scapular fractures: a systematic review’ Sudhir Kannan, H P Singh, R Pandey

19

CONFERENCE CLOSE

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‘Results following revision of the femoral prosthesis for periprosthetic hip fractures using a modular hydroxyapatite coated interlocked femoral stem’ ‘An audit of primary traumatic hip dislocations according to BOAST3 guidelines’ ‘The effect of Major Trauma Centre (MTC) status on the admissions and outcomes with pelvic fractures in a teaching hospital’ ‘Total hip arthroplasty periprosthetic fractures: A seven year, single centre experience’ ‘Are stainless steel elastic nails the solution to heavier children with femoral shaft fractures’ ‘Locking versus non-locking plates for distal fibula fractures’

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BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

Alistair Jones Jessica Lunn, Abigail Clark-Morgan, Paul Harnett, Matthew Gee Emma Merrick, Sumita Chawla, John Taylor Amanda King, Alex Feben, Asim Siddiqui, Ben Brooke, Bob Metcalf, Guy McWilliams Amanda King, Jan Marciniak, Chris Lewis, Gareth Wells, Sudhi Ankarath, Aneil Shenolikar, Simon Sturdee Uthman Alao, Jonathan Yates, Cronan Kerin Zoe Little, Samuel McMahon, Toby O Smith, Alex Trompeter, Caroline Hing Jonathan Yates, Harry Casserley Hesham Al-Khateeb, Hussain Al Omar, David Cohen Rana Q H Mehdi, Soliman Noureldin, Ramasubramanian Dharmarajan, Manjula Meda, Michael Orr, Biju Sankar, Timothy Petheram Atanu Bhattacharjee, HS McCarthy, B Tins, JH Kuiper, S Roberts, JB Richardson Sebastian Crosswell, O Salar, CER Meyer, SM Hay, DJ Ford Lisa Grandidge, Antony Rex Michael Pratima Khincha, Kohila vani Sigamoney, Neelam Patel, Ravi Badge, Lindy Fairhurst, Puneet Monga Henry Wynn Jones, Robert Hewitt, Nikhil Shah, Timothy Board, Martyn Porter Muhammad Adeel Akhtar, Lysander Gourbault, Amir Mukhtar, Andrew Colin Gray Muhammed Adeel Akhtar, Oladiran Olatunbode, Jim McVie Jonathan Yates, James Fountain Richard Hutchinson, Prof Sam Evans Shirley A Lyle, Catherine Malik, Michael J Oddy

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POSTER PRESENTATIONS – Thursday 5th November POSTER NUMBER

POSTER TITLE

MAIN AUTHOR AND CO AUTHORS

1

‘Outcome of plate fixation of complex Olecranon fractures. A retrospective study’ ‘A case of unprovoked shoulder haemarthrosis associated with rivaroxaban therapy’ ‘The compliance to NICE guidelines and its impact on care of patients with neck of femur fracture a completed audit loop’ ‘Outcome of the unaffected contralateral hip in unilateral slipped capital femoral epiphysis: Comparison of prophylactic fixation with observation’ ‘Dislocation rates of hip hemiarthroplasty’ ‘Sports Injuries: The radial nightstick fracture and its treatment’ ‘ETS Versus Thompson hemiarthroplasty. How nice are the NICE guidelines?’

‘Recovery of radial nerve palsy after locking plate fixation of diaphyseal humerus fractures: A seven year series’

Mohammed Ali, Dimitrios Aspros, David Clark, Amol Tambe Ahmed Ezzat, Daragh Chakravarty, David Cairns, Niall Craig Sudhir Kanan, Arjit Ghosh, Alwyn Abraham, Nicky Morgan Atanu Bhattacharjee, Robert Freeman, Andrew P Roberts, Nigel T Kiely

2 3 4 5 6 7

Peter Craig, Ross Fawdington, Philip Roberts Alistair Jones, Andrew Pearse

9

‘Review of patient transfers from spinal surgery to the Spinal Injuries unit’

10 11

‘Closing the loop on lower limb open fracture management: A major trauma centre audit of BOAST 4 guidance’ ‘Predicting blood transfusion in hip fracture patients’

Saif Ul Islam, Sadaf Afzaal, James Fountain, Paul Carter Alexander Duguid, Robert Burton, Conal Keene, Marius Espag, Tim Cresswell, David Clark, Amol Tambe Lisa Grandidge, Michael Atanassacopoulos, Lee Breakwell, Neil Chiverton, Ashley Cole, Marcel Ivanov, Antony Michael Aranghan Lingham, Amy Laurent, Yashashwi Sinha, John Blackwell, Justin Lim Calum Thomson, Helen Owen, Phillip Holland

12

‘The traumatic abdomen: How exposed are trainees?’

Sarah Barkley, Hayley Hutchings

13

‘Stemming the tide? Can an extra, weekly consultantdelivered operating session of 3 neck of femur fractures really make a difference to a trauma service?’

‘Hip fracture surgery and newer anticoagulants: A matter of debate?’

‘The epidemiology and outcomes of pelvic fractures in the South Tees during the last 6 years’ ‘Cemented vs Uncemented total hip replacement for neck of femur fractures’ ‘Postoperative nausea and vomiting and delayed discharge in elective orthopaedic surgery’ ‘Management of suspected clinical scaphoid fracture in Wigan, Wrightington and Leigh’ ‘Implementation of formal documentation of tertiary trauma survey for transferred polytrauma patients (tertiary pelvic referral)’ ‘Are post ankle fixation repeat radiographs in fracture clinics necessary?’

‘The management of hip fracture in adults: Imaging options in occult hip fracture implementing NICE guidelines’

Gavin McLean, Ryan Moffatt, Sinead McDonald, David Kealey

8

14 15 16 17 18 19 20

Ahmed Fadulelmola, T Kwaees, A Turaev, J Davenport, N Shah, M Walt Kohila Sigamoney, Abdullah Gabr, Hugo Lewkowicz, Ceyon Jeyarajah, Adam Watts Kohila Sigamoney, Abdullah Gabr, Pratima Khincha, Nikhil Shah Angus Fong, Samuel Osieku, Paul Haslam Akmal Turaev, Ahmed Fadulelmola, S Ramachandran, Nikhil Shah, R Smith, J Davenport

16

BTS - 25th Annual Scientific Meeting

AUMA TR

CIETY SO

BRITISH

21

Muhammad Adeel Akhtar, Amir Mukhtar, Lysander Gourbalt, Andrew Colin Gray Muhammad Adeel Akhtar, Oladiran Olatunbode, Jim McVie Atif Mahmood, Ansar Mahmood

www.bts-org.co.uk

Oral Presentations Session 1 – Wednesday 4th November

MAIN AUTHOR

Abstract 1

AUDIT OF A FRACTURE CLINIC SERVICE USING THE BRITISH ORTHOPAEDIC ASSOCIATION STANDARD FOR TRAUMA GUIDANCE 7 (BOAST 7) IN A LEVEL ONE TRAUMA CENTRE Henry Slade Aintree University Hospital, Liverpool, UK

Oral Presentations – Session 1 – Wednesday 4th November Oral Presentations – Session 1 – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR

Abstract 2 Abstract 2

VENOUS THROMBO-EMBOLISM (VTE) PROPHYLAXIS IN UK VENOUS THROMBO-EMBOLISM (VTE) PROPHYLAXIS IN UK NEUROSURGICAL TRAUMA: IS THERE A NATIONAL CONSENSUS? NEUROSURGICAL TRAUMA: IS THERE A NATIONAL CONSENSUS?

Alexander Bolt Alexander Bolt Russells Hall Hospital Dudley Russells Hall Hospital Dudley Bilal Khan, Faisal Iqbal, Alastair Marsh Bilal Khan, Faisal Iqbal, Alastair Marsh Russells Hall Hospital Dudley Russells Hall Hospital Dudley Alexander Bolt Alexander Bolt

CO AUTHORS

Jonathan Yates, Cronan Kerin, Simon Scott, Aintree University Hospital, Liverpool, UK

CO AUTHORS CO AUTHORS

PRESENTER

Henry Slade

PRESENTER PRESENTER

OBJECTIVES

In August 2013 the British Orthopaedic Association (BOA) issued guidance for all Trusts providing fracture clinic services. Whilst workload within the trauma centres increased over this time it was acknowledged that high standards must also be maintained. This audit examines a level one trauma centres fracture clinic service using this BOA guidance.

OBJECTIVES OBJECTIVES

Determine if there are protocols for VTE prophylaxis in cases of neurosurgical trauma in Determine if there are protocols for VTE prophylaxis in cases of neurosurgical trauma in UK neurosurgical centres and if not is there a national consensus on VTE prophylaxis.

UK neurosurgical centres and if not is there a national consensus on VTE prophylaxis.

METHODS METHODS

Neurosurgical centres across the UK were contacted by telephone and asked what Neurosurgical centres across the UK were contacted by telephone and asked what their routine VTE prophylaxis protocol was for neurosurgical cases using a their routine VTE prophylaxis protocol was for neurosurgical cases using a standardised questionnaire. Data was obtained on head injuries, spinal fractures and standardised questionnaire. Data was obtained on head injuries, spinal fractures and spinal cord injuries. spinal cord injuries.

RESULTS RESULTS

Very few neurosurgical centres had protocols for VTE prophylaxis in trauma.

Very few neurosurgical centres had protocols for VTE prophylaxis in trauma.

METHODS

RESULTS

CONCLUSIONS

18

A single week (ten clinic sessions) in November 2014 was retrospectively analysed. A random number generator was used to select ten patients per clinic. An audit tool created by the British Orthopaedic Trainees Association was utilised. Results were analysed by one person in conjunction with fracture clinic staff. Six months later, using the same methods mentioned above, the audit loop was closed.

In head injuries there was not a national consensus. The majority of centres advised In head injuries there was not a national consensus. The majority of centres advised mechanical prophylaxis in the form of TEDS for all patients, using pneumatic mechanical prophylaxis in the form of TEDS for all patients, using pneumatic compression devices if patients were immobilised. Chemical prophylaxis in the form of compression devices if patients were immobilised. Chemical prophylaxis in the form of low molecular weight heparin (LMWH) was largely based on consultant input, but some low molecular weight heparin (LMWH) was largely based on consultant input, but some centres would advocate this if imaging demonstrated no haemorrhage. All agreed that centres would advocate this if imaging demonstrated no haemorrhage. All agreed that VTE prophylaxis should be stopped when patients were fully mobile. In cases of VTE prophylaxis should be stopped when patients were fully mobile. In cases of haemorrhagic head injury all advocated mechanical prophylaxis and the majority haemorrhagic head injury all advocated mechanical prophylaxis and the majority required consultant input regarding chemical prophylaxis. A small number would start required consultant input regarding chemical prophylaxis. A small number would start chemical prophylaxis 24 hours post-operatively. chemical prophylaxis 24 hours post-operatively.

We looked at 33 new and 67 follow up patients. One patient was seen over 72 hours.

All patients were under the care of a single named consultant leading that clinic. All management plans were relayed to GPs directly. All clinics had plaster room and radiology services readily available. Referrals to physiotherapy and occupational therapy are made directly in clinic. There is a fully integrated fracture liaison service and rapid access for patients to discuss their treatment with staff. We did not have up-todate information leaflets for common fractures or a complex regional pain syndrome (CRPS) treatment protocol. Local referral guidelines for fracture clinic were already in place and working. Following the initial audit patient information leaflets for common fractures and injuries were developed. After consultation with local specialist CRPS services, pain team and physiotherapists a treatment protocol was also developed and implemented into the fracture clinic.

Initially, ten out of thirteen BOAST 7 recommendations were fully met during the first audit cycle. We have developed new patient information leaflets and developed a CRPS treatment protocol. The re-audit demonstrated that we now meet the full criteria using the BOAST 7 guidance. This audit also prompted discussion about how to maintain the 72 hour target for seeing new patients throughout the year, especially during bank holiday weekends and Christmas holidays and the challenge this presents.

This audit gave us a snapshot of our current service and an early opportunity to develop and improve our fracture clinic services. In the next audit round, we will be keen to obtain patient reported outcome measures and opinions to further guide and drive service improvement.

BTS - 25th Annual Scientific Meeting

In spinal fractures and spinal cord injuries there was equally no consensus on VTE In spinal fractures and spinal cord injuries there was equally no consensus on VTE prophylaxis. The majority of centres recommended mechanical compression of variable prophylaxis. The majority of centres recommended mechanical compression of variable duration. There was a varied approach to chemical prophylaxis with some centres led duration. There was a varied approach to chemical prophylaxis with some centres led by consultant decisions, others would start immediately if there was no evidence of by consultant decisions, others would start immediately if there was no evidence of haematoma or oedema. A small minority would only use mechanical prophylaxis if a haematoma or oedema. A small minority would only use mechanical prophylaxis if a spinal fracture was associated with a spinal cord injury. Most centres started chemical spinal fracture was associated with a spinal cord injury. Most centres started chemical prophylaxis >24 hours post-operatively and recommended stopping prophylaxis on prophylaxis >24 hours post-operatively and recommended stopping prophylaxis on discharge. discharge.

Spinal rehabilitation units did have a general consensus on VTE prophylaxis. They Spinal rehabilitation units did have a general consensus on VTE prophylaxis. They suggest chemical prophylaxis for 3 months but with a variable duration of mechanical suggest chemical prophylaxis for 3 months but with a variable duration of mechanical prophylaxis. prophylaxis.

CONCLUSIONS CONCLUSIONS

We conclude that there are few protocols in neurosurgical centres to prevent VTE in We conclude that there are few protocols in neurosurgical centres to prevent VTE in neurosurgical trauma. There is no national consensus on VTE prophylaxis in neurosurgical trauma. There is no national consensus on VTE prophylaxis in neurosurgical trauma except in spinal rehabilitation units. Neurosurgical centres vary in neurosurgical trauma except in spinal rehabilitation units. Neurosurgical centres vary in their approach to VTE prophylaxis but there are common themes and from these we their approach to VTE prophylaxis but there are common themes and from these we should endeavour to develop a national protocol. should endeavour to develop a national protocol.

BTS - 25th Annual Scientific Meeting

19

Oral Presentations – Session 1 – Wednesday 4th November Oral Presentations – Session 1 – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

20

Abstract 3 Abstract 3

TREATMENT OUTCOMES IN LOW ENERGY OPEN ANKLE FRACTURES IN TREATMENT OUTCOMES IN LOW THE ENERGY ELDERLYOPEN ANKLE FRACTURES IN THE ELDERLY Asanka Wijendra Asanka Wijendra Oxford University Hospitals NHS Trust Oxford University Hospitals NHSHospitals Trust Rupali Alwe - Oxford University NHS Trust Rupali Alwe - Oxford University Hospitals NHSHospitals Trust NHS Trust George Grammatopoulos - Oxford University George University Hospitals NHS Trust Michael Grammatopoulos Lamyman - Oxford- Oxford University Hospitals NHS Trust Michael - Oxford University Hospitals NHS Trust GregorisLamyman Kambouroglou - Oxford University Hospitals NHS Trust Gregoris Kambouroglou - Oxford University Hospitals NHS Trust Asanka Wijendra Asanka Wijendra

The objectives of this retrospective study were to review the outcome of low energy The of the this elderly retrospective study parameters were to review outcome of lowfollowing energy openobjectives fractures in and identify that the improve outcome open fractures in the this elderly identify parameters improve following treatment.

To achieve we and present the largest seriesthat of low energyoutcome ankle open ankle treatment.

To aachieve this we presentalgorithm the largest series energy ankle open ankle fractures and suggested treatment based on of ourlow findings. fractures and a suggested treatment algorithm based on our findings.

All patients who presented to the Major Trauma Centre (MTC) at John Radcliffe All patients who presented the Major Centre at John Hospital in Oxford between to January 2010Trauma and 2015 with(MTC) an open ankle Radcliffe fracture Hospital Oxford between and 2015Data with collected an openincluded ankle fracture following in a fall of less than twoJanuary meters 2010 were identified. patient following a fall and of less than two meters wereassessed identified.according Data collected patient demographics comorbidities with injury to theincluded Association for demographics comorbidities injury assessed Association for the Study of and Internal Fixationwith classification (AO)according and theto the Gustilo Anderson the Study ofStudy Internal Fixationwere classification (AO)fixation and the Gustilo Anderson classification. end-points wound related, related, mobility status classification. end-pointsfunctional were wound related, fixation related,score. mobility status post-injury andStudy patient-reported outcome using the Enneking post-injury and patient-reported functional outcome using the Enneking score.

The cohort comprised 61 patients with a mean age of 73 years, 82% female, 18% The cohort 61 patients with a mean age fracture. of 73 years, 18% diabetic andcomprised 10% having had a previous fragility 80% 82% werefemale, ambulating diabetic and 10% having had Definitive a previous fragility fracture.

80% were ambulating independently prior to the injury. surgical treatment was osteosynthesis in 49, independently the injury.

Definitive surgical treatment in 49, retrograde nail prior in 2, to external fixator in 8 and amputation in 2. was 39 ofosteosynthesis the fracture wounds retrograde nailclosed, in 2, external fixator in 8skin andgraft amputation 2. 39treated of the fracture wounds were primary 6 required a split (SSG), 6inwere with 2° intention were primary closed, 6 required a split skin graft (SSG), 6 were treated with 2° intention and 10 required free tissue flap and SSG. and 10 required free tissue flap and SSG. There were five (16.1%) hospital deaths, four fixation failures and three cases of wound There were five (16.1%) hospitalintervention. deaths, four Superficial fixation failures and three casesinof4 wound dehiscence requiring operative infection occurred cases dehiscence requiring operative intervention.

Superficial infection occurred in and 4 cases and deep infection in 6.

The overall complication rate was 23%. The 3-month 1-yr and deep rates infection in 6.

Theand overall complication rateIndependent was 23%. The 3-month and was 1-yr mortality were 16% 21% respectively. mobility status mortality were 16% and 21% respectively. Independent mobility status was present inrates 50% at follow-up. present in 50% at follow-up.

The mean Enneking score was 35.49 out of 40 (SD: 5.90) suggesting successful and The mean Enneking score was 35.49 of 40 (SD:significant 5.90) suggesting successful and acceptable reconstruction.

There wasout a statically difference in Enneking acceptable reconstruction.

Therewith was2°aclosure statically significant difference in Enneking score with patients fairing worse compared to both 1° closure and free score fairing worse withimproved 2° closure compared bothseen 1° closure and free tissue with flap patients with SSG. A significantly outcome wastoalso in patients that tissue flap with SSG. A significantly seenwalking in patients were walking independently pre-injuryimproved comparedoutcome to thosewas that also required aids.that were walking independently pre-injury compared to those that required walking aids.

The high morbidity rate associated with these injuries may reflect the hosts’ reserves The high morbiditytorate associated the hosts’ reserves and is comparable other fractures with seenthese in theinjuries elderly. may This reflect series found that definitive and comparable to other seen inbetter the elderly. seriesoutcome. found thatWe definitive soft is tissue cover results in fractures a significantly patientThis reported hence soft tissue cover a significantly better patient reported Weofhence recommend that results patientsinbe treated in dedicated MTCs with anoutcome. algorithm early recommend that patients be treated in dedicated primary MTCs with an algorithm of early surgery, cautious debridement, rigid stabilisation, closure, close monitoring, surgery, debridement, rigid stabilisation, primary closure, close monitoring, secondarycautious reconstruction (if needed). secondary reconstruction (if needed).

BTS - 25th Annual Scientific Meeting

th November Oral Presentations – Session 1 – Wednesday 4th

Abstract 4

THE COST OF TIME: MAJOR TRAUMA CENTRE REPATRIATION MAIN MAIN AUTHOR AUTHOR

Christopher Bano and Joanna Bovis Kings College Hospital NHS Foundation Trust, London, United Kingdom

CO CO AUTHORS AUTHORS

Malacova, Tereza Malacova Kumar Kunasingam Adel Tavakkolizadeh

PRESENTER PRESENTER

Christopher Bano and Joanna Bovis

OBJECTIVES OBJECTIVES

To assess the time to repatriation of out of area, major trauma patients to their local hospital from a major trauma centre.

METHODS METHODS

A retrospective study was carried looking at 1261 out area major trauma patients brought to Kings College Hospital between 01/01/2014 and 31/12/2014. Out of area was defined as any patient whose postcode was not within the KCH catchment area.

Any patients that were not admitted from A+E or stayed less than 24 hours were omitted as well as patients who died during the admission or who self-discharged.

Patients of no fixed abode were counted as within catchment area. This left 878 cases to be included in the study. Their trauma needs were defined as ‘completed’ once it was stated in the notes that the patient should be repatriated. Patients were considered accepted at the local hospital when it was stated in the notes, or when the repartition paper work was completed with a named receiving consultant at the other hospital.

RESULTS RESULTS

878 patients where eligible for repatriation, of which 156 (12.4%) were successfully repatriated. The median length of stay once medically stable was 11 days (inter-quartile range 23.5). The total number of days medically stable patients spent waiting for repatriation totalled 2599 hospital days. The median length of stay from a’ hospital acceptance’, to all the paper work being complete and the patient actually being repatriated was 4 days (IQR 8).

CONCLUSIONS CONCLUSIONS

KCH is part of the SELKaM trauma network, one of the biggest trauma networks in the country. There is an agreement within the network that KCH will notify local hospitals within 48 hours of any major trauma patients admitted from their catchment area. Local hospitals will then accept the repatriation of patients within 48 hours of their major trauma needs being met. This allows flow of patients through the MTC and is more convenient for patients.

Our results show two delays in the repatriation of MTC patients. Firstly, the MTC is poor at notifying the local trauma centres that patients are medically stable (median length of 11 days). Secondly, local trauma centres are taking twice as long as required to accept the repatriable patients once they are stable (median length of stay post acceptance of care 4 days). This delay in repatriation occupies the MTC beds inappropriately. It also places an extra economic burden on the MTC in what is already a fiscally challenging time for most trusts.

BTS - 25th Annual Scientific Meeting

21

th November Oral Presentations – Session 1 – Wednesday 4th

Abstract 5

Steven Churchill University Hospitals of South Manchester

CO CO AUTHORS AUTHORS

Cezary Kocialkowski – UHSM, Manchester, UK Ladan Hajipour – UHSM, Manchester, UK Anand Pillai – UHSM, Manchester, UK Steven Churchill

OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

22

The ruling of the Montgomery case this year emphasised the importance of explicit and legally defensible consent in the modern era; the particular nuances relating to informing patients of risks specifically relevant to them. We performed an audit of the current consenting standards in our trauma department to ascertain what can be done to make the consenting process more consistent and justifiable.

We audited 68 consent forms for patients having elective orthopaedic and trauma procedures between February and April 2015. Specifically looking at who consented the patient, the procedure, as well as each risk/complication identified on the form. We also noted any key differences in the way people consented.

Consent for 31 trauma procedures were assessed in the audit: 26 neck of femur (NOF) repairs, three ORIFs and two hip revisions; all of the consent forms were completed by SHO grade doctors. The median day of consent was 1 day pre-procedure. For NOF patients, the proportion consented for specific risks were: pain (53.8%), infection (100%), bleeding (96.2%), leg length discrepancy (11.5%), neurovascular (NV) injury (88.5%), MI (42.3%), DVT/PE (84.6%), fatal PE (3.8%), death (36.4%)

MAIN MAIN AUTHOR AUTHOR

Mr Efstratios Gerakopoulos

CO CO AUTHORS AUTHORS

Aintree University Hospital, Liverpool, UK Dr Leonie Walker, Mr David Melling, Mr Simon Scott, Mrs Sharon Scott, Aintree University Hospital , Liverpool, UK

PRESENTER PRESENTER

Mr Efstratios Gerakopoulos

OBJECTIVES OBJECTIVES

Thoracic injury (TI) is the second biggest cause of trauma-related deaths and flail chests (FC) are associated with serious respiratory complications and high mortality rates. Current evidence on open reduction and internal fixation (ORIF) of rib fractures is limited and the procedure poorly understood and not widely practiced in the acute setting. This comparative study, aimed to evaluate the effectiveness of rib fracture ORIF following implementation of a surgical guideline in March 2014.

METHODS METHODS

A group of major trauma patients with TI who underwent ORIF from 03/2014-03/2015 were compared with patients treated conservatively after major TI between 08/201203/2014. Both groups' patients fulfilled the hospital’s evidence-based guideline regarding eligibility for surgical fixation. Characteristics and outcomes between the operative and non-operative groups were measured and compared.

RESULTS RESULTS

47 patients identified in the operative group, mean age = 57.32 years and mean fractured ribs = 7.32, 55.3% presenting with FC. 36 patients included in the nonoperative group, mean age = 57.47 years and mean fractured ribs = 7.72, 44.4% demonstrating FC. ORIF group: Mean hospital length of stay (LOS) = 14.53 days, 48.9% necessitated ICU admission (mean LOS = 12.43). 38.3% received mechanical ventilation (MV) (mean duration = 9.33) and 18 patients (38.3%) developed Hospital Acquired Pneumonia (HAP). One death recorded (2.1%).

Non-operative group: Mean hospital LOS = 30.47 days, 77.8% necessitated ICU admission(mean LOS=12). 50% received MV (mean duration = 5.67) and 18 patients (50%) developed HAP. Five deaths recorded (13.9%).

CONCLUSIONS CONCLUSIONS

Rib fractures’ ORIF significantly improved outcomes relating to hospital and ICU LOS, respiratory complications and mortality in major trauma patients with severe TI. Careful patient selection, multi-disciplinary team working and surgical expertise are paramount.

We hope our findings will promote further understanding and inform widespread use of this innovative surgical intervention.

Some risks are being well consented consistently such as infection, bleeding and NV injury. However, even though the evidence tells us that the risk of PE following a NOF fracture is around 5% with a 1-year mortality of 20-35%, these are not being consented for universally. This would suggest a more reliable form of consenting maybe appropriate, either through consenting “stickers” or by standardised consent forms.

BTS - 25th Annual Scientific Meeting

Abstract 6

SURGICAL FIXATION OF RIB FRACTURES IMPROVES OUTCOMES IN MAJOR TRAUMA PATIENTS WITH THORACIC INJURY: A COMPARATIVE STUDY AT A UK MAJOR TRAUMA CENTRE (MTC)

CURRENT PRACTICE OF CONSENT FOR TRAUMA SURGERY: A TIME FOR CHANGE?

MAIN MAIN AUTHOR AUTHOR

PRESENTER PRESENTER

th November Oral Presentations – Session 2 – Wednesday 4th

BTS - 25th Annual Scientific Meeting

23

Oral Presentations – Session 2 – Wednesday 4th November Oral Presentations – Session 2 – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR

Abstract 7 Abstract 7

th Oral Oral Presentations Presentations –– Session Session 2 2 –– Wednesday Wednesday 4 4th November November

THE GLASGOW COMA SCALE: DO WE KNOW HOW TO ASSESS? THE GLASGOW COMA SCALE: DO WE KNOW HOW TO ASSESS?

Abstract Abstract 8 8

MANAGEMENT OF OF FEMORAL FEMORAL AND AND TIBIAL TIBIAL SHAFT SHAFT FRACTURES FRACTURES IN IN MANAGEMENT PATIENTS PATIENTS WITH WITH MULTIPLE MULTIPLE INJURIES: INJURIES: EXPERIENCE EXPERIENCE OF OF A A MAJOR MAJOR TRAUMA TRAUMA CENTRE CENTRE..

CO AUTHORS CO AUTHORS

John Jeffery John Jeffery Northampton General Hospital Northampton General Hospital Mohamed Mussa (Northampton General Hospital), Euan Stirling (Northampton General Mohamed Mussa (Northampton General Hospital), Euan Stirling (Northampton General Hospital), Ihsaan Al-Hadad (Northampton General Hospital), Jason Auld (Northampton Hospital), Ihsaan Al-Hadad (Northampton General Hospital), Jason Auld (Northampton General Hospital), Simon West (Northampton General Hospital) General Hospital), Simon West (Northampton General Hospital)

MAIN AUTHOR AUTHOR MAIN

Hossam Hossam Fraig Fraig

PRESENTER PRESENTER

John Jeffery John Jeffery

CO CO AUTHORS AUTHORS

OBJECTIVES OBJECTIVES

For the last 40 years, the level of consciousness following traumatic brain injury (TBI) For the last 40 years, the level of consciousness following traumatic brain injury (TBI) has been quantified using the Glasgow Coma Scale (GCS). Our objective was to has been quantified using the Glasgow Coma Scale (GCS). Our objective was to determine the level of knowledge of the GCS amongst clinical staff who care for TBI determine the level of knowledge of the GCS amongst clinical staff who care for TBI patients and to see if this could be improved. patients and to see if this could be improved.

University University Hospital Hospital Southampton Southampton NHS NHS Foundation Foundation Trust Trust Southampton Southampton United United Kingdom Kingdom Marsland Marsland Daniel.

Daniel. University University Hospital Hospital Southampton Southampton NHS NHS Foundation Foundation Trust.

Trust.

Qureshi Qureshi Amir.

Amir. University University Hospital Hospital Southampton Southampton NHS NHS Foundation Foundation Trust.

Trust.

Hancock Nick.

University Hospital Southampton NHS Foundation Trust.

Hancock Nick. University Hospital Southampton NHS Foundation Trust.

Hossam Fraig Fraig Hossam

METHODS METHODS

A self-administered anonymous questionnaire was used to assess the knowledge of A self-administered anonymous questionnaire was used to assess the knowledge of Junior Nurses (JNs), Senior Nurses (SNs), Junior Doctors (JDs) and Specialist Junior Nurses (JNs), Senior Nurses (SNs), Junior Doctors (JDs) and Specialist Registrars (SRs) working within TBI patients. Following this, a PowerPoint based Registrars (SRs) working within TBI patients. Following this, a PowerPoint based tutorial was given to staff within the department. 4 months later, the same questionnaire tutorial was given to staff within the department. 4 months later, the same questionnaire was given out and results compared. was given out and results compared.

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

24

The initial questionnaire had an overall correct response rate of 53.5% with only 9.7% The initial questionnaire had an overall correct response rate of 53.5% with only 9.7% of all healthcare professionals accurately scoring the GCS of a patient in a clinical of all healthcare professionals accurately scoring the GCS of a patient in a clinical scenario (JNs=0%, SNs=9.1%, JDs=20%, SRs=20%). Following the delivery of scenario (JNs=0%, SNs=9.1%, JDs=20%, SRs=20%). Following the delivery of teaching the repeat questionnaire had an overall correct response rate of 92.9% with teaching the repeat questionnaire had an overall correct response rate of 92.9% with 71% accurately scoring the GCS in the scenario (JNs=63.6%, SNs=70%, JDs=83.3%, 71% accurately scoring the GCS in the scenario (JNs=63.6%, SNs=70%, JDs=83.3%, SRs=75%). Results demonstrated a higher level of knowledge amongst doctors with SRs=75%). Results demonstrated a higher level of knowledge amongst doctors with overall correct response rates of 84% for JDs and SRs, compared to 36% and 41.8% overall correct response rates of 84% for JDs and SRs, compared to 36% and 41.8% for JNs and SNs respectively. The greatest improvement overall was seen in JNs who for JNs and SNs respectively. The greatest improvement overall was seen in JNs who gave correct responses to 89.1% of the questions in the follow up questionnaire gave correct responses to 89.1% of the questions in the follow up questionnaire compared to 36% in the initial questionnaire. compared to 36% in the initial questionnaire.

Our study identified inconsistencies in knowledge of the GCS and its application Our study identified inconsistencies in knowledge of the GCS and its application amongst staff in the department and demonstrated that the intervention of a single amongst staff in the department and demonstrated that the intervention of a single teaching session could improve this. Improving the accuracy of GCS calculation allows teaching session could improve this. Improving the accuracy of GCS calculation allows for better assessment, monitoring, prognostication and use of imaging facilities and is for better assessment, monitoring, prognostication and use of imaging facilities and is necessary to optimise outcome in TBI patients. necessary to optimise outcome in TBI patients.

BTS - 25th Annual Scientific Meeting

PRESENTER PRESENTER

OBJECTIVES OBJECTIVES

To To audit audit the the management management of of lower lower limb limb long long bone bone fractures fractures in in polytrauma polytrauma patients patients (damage (damage control control orthopaedics orthopaedics (DCO) (DCO) vs vs definitive definitive care) care) timing timing of of definitive definitive surgery surgery and and complication rates. complication rates.

METHODS METHODS

The trauma trauma audit audit and and research research network network (TARN) (TARN) database database was was queried queried to to identify identify all all The patients managed managed at at the the regional regional major major trauma trauma centre centre (MTC) (MTC) with with an an injury injury severity severity patients score score (ISS) (ISS) of of > > 15 15 and and associated associated orthopaedic orthopaedic injury injury from from April April 2012 2012 to to December December 2014.

2014. A A total total of of 225 225 patients patients were were identified, identified, of of which which 36 36 were were identified identified as as having having either femoral or tibial shaft fractures.

Mean age was 40.9 years (Standard either femoral or tibial shaft fractures. Mean age was 40.9 years (Standard deviation deviation +/19 years).

Mean ISS was 26.7 (Standard deviation +/10.1). +/- 19 years). Mean ISS was 26.7 (Standard deviation +/- 10.1).

RESULTS RESULTS

Of Of the the 36 36 patients, patients, 20 20 had had femoral femoral shaft shaft fractures, fractures, 12 12 had had tibial tibial shaft shaft fractures fractures and and 4 4 had had both both femoral femoral and and tibial tibial shaft shaft fractures. fractures. Nineteen Nineteen patients patients (58%) (58%) had had open open fractures. fractures.

DCO was used in the initial management in 14/36 (39%) of cases.

In the 22 patients in DCO was used in the initial management in 14/36 (39%) of cases. In the 22 patients in whom whom the the long long bone bone fracture fracture was was treated treated definitively, definitively, surgery surgery was was performed performed within within 24 24 hours hours in in 14/22 14/22 (64%), (64%), with with a a mean mean time time to to surgery surgery of of 23.3 23.3 hours. hours. Associated Associated injuries injuries included pelvis pelvis fracture fracture (39%), (39%), intra-abdominal intra-abdominal injury injury (42%), (42%), and and head head injury injury (31%).

(31%). included Chest injuries injuries were were common common (62%), (62%), including including haemopneumothorax haemopneumothorax in in 9 9 patients patients and and Chest rib/sternal rib/sternal fractures fractures in in 12 12 patients. patients. Mean Mean lactate lactate on on admission admission was was 3.4 3.4 mmol/L. mmol/L. Mean Mean length length of of intensive intensive therapy therapy unit unit (ITU) (ITU) stay stay and and hospital hospital stay stay was was 20.4 20.4 and and 4.8 4.8 days days respectively. respectively. Only Only one one patient patient had had died died at at follow follow up. up.

CONCLUSIONS CONCLUSIONS

Most patients patients in in our our series series had had their their long long bone bone fractures fractures definitely definitely Most having having multiple multiple injuries. injuries. Mortality Mortality and and complication complication rates rates were were low, low, patients patients were were appropriately appropriately selected selected for for either either DCO, DCO, early early appropriate appropriate definitive care. definitive care.

BTS - 25th Annual Scientific Meeting

treated despite despite treated suggesting suggesting that that care care or or delayed delayed

25

th November Oral Presentations – Session 2 – Wednesday 4th

Abstract 9

A SNAP-SHOT AUDIT OF ORTHOPAEDIC TRAUMA AT A MAJOR TRAUMA CENTRE

MAIN MAIN AUTHOR AUTHOR

Edward John Nevins.

Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool UK

CO CO AUTHORS AUTHORS

Jonathan Yates Matthew Richard Gaines Cronan Christopher Kerin Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool.

Matthew Richard Gaines

PRESENTER PRESENTER

th Oral Oral Presentations Presentations –– Session Session 3 3 –– Wednesday Wednesday 4 4th November November

MAIN MAIN AUTHOR AUTHOR

Abstract Abstract 10 10

HAVE POST POST PELVIC PELVIC BINDER BINDER FILMS FILMS BECOME BECOME OBSOLETE OBSOLETE IN IN THE THE FACE FACE HAVE OF THE THE TRAUMA TRAUMA CT? CT? OF

David David Wood Wood

Department of of Trauma Trauma and and Orthopaedic Orthopaedic Surgery, Surgery, Northern Northern General General Hospital, Hospital, Sheffield, Sheffield, Department CO AUTHORS AUTHORS CO

Rathan Jeyapalan, Jeyapalan, Clara Clara Tetty, Tetty, Jonathan Jonathan McGregor-Riley.

McGregor-Riley.

Rathan Department Department of of Trauma Trauma and and Orthopaedic Orthopaedic Surgery, Surgery, Northern Northern General General Hospital, Hospital, Sheffield, Sheffield,

PRESENTER PRESENTER

Rathan Rathan Jeyapalan Jeyapalan

OBJECTIVES OBJECTIVES

To identify identify the the prevalence prevalence of of occult occult pelvic pelvic injury injury not not visible visible on on trauma trauma CT CT and and determine determine To the necessity necessity for for plain plain radiograph radiograph following following binder binder removal. removal. the

OBJECTIVES OBJECTIVES

To obtain real time feedback on performance and to determine the orthopaedic operative case mix within a regional trauma centre in the North-West of England.

METHODS METHODS

Electronic handover and theatre records were used to identify those patients operated on by the orthopaedic team over a two week period in October 2014. Retrospective data was then collected and analysed from the electronic patient record by the lead author. Patients without complete electronic medical records were excluded.

METHODS METHODS

A A retrospective retrospective review review of of all all Trauma Trauma CT CT scans scans performed performed at at the the Sheffield Sheffield Major Major Trauma Trauma Centre Centre in in one one year. year. A A comparison comparison was was made made between between the the initial initial CT CT scan scan and and postpostbinder removal radiographs.

Subsequent imaging was also assessed to determine binder removal radiographs. Subsequent imaging was also assessed to determine compliance with with local local and and national national pelvic pelvic binder binder guidelines. guidelines. compliance

RESULTS RESULTS

96 patients who presented to the on call orthopaedic service were identified within the 14 day period. The median age was 57 years (standard deviation 23, range 16-98) with exactly half of the patients being male. 33 (34%) patients did not require any surgery.

63 (66%) required operative intervention, with 57 (59%) of these interventions being conducted during the two week study time frame.

RESULTS RESULTS

st st 464 464 patients patients underwent underwent Trauma Trauma CT CT scan scan between between 1 1st April April 2014 2014 – – 31 31st March March 2015.

2015.

Of the 464 patients – 318 patients had a pelvic binder in situ at the time Of the 464 patients – 318 patients had a pelvic binder in situ at the time of of CT. CT. Only Only one patient (0.2%) had a pelvic fracture identified on radiograph and but not CT. one patient (0.2%) had a pelvic fracture identified on radiograph and but not CT.

CONCLUSIONS CONCLUSIONS

The trauma trauma CT CT has has become become the the ‘gold ‘gold standard’ standard’ modality modality for for imaging imaging in in major major trauma. trauma.

The The post-pelvic post-pelvic binder binder radiograph radiograph provides provides no no additional additional diagnostic diagnostic value value and and can can The safely safely be be eliminated eliminated from from the the management management pathway. pathway.

The most commonly occurring fractures were hip (n=17), ankle (n=8), wrist (n=8), ribs and sternum (n=5) and femoral or tibial shaft (n=5). 10 patients had multiple fractures.

21 patients presented with infections, abscesses or post-operative wound complications.

Of the 57 operations, 49% were performed by consultants and 47% by trainees under direct supervision of consultants. The level of supervision was not clear in 2 instances.

However, both of these operations were performed out of hours. 93% of operations were led by a consultant anaesthetist. In 90% of cases our intra-operative antibiotic policy was adhered to. Our venous thromboprophylaxis policy was adhered to in all cases.

2 patients in each of the operative and conservatively managed group died of medical conditions deemed unrelated to their orthopaedic trauma; and 3 were readmitted for revision surgery. All remaining patients were discharged in accordance with hospital policy.

CONCLUSIONS CONCLUSIONS

26

This audit has provided us with real time feedback on our trauma service as well as identifying areas where we can improve. Firstly, we identified an aim to improve antibiotic prescription and documentation. Secondly, we identified a requirement to improve documentation regarding the level of supervision of trainees. Both these features have now been added to our default operative note. This data also gave us great insight into the service we offer and has facilitated plans to create policies for relatively new services such as rib fixation. We hope to use this data to continue to develop and improve our regional orthopaedic trauma service for both patients and trainees.

BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

27

th November Oral Presentations – Session 3 – Wednesday 4th

Abstract 11

PELVIC PRESSURE CHANGES AFTER A FRACTURE: A PILOT CADAVERIC STUDY ASSESSING THE EFFECT OF PELVIC BINDERS AND LIMB BANDAGING

MAIN MAIN AUTHOR AUTHOR

Rhys Morris College of Medicine, Swansea University, SA2 8PP, UK

CO CO AUTHORS AUTHORS

Andrew Loftus (Queen Elizabeth University Hospital Birmingham, B15 2TH), Anna Lygas (College of Medicine, Swansea University, SA2 8PP), Rozina Mahmood (College of Medicine, Swansea University, SA2 8PP), Ian Pallister (Morriston Hospital, Swansea, SA6 6NL) Rhys Morris

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Pelvic binders are a life-saving intervention for hypovolaemic shock following displaced pelvic fractures, thought to act through increasing intra-pelvic pressure to reduce venous bleeding. This cadaveric study assesses changes in intra-pelvic pressure with different binders augmented by bandaging the thighs to recruit the femora as levers to close the pelvis. Access to femoral vessels via an in situ binder was also assessed.

METHODS METHODS

Two embalmed cadavers were used with unstable pelvic injuries (OA/OTA 61-C1) created through disrupting the pelvic ring anteriorly and posteriorly. To measure intravesical pressure, which reflects intra-pelvic pressure, a supra-pubic catheter was inserted and connected to a water manometer whilst a spigot was placed in a urethral catheter to reduce leakage of fluid.

The common and superficial femoral arteries were dissected in the left groin for each specimen prior to any intervention to allow inspection following binder application. A SAM pelvic sling II, Trauma Pelvic Orthotic Device (T-POD), Prometheus pelvic splint and an improvised pelvic binder were used on each cadaver, with each applied following lower limb bandaging with the knees slightly flexed. The groins were then inspected to assess if the femoral vessels were visible. Statistical analysis was performed in SPSS using a paired samples t test to determine if any difference existed between initial pelvic pressure in specimens compared to pressures with bandaging on and binders applied.

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

28

th November Oral Presentations – Session 3 – Wednesday 4th

Bandaging the lower limbs alone produced a significant increase in both peak and steady mean intra-pelvic pressure, 15.69 cmH22O and 12.38 cmH22O respectively compared to the baseline pressure, 8.73cm H22O (p=0.002 and p=0.001 respectively).

Applying the pelvic binder with the bandaging in place increased intra-pelvic pressure compared to the baseline (peak pressure of 25.38 cmH22O ((p<0.001) and steady pressure of 15.13 cm H22O ((p=0.003)).

Steady mean pressures between bandaging alone and bandaging with the binder applied were not significantly different (p=0.09), whilst the peak pressures were significantly greater when the binder was applied (p=0.005).

The improvised binder and T-POD both required cutting to access the femoral vessels which resulted in decreasing efficacy.

Intra-pelvic pressure was significantly increased through bandaging the lower limbs alone, and this represents a simple measure to increase intra-pelvic pressure and therefore efficacy of the binder. Access to the femoral vessels varied with binder type and represents an important consideration in polytrauma patients.

BTS - 25th Annual Scientific Meeting

THE MANAGEMENT OF ADULT MOTORCYCLISTS AND PILLION PASSENGERS WITH ISOLATED OPEN LOWER LIMB FRACTURES IN ENGLAND, 2007-2014: A STUDY USING DATA FROM THE TARN DATABASE

MAIN MAIN AUTHOR AUTHOR

Aurélie Hay-David Royal Cornwall Hospital

CO CO AUTHORS AUTHORS

Thomas Stacey, TARN, University of Manchester.

Ian Pallister, Morriston Hospital, Swansea, Wales TARN Research Committee, University of Manchester Aurélie Hay-David

PRESENTER PRESENTER

Abstract 12

OBJECTIVES OBJECTIVES

To identify population demographics of adult motorcyclists and pillion passengers with isolated open lower limb fractures and to ascertain the impact of the British Orthopaedic Standards for Trauma (BOAST 4): the management of severe open fractures of the lower limb in terms of time to skeletal stabilisation and soft tissue coverage.

METHODS METHODS

Retrospective data collected by TARN on adult motorcyclists and pillion passengers with open lower limb fractures, in England 2007-14, was analysed. Demographics and time to skeletal stabilisation and soft tissue coverage was compared in the years prior to the introduction of BOAST 4 (2007-2009) and the subsequent years (2010-2014).

RESULTS RESULTS

1564 motorcyclists and 64 pillion passengers were identified. 93% (1521/1628) were male, median age 30.5 years; 7%(107/1628) female, median age 36.7 years. Males constituted 95%(1491/1564) of motorcyclists and 47%(30/64) of pillion passengers. The mechanism of injury was blunt in the majority (95%,1553/1628). Where data was available, there was no change in alcohol, drug nor helmet use between injured motorcyclists and pillion passengers. Injury Severity Score and 30 day mortality did not differ significantly between the two time frames. There was a statistically significant difference in the number of patients who underwent skeletal stabilisation (49% vs 65%, p<0.0001) and the proportion of patients requiring formal soft coverage between the two time frames (26% vs 43%, p<0.0001). No statistically significant difference was found in the time from injury to soft tissue coverage (62.3 hours vs 63.7 hours, p=0.726). There was a statistically significant difference in the time from injury to skeletal stabilisation (7.33 hours vs 14.3 hours, p=0.000). There was also a statistically significant difference between the number of patients taken directly to a Major Trauma Centre between the two time frames (12.5% vs 41%, p<0.001).

CONCLUSIONS CONCLUSIONS

At risk individuals are young males, more frequently injured as motorcyclists rather than pillion passengers. Since the introduction of BOAST 4, the data demonstrates no difference in the time taken from injury to soft tissue coverage, but the time from injury to skeletal stabilisation is longer. There has also been an increase in patient movement to centres offering joint Orthopaedic and Plastics care. This lends support to the impact BOAST 4 has had on the management of open lower limb fractures with a more timely staged approach being adopted. The increase in patient movement may also reflect BOAST 4’s influence as well as that of the Trauma Network and the trauma divert policy.

BTS - 25th Annual Scientific Meeting

29

th Oral Oral Presentations Presentations –– Session Session 3 3 –– Wednesday Wednesday 4 4th November November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Abstract Abstract 13 13

HEAD INJURIES INJURIES AND AND WARFARIN: WARFARIN: WHEN WHEN ARE ARE PATIENTS PATIENTS SAFE SAFE TO TO BE BE HEAD DISCHARGED? DISCHARGED?

Aranghan Aranghan Lingham Lingham Royal Royal Stoke Stoke University University Hospital Hospital

Oral Presentations – Session 4 – Wednesday 4th November

MAIN AUTHOR

CONCLUSIONS CONCLUSIONS

Syed Nawaz

It is is widely widely accepted accepted that that anticoagulation anticoagulation increases increases the the risk risk of of intracerebral intracerebral It haemorrhage (ICH) (ICH) in in head head injury injury (HI).

(HI). NICE NICE guidelines guidelines 2014 2014 recommend recommend early early CT CT haemorrhage scanning scanning and and correction correction of of over-anticoagulation over-anticoagulation in in all all anticoagulated anticoagulated HI HI patients patients

CO AUTHORS

Sophie Wrigley, Young-Seok Cho; Andrew Keightley; Arshad Khaleel

PRESENTER

Syed Nawaz

OBJECTIVES

To review outcome measures (intra-operative complications, mortality and revision surgery) in a prospective series of uncemented HAC stem Hemiarthroplasties.

METHODS

A review of a consecutive series of uncemented hip hemiarthroplasties entered prospectively into a database between January 2008 to June 2014. Medical records and radiographic review.

RESULTS

810 consecutive Taperloc uncemented hemiarthroplasties with monopolar heads were performed in 763 patients, with minimum 12 month (12-90) follow-up. Mean age 83 years; 71% female. Mean time to operation was 28.5hrs. 30-day mortality: 4.4% (33/763). One-year mortality: 11.2% (89/763).

2.5% (20/810) were readmitted at separate admission with a Periprosthetic fracture; 0.9% (7/810) were complicated by dislocation and 0.7% (6/810) were revised to THR for subsidence and associated pain. 2.5% (20/810 including those above) were converted to THR at a later date. Only 0.6% (5/810) had intraoperative calcar cracks or fractures, all of which were treated with intra-operative cabling.

CONCLUSIONS

Parker et al 2010 demonstrated cemented hemiarthroplasty were associated with a 25% one-year mortality; 5.3% further surgery rate. Although our follow-up period is minimally shorter, our results are comparable. We believe that uncemented proven stem design hemiarthroplasty remains a safe and reasonable surgical option.

What What are are the the outcomes outcomes for for our our patients patients with with HI HI on on anticoagulation anticoagulation and and how how do do they they compare to to the the evidence? evidence? compare

RESULTS RESULTS

FOLLOW-UP OF 810 CONSECUTIVE TITANIUM HYDROXYAPATITE COATED UNCEMNTED STEM HEMIARTHOPLASTIES.

St Peter’s Hospital, Chertsey

Yashashwi Yashashwi Sinha, Sinha, Keele Keele University University Medical Medical School; School; Saleem Saleem Riaz, Riaz, Royal Royal Stoke Stoke University University Hospital Hospital Aranghan Lingham Lingham Aranghan

There There is is however however no no consensus consensus on on suitable suitable observation observation time. time. BestBETs BestBETs systematic systematic review reported reported a a rate rate of of 1% 1% for for developing developing a a delayed delayed ICH ICH given given a a normal normal CT CT and and an an review INR < < 3.

3. The The delayed delayed ICH’s ICH’s that that occurred occurred were were not not clinically clinically significant. significant. Therefore Therefore best best INR practise dictates dictates no no observation observation is is required. required. Our Our current current protocol protocol is: is: early early head head CT, CT, practise correction correction of of over-anticoagulation, over-anticoagulation, and and observation observation for for 24h.

24h.

METHODS METHODS

Abstract 14

We We reviewed reviewed CDU CDU (clinical (clinical decision decision unit) unit) admissions admissions between between 10/12/2012 10/12/2012 to to 08/09/2013 08/09/2013 included included patients patients with with HI, HI, on on anticoagulation, anticoagulation, and and no no ICH ICH on on early early CT CT Inclusion.

We reviewed electronic patient records for subsequent hospital presentations Inclusion. We reviewed electronic patient records for subsequent hospital presentations to determine determine ifif they they had had a a delayed delayed ICH. ICH. to 66 66 patients patients met met inclusion inclusion criteria criteria between between 10/12/2012 10/12/2012 and and 08/09/2013.

08/09/2013. No No patient patient had had a a delayed delayed intracerebral intracerebral haemorrhage. haemorrhage. 55/66 55/66 were were observed observed for for 24h, 24h, then then discharged. discharged.

29/66 had no CT head.

3/66 had no INR check.

12/66 had supra-therapeutic and 17/66 29/66 had no CT head. 3/66 had no INR check. 12/66 had supra-therapeutic and 17/66 had sub-therapeutic sub-therapeutic INR. INR. had We We must must ensure ensure early early CT CT scanning scanning and and INR INR is is checked checked in in all all anticoagulated anticoagulated HI HI patients. patients. Literature Literature states states that that the the rate rate of of delayed delayed ICH ICH is is 1% 1% ifif the the early early CT CT scan scan is is normal and INR is < 3 which is in accordance with our results.

There is a low normal and INR is < 3 which is in accordance with our results. There is a low risk risk of of delayed ICH ICH in in our our patients patients with with a a normal normal CT CT and and an an INR INR < < 3.

3. delayed We should should decrease decrease or or eliminate eliminate the the observation observation period period for for patients patients not not meeting meeting NICE NICE We criteria criteria for for observation, observation, have have a a HI, HI, are are anticoagulated, anticoagulated, with with a a normal normal CT CT and and INR INR <3. <3.

30

BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

31

th November Oral Presentations – Session 4 – Wednesday 4th

Abstract 15

THE EFFECT OF EDUCATION ON TIP-APEX DISTANCE IN DYNAMIC HIP SCREW NECK OF FEMUR FRACTURE FIXATION MAIN MAIN AUTHOR AUTHOR

Agneish Dutta Royal Stoke University Hospital

CO CO AUTHORS AUTHORS

Parag Raval, Royal Stoke University Hospital Agneish Dutta

PRESENTER PRESENTER

th Oral Oral Presentations Presentations –– Session Session 4 4 –– Wednesday Wednesday 4 4th November November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

The dynamic hip screw (DHS) is commonly used for fixation of extracapsular neck of femur fractures. A complication that may occur is cut-out of the screw. Therefore correct positioning of the screw is crucial in preventing failure. Tip-Apex Distance (TAD) is a measurement that is a reliable predictor of cut-out. This audit assessed our centre’s TAD measurements before and after surgeons were informed of the measurement and its benefits.

A sample of 129 DHS procedures performed at a large tertiary trauma centre between December 2012 and December 2013 were included in the initial audit. They were provided via the clinical audit team and the TAD score calculated by measurements of radiographs identified and compared as per Baumgartner’s seminal paper on the topic, which also served as our standard. The initial results were presented in a departmental audit meeting and the importance of the TAD highlighted to surgeons of all levels. 100 DHS procedures performed between January and June 2014 at the same centre were then reviewed to close the audit loop.

RESULTS RESULTS

In the first audit cycle, 129 patients were studied, with 79% of patients having TAD scores of less than or equal to 25mm. The second cycle included 100 patients, with 87% of patients having TAD scores below 25mm.

CONCLUSIONS CONCLUSIONS

Following audit and presentation of TAD score results to the department, we have demonstrated an improvement in the TAD scores of subsequent DHS procedures.

Evidence shows that this likely leads to better outcomes for patients. We will look to confirm this by assessing cut-out rates in the patients audited. It is important that these standards are upheld, and surgeons continue to be aware of the predictive value of TAD scores in DHS fixation.

32

BTS - 25th Annual Scientific Meeting

Abstract Abstract 16 16

WARFARIN WARFARIN REVERSAL REVERSAL IN IN NECK NECK OF OF FEMUR FEMUR FRACTURESFRACTURES- CURRENT CURRENT FAILINGS FAILINGS AND AND FUTURE FUTURE STRATEGIES STRATEGIES

John John E E Lawrence Lawrence Orthopaedic department, department, Addenbrooke’s Orthopaedic Addenbrooke’s Hospital, Hospital, Cambridge, Cambridge, UK UK Daniel Fountain, Fountain, Cambridge Cambridge University University School School for for Clinical Clinical medicine medicine Daniel Andrew Andrew Carrothers, Carrothers, Orthopaedic Orthopaedic department, department, Addenbrooke’s Addenbrooke’s Hospital, Hospital, Cambridge, Cambridge, UK UK Duncan Duncan Cundall-Curry, Cundall-Curry, Orthopaedic Orthopaedic department, department, Addenbrooke’s Addenbrooke’s Hospital, Hospital, Cambridge, Cambridge, UK UK John John E E Lawrence Lawrence

OBJECTIVES OBJECTIVES

At At the the time time of of publication, publication, the the 2007 2007 British British Orthopaedic Orthopaedic Association Association (BOA) (BOA) blue blue book book on on fragility fragility fracture fracture care care highlighted highlighted the the need need to to “develop “develop an an evidence evidence base base for for decisions decisions about patients on warfarin”.

Eight years later there remain no formal guidelines on the about patients on warfarin”. Eight years later there remain no formal guidelines on the use use of of warfarin warfarin reversal reversal agents agents in in hip hip fracture fracture patients. patients. This This study study aimed aimed to to analyse analyse warfarin warfarin reversal reversal in in our our centre, centre, and and examine examine its its impact impact on on patient patient outcome. outcome.

METHODS METHODS

A A retrospective retrospective analysis analysis of of data data for for all all patients patients presenting presenting with with fractured fractured neck neck of of femur femur at at Addenbrooke’s Addenbrooke’s Hospital, Hospital, Cambridge, Cambridge, UK UK from from July July 2009 2009 to to July July 2014 2014 was was performed performed using using the the National National Hip Hip Fracture Fracture Database.

Database. All All patients patients taking taking warfarin warfarin at at the the time time of of admission admission were were considered considered for for the the study study and and case case notes notes for for these these patients patients were were obtained obtained for for analysis analysis of of the the use use of of reversal reversal agents. agents.

RESULTS RESULTS

1,978 1,978 patients patients presented presented to to our our centre centre during during the the time time period, period, of of which which 9% 9% were were being being treated treated with with warfarin. warfarin. The The warfarinised warfarinised group group were were significantly significantly less less likely likely to to receive receive operative operative treatment treatment before before 36 36 hours hours (p<0.05) (p<0.05) and and had had significantly significantly longer longer stays stays in in hospital hospital (p<0.05). (p<0.05). Survival Survival analysis analysis to to June June 2015 2015 showed showed a a significantly significantly higher higher mortality mortality for for patients patients receiving receiving warfarin warfarin therapy therapy at at the the time time of of admission admission (P<0.05).

(P<0.05). There There was was a a consistent consistent delay delay from from presentation presentation to to the the administration administration of of warfarin warfarin reversal reversal agents. agents.

CONCLUSIONS CONCLUSIONS

Patients Patients who who sustain sustain a a fractured fractured neck neck of of femur femur whilst whilst on on warfarin warfarin therapy therapy have have significantly significantly poorer poorer outcomes outcomes than than those those not not on on warfarin. warfarin. Administration Administration of of reversal reversal agents agents was was delayed delayed in in almost almost all all cases. cases.

Reversal Reversal of of warfarin warfarin represents represents a a significant significant yet yet avoidable avoidable delay delay in in patient patient care. care. The The poor poor outcomes outcomes for for patients patients receiving receiving warfarin warfarin therapy therapy supports supports a a policy policy of of reversal reversal at at the the point point of of diagnosis. diagnosis. Our Our newly newly implemented implemented neck neck of of femur femur anticoagulation anticoagulation pathway pathway is presented. is presented.

BTS - 25th Annual Scientific Meeting

33

Oral Presentations – Session 4 – Wednesday 4th November

Abstract 17

Oral Presentations – Session 4 – Wednesday 4th November Oral Presentations – Session 4 – Wednesday 4th November

MEDIUM TO LONG TERM FOLLOW UP OF A CONSECUTIVE SERIES OF 604 MEDIUM TO LONGTRAUMA TERM FOLLOW UP OF A CONSECUTIVE(ETS) SERIES OF 604 EXETER STEM HEMIARTHROPLASTIES EXETER TRAUMA STEM HEMIARTHROPLASTIES (ETS)

RELATIONSHIP OF VITAMIN D WITH BONE MINERAL DENSITY, FRACTURE TYPE AND SOCIAL DEPRIVATION IN NECK OF FEMUR FRACTURES MAIN AUTHOR

MAIN AUTHOR MAIN AUTHOR

Emma Formoy Department of Trauma and Orthopaedics, University Hospital of South Manchester

CO AUTHORS

Ekemini Eko, Timothy Thomas, Cezary Kocialkowski, Anand Pillai

PRESENTER

Emma Formoy, Ekemini Ekpo

OBJECTIVES

Reduced bone mineral density is recognised as a risk factor for hip fractures and fragility fractures in general. Vitamin D is important in maintaining healthy bone mineral levels and can therefore affect risk of hip fracture. We investigated the correlation between vitamin D levels and bone mineral density, as well as fracture type, in neck of femur fractures and also assessed the relationship of vitamin D and social deprivation.

METHODS

We included all patients admitted to our department, with a neck of femur fracture over one year (October 2013 to October 2014). We analysed vitamin D levels for all patients during admission and compared these to bone mineral density scores, based on DEXA scan results, hip fracture type and comminution, based on admission radiographs; and levels of social deprivation, based on the patient’s address.

RESULTS

In total 360 patients were admitted over the study period, with a neck of femur fracture, of which 298 had vitamin D assessed and 76 had DEXA scans. Of these cohorts, 71% were found to be vitamin D deficient and 7% had osteoporosis. No significant correlation was found between vitamin D scores and bone density, r with level of vitamin D deficiency and fracture type or comminution. A significant correlation was however identified, between low vitamin D levels and decreasing levels of social deprivation (R=0.11, p=0.04).

CONCLUSIONS

No relationship was identified between vitamin D levels and hip fracture type, suggesting that vitamin D cannot be used to predict patients at risk of more comminuted fractures. Although no relationship was also identified for bone mineral density and vitamin D, this may be because the sample size of DEXA scans was relatively small. Interestingly the relationship between vitamin D and social deprivation was the reverse of what was expected and suggests that affluent individuals may be at greater risk of low vitamin D.

34

BTS - 25th Annual Scientific Meeting

Abstract 18 Abstract 18

CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Shruti RAUT Shruti RAUT Peterborough and Stamford Hospitals NHS Foundation Trust Peterborough and Stamford Hospitals NHS Foundation Trust Martyn PARKER, Peterborough and Stamford Hospitals NHS Foundation Trust Martyn PARKER, Peterborough and Stamford Hospitals NHS Foundation Trust Shruti RAUT Shruti RAUT The aim of this study was to evaluate the medium to long term follow up results for the The aimTrauma of this study to evaluate the medium to long term follow up results for the Exeter Stem was (ETS).

Exeter Trauma Stem (ETS).

We evaluated a consecutive series of 604 ETS hemiarthroplasties performed at our We evaluated a consecutive 604was ETScollected hemiarthroplasties performed our institution between 2007 and series 2012. of Data for all patients on theiratage, institution between 2007 and 2012.

Data was for all patientsintervention on their age, sex, ASA grade, initial hospital treatment and anycollected subsequent operative for sex, ASA mobility grade, initial hospital treatment and any subsequent intervention for the hip, scores, residential status, length of stay, operative complications including the hip, rate, mobility scores, residential length complications including revision post-operative pain andstatus, mortality.

Afterof astay, minimum of two years post revision post-operative mortality. This After follow a minimum of two post injury, allrate, surviving patientspain wereandcontacted. up was via years telephone injury, all surviving patients contacted. follow up of was telephone conversation, either with the were patients or their This carers.

Details anyviaresidual hip conversation, eitherand with the patients carers.

Detailswere of any residual hip symptoms, mobility residential statusor andtheir further hip surgery sought. symptoms, mobility and residential status and further hip surgery were sought.

The range of follow-up was 2 to 7 years (mean 4.1 years).The mean age of the patient The range of follow-up was(range 2 to 7 years (mean years).The age of thepatients patient population was 84 years 46-106) with4.1 81.3% femalemean patients.

382 population was 84 years (range 46-106)Postoperative with 81.3% female patients. patients (63.2%) died within the follow up period. superficial sepsis382 occurred in (63.2%) died withinand the follow up period.in Postoperative superficial sepsis occurred occurred in in 11(1.8%) patients deep infection 5(0.8%) patients.

Dislocation 11(1.8%) patients patients and and periprosthetic deep infectionfracture in 5(0.8%) patients.

Dislocation occurred in 11(1.8%) occurred in 7(1.2%) patients.

11(1.8%) 11(1.8%)underwent patients and periprosthetic fracture occurred 7(1.2%) patients.

11(1.8%) patients Girdlestone excision arthroplasty and in 6(1.0%) patients were revised patients underwent Girdlestone excisionassessed arthroplasty and final 6(1.0%) patients revised to total hip replacement.

For patients at their follow up thewere mean pain to totalwas hip 1.6 replacement.

ForOnly patients assessed at their final follow thehip mean pain score (range 1-6).

4 patients described regular pain inupthe requiring score was 1.6 (range 1-6).

Only 4 patients described regular pain in the hip requiring frequent analgesia. 154(71.3%) were living in their own home and the remainder in frequent analgesia.

154(71.3%) were living in their own home and the remainder in institutional care. institutional care.

This paper represents the largest consecutive series, with the longest follow up This paper represents largest consecutive with the follow up for currently available.

Thethe results confirm that theseries, prosthesis is anlongest excellent implant currently available.

The the prosthesis these patients with a lowresults risk ofconfirm needingthat revision surgery. is an excellent implant for these patients with a low risk of needing revision surgery.

BTS - 25th Annual Scientific Meeting

35

Oral Presentations – Session 5 – Wednesday 4th November Oral Presentations – Session 5 – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR

Abstract 19 Abstract 19

OUTCOME OF ILIZAROV FRAME TREATMENT IN THE ELDERLY. THE OUTCOME OF ILIZAROV FRAME TREATMENT IN THE ELDERLY. THE CHERTSEY EXPERIENCE. CHERTSEY EXPERIENCE.

CO AUTHORS CO AUTHORS

Robert Boyd Robert Boyd Ashford & St. Peter’s Hospital, Chertsey Ashford & St. Peter’s Hospital, Chertsey Ankit Desai, Verona Beckles, Arshad Khaleel, Ashford & St. Peters Hospital, Chertsey Ankit Desai, Verona Beckles, Arshad Khaleel, Ashford & St. Peters Hospital, Chertsey

PRESENTER PRESENTER

Robert Boyd / Ankit Desai Robert Boyd / Ankit Desai

OBJECTIVES OBJECTIVES

From 1.1.2010 to date we have reviewed our experience in managing patients >65 From 1.1.2010 to date we have reviewed our experience in managing patients >65 years old who required Ilizarov surgery for the treatment of their injuries/pathology. years old who required Ilizarov surgery for the treatment of their injuries/pathology.

METHODS METHODS

This cohort included 75 consecutive patients. There were no exclusion criteria. Fine This cohort included 75 consecutive patients. There were no exclusion criteria. Fine wire frames were applied in a standard fashion. Perioperative care was routine and wire frames were applied in a standard fashion. Perioperative care was routine and patients were mobilised full weight bearing as soon as possible. Covered pin-site care patients were mobilised full weight bearing as soon as possible. Covered pin-site care was used. Patients were reviewed in outpatients at regular intervals with radiology. was used. Patients were reviewed in outpatients at regular intervals with radiology.

NSAIDs were avoided and smoking actively discouraged.

NSAIDs were avoided and smoking actively discouraged.

Staged dynamisation of the frame was performed and frames removed under sedation Staged dynamisation of the frame was performed and frames removed under sedation as a day case procedure. as a day case procedure.

RESULTS RESULTS

The mean age was 72 years. >50% were tibial fractures; plateau (23) and pilon (16).

The mean age was 72 years. >50% were tibial fractures; plateau (23) and pilon (16).

All fractures united. Mean time to union was 31 weeks. There was no deep infection.

All fractures united. Mean time to union was 31 weeks. There was no deep infection.

There were numerous pin-site infections treated with oral antibiotics.

There were numerous pin-site infections treated with oral antibiotics.

CONCLUSIONS CONCLUSIONS

We find this a useful tool in the management of severe fractures in osteoporotic bone We find this a useful tool in the management of severe fractures in osteoporotic bone with predictably good outcomes. with predictably good outcomes.

36

BTS - 25th Annual Scientific Meeting

th Oral Oral Presentations Presentations –– Session Session 5 5 –– Wednesday Wednesday 4 4th November November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Abstract Abstract 20 20

RESULTS RESULTS OF OF THE THE MANAGEMENT MANAGEMENT OF OF OPEN OPEN TIBIAL TIBIAL SHAFT SHAFT FRACTURE FRACTURE WITH WITH SEGMENTAL SEGMENTAL DEFECT DEFECT USING USING THE THE MASQUELET MASQUELET TECHNIQUE TECHNIQUE

Munier Munier Hossain Hossain Morriston Hospital Hospital Morriston

Rhys Rhys Morris, Morris, Alun Alun Evans, Evans, II Pallister, Pallister, Morriston Morriston Hospital Hospital Munier Hossain Hossain Munier

OBJECTIVES OBJECTIVES

We We present present our our experience experience of of undertaking undertaking the the Masquelet Masquelet Technique Technique (MT) (MT) in in a a trauma trauma centre centre with with combined combined ortho-plastic ortho-plastic care care for for severe severe open open tibial tibial shaft shaft fractures. fractures.

METHODS METHODS

We We retrospectively retrospectively reviewed reviewed the the case case notes notes and and X-rays X-rays of of 11 11 consecutive consecutive patients patients with with acute acute open open tibial tibial shaft shaft fracture fracture with with segmental segmental defect defect who who underwent underwent the the MT MT between between 2011-2014.

2011-2014. We We assessed assessed complications, complications, re-operations re-operations and and bony bony union. union. All All patients patients initially initially underwent underwent wound wound debridement debridement and and provisional provisional skeletal skeletal stabilisation stabilisation with with external external fixator fixator before before undergoing undergoing the the MT. MT. MT MT was was performed performed in in two two stages: stages: first first stage stage involved debridement, antibiotic loaded cement spacer insertion and skeletal involved debridement, antibiotic loaded cement spacer insertion and skeletal stabilisation. stabilisation. Gentamycin Gentamycin impregnated impregnated methylmethacrylate methylmethacrylate (plus (plus Vancomycin Vancomycin in in selected selected cases) cases) was was used used as as cement cement spacer spacer and and soft soft tissue tissue reconstruction reconstruction was was achieved. achieved. Second Second stage stage was was performed performed later later when when wound wound had had healed, healed, there there was was no no evidence evidence of of infection infection and and a a suitable suitable interval interval for for membrane membrane induction induction had had elapsed. elapsed.

Wound Wound was was re-opened, re-opened, induced induced membrane membrane incised incised and and the the cavity cavity packed packed with with autologous autologous bone bone graft graft (ABG).

(ABG). Follow-up Follow-up ranged ranged from from 1-4 1-4 years. years.

RESULTS RESULTS

There There were were 9 9 males males and and 2 2 females. females. Mean Mean age age was was 35 35 (17-62).

(17-62). Injury Injury severity severity score score ranged ranged from from 9-22 9-22 (mode (mode 9).

9). All All except except one one patient patient had had grade grade IIIb IIIb injury. injury. Bone Bone loss loss ranged ranged from from 2-15 2-15 cm cm (mean (mean 5.6 5.6 cm). cm). Skeletal Skeletal stabilisation stabilisation was was achieved achieved by by Intramedullary Intramedullary nail nail (( 7), 7), plates plates (4).

(4). Soft Soft tissue tissue cover cover was was achieved achieved with with local local muscle muscle flap flap and split skin graft (5), split skin graft alone (3), free tissue transfer (2), primary closure and split skin graft (5), split skin graft alone (3), free tissue transfer (2), primary closure (1).

(1). Second Second stage stage surgery surgery was was performed performed after after a a median median interval interval of of 2 2 months. months. Induced Induced membrane membrane was was found found in in all all except except two two patients patients one one of of whom whom was was a a chronic chronic smoker. smoker.

ABG ABG was was obtained obtained from from the the iliac iliac crest crest (5), (5), from from the the femur femur using using the the reamer-irrigatorreamer-irrigatoraspirator aspirator system system (3), (3), and and distal distal femur femur and and tibia tibia (3).

(3). ABG ABG was was augmented augmented with with bone bone morphogenic morphogenic protein protein (BMP-7) (BMP-7) in in 5 5 patients. patients. 2 2 patients patients were were lost lost to to follow follow up up following following the First stage MT and presented later with frank infection that required below the First stage MT and presented later with frank infection that required below knee knee amputation. amputation. 5 5 patients patients had had full full bony bony union. union. There There were were 4 4 non-unions, non-unions, 6 6 wound wound infections, infections, 2 2 re-operations re-operations (revision (revision nail nail 1, 1, distraction distraction osteogenesis osteogenesis 1).

1). 1 1 patient patient with with non-union non-union is is awaiting awaiting revision revision surgery surgery and and 1 1 patient patient is is asymptomatic asymptomatic but but remain remain under under follow follow up. up.

CONCLUSIONS CONCLUSIONS

Our Our experience experience highlights highlights the the difficulty difficulty of of achieving achieving reliable reliable bony bony union union of of critical critical size size bony bony defects defects in in presence presence of of open open tibial tibial shaft shaft fracture fracture with with segmental segmental defect defect using using the the MT. MT. We We found found a a high high rate rate of of complications complications compared compared to to the the published published literature. literature.

BTS - 25th Annual Scientific Meeting

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th Oral Oral Presentations Presentations –– Session Session 5 5 –– Wednesday Wednesday 4 4th November November

Abstract Abstract 21 21

th November Oral Presentations – Session 5 – Wednesday 4th

Abstract 22

RESULTS OF THE MODIFIED PAPINEAU TECHNIQUE FOR MANAGEMENT OF POST-TRAUMATIC CHRONIC OSTEOMYELITIS OR OPEN FRACTURE WITH LARGE SOFT TISSUE DEFECT.

USE OF OF POLLER POLLER SCREWS SCREWS WITH WITH INTRAMEDULLARY INTRAMEDULLARY NAILING NAILING TO TO USE INCREASE FRACTURE FRACTURE STABILITY STABILITY AND AND GAIN GAIN INTERFRAGMENTARY INTERFRAGMENTARY INCREASE COMPRESSION COMPRESSION MAIN MAIN AUTHOR AUTHOR

Munier Hossain Morriston Hospital

John E E Lawrence Lawrence Addenbrookes Addenbrookes Hospital Hospital John Daniel Daniel M M Fountain Fountain Cambridge Cambridge University University Medical Medical School School Matija Matija Krkovic Krkovic Addenbrookes Addenbrookes Hospital Hospital

CO CO AUTHORS AUTHORS

Ian Pallister, Morriston Hospital Munier Hossain

PRESENTER PRESENTER

Duncan Cundall-Curry Cundall-Curry Duncan

OBJECTIVES OBJECTIVES

OBJECTIVES OBJECTIVES

To test test a a new new method method of of callus callus measurement measurement and and investigate investigate the the invivo invivo effect effect of of Poller Poller To screw placement placement on on the the stability stability of of tibial tibial fractures fractures screw

We present our results of managing post-traumatic chronic osteomyelitis with large skin defect and severe open fracture with the modified Papineau technique (MPT) in a group of patients where more conventional reconstructive options were deemed unsuitable.

METHODS METHODS

METHODS METHODS

This This is is a a retrospective retrospective cohort cohort study study at at a a level level II Major Major Trauma Trauma Centre.

Centre. The The cohort cohort was was formed formed from from 24 24 consecutive consecutive trauma trauma patients patients treated treated with with tibial tibial intramedullary intramedullary nailing nailing and use use of of a a Poller Poller screw, screw, under under the the supervision supervision of of a a single single trauma trauma consultant. consultant. These These and were compared compared to to a a control control group group of of patients patients with with similar similar injuries injuries treated treated with with were intramedullary nailing nailing but but no no Poller Poller screw. screw. Radiographic Radiographic measurements measurements made made by by two two intramedullary orthopaedic orthopaedic registrars registrars and and an an academic academic fellow fellow blinded blinded to to the the purpose purpose of of the the trial trial and and each-others each-others measurements. measurements. Two Two sets sets of of measurements measurements were were made made representing representing the the Callus Callus Index Index and and a a new new technique technique of of assessing assessing callus callus development development in in the the form form of of a a Modified Callus Callus Index, Index, allowing allowing measurement measurement of of the the callus callus at at each each cortex cortex Modified independently. Inter-rater Inter-rater reliability reliability was was assessed assessed on on all all measures, measures, with with calculation calculation of of independently. the intraclass intraclass correlation correlation coefficient coefficient (ICC).

(ICC). Additionally, Additionally, F-test F-test and and confidence confidence intervals intervals the were were computed. computed. For For hypothesis hypothesis testing, testing, one-tailed one-tailed paired paired t-tests t-tests were were computed. computed. In In order order to to evaluate evaluate the the relationship relationship between between callus callus size, size, age age and and injury injury classification, classification, an an analysis of variance (ANOVA) was performed analysis of variance (ANOVA) was performed

We reviewed the results of five consecutive patients who underwent the MPT between 2010-2014. MPT is a two stage procedure. Initially we perform aggressive debridement of infected bone until healthy bleeding bone is exposed which is then impacted with autogenous cancellous bone graft (ABG) and the wound is covered with topical negative pressure dressing. Antibiotics are administered for 6 weeks or longer if necessary. Wound is reviewed weekly in a dressing clinic. Skin defect is closed at a later stage with split skin graft (SSG) when healthy granulation bed appears.

RESULTS RESULTS

There were 4 males and 1 female. Mean age was 56 (range 42-72). Diagnosis was chronic osteomyelitis from open ankle fracture (3), previous open tibial fracture (1) and self-immolation (1). All except one patient underwent multiple previous unsuccessful debridement. Two patients were smoker with peripheral vascular disease and one of them had previous unsuccessful attempt at radial forearm flap transfer. One patient had 85% body surface burn. 3 patients were Cierny-Mader type B host and two patients type C. Severity of osteomyelitis was stage III (3) and stage II (1). Infecting organisms were Methicillin resistant Staphylococcus aureus (MRSA) (2), Staphylocccous aureus (1), Streptococcus viridans (1), enterococcus, pseudomonas, proteus (1). Mean bone defect following debridement was 6 cm (range 3-12cm). ABG was taken from the iliac crest in all patients. Additional ABG was harvested from the lateral femoral condyle (2), the greater trochanter (1) and the proximal tibia (2). One patient required revision debridement and grafting. Skin defect was closed at 8-16 wks with SSG. 2 patients developed wound infection following 1st stage MPT and required intravenous antibiotics and delayed SSG. Follow up ranged from 6 months to 4 years. At latest follow up all patients were fully mobile, there was no sign of infection and bone defect had completely healed. Wound had healed in all except one patient who had SSG two months back. The healed leg had an unsightly scar and SSG was tethered to the bone graft site in two patients but none required revision surgery.

CONCLUSIONS CONCLUSIONS

The MPT may be a useful reconstructive option in selected patients with post-traumatic chronic osteomyelitis and difficult bone defect who may be unsuitable for conventional techniques.

MAIN AUTHOR AUTHOR MAIN CO AUTHORS AUTHORS CO

Duncan Cundall-Curry Cundall-Curry Duncan Addenbrookes Hospital, Hospital, Cambridge Cambridge University University Hospitals Hospitals NHS NHS Foundation Foundation Trust Trust Addenbrookes

RESULTS RESULTS

One-tailed paired paired t-testing t-testing of of patients patients with with Poller Poller screws screws and and controls controls revealed revealed that that the the One-tailed modified modified method method calculated calculated a a significantly significantly larger larger callus callus size size than than the the original original method method (t (t = = -4.75, -4.75, df df = = 34, 34, p p = = <0.001) <0.001) with with a a mean mean callus callus size size of of 7.84mm 7.84mm in in the the standard standard measurement compared to 10.12mm in the modified measurement.

In the plane of measurement compared to 10.12mm in the modified measurement. In the plane of action action of of the the Poller Poller screw, screw, the the contralateral contralateral callus callus (mean (mean size size 2.82mm) 2.82mm) was was significantly significantly smaller than than the the ipsilateral ipsilateral callus callus (mean (mean size size 5.49mm) 5.49mm) relative relative to to the the Poller Poller screw screw smaller location (t (t = = -4.56, -4.56, df df = = 23, 23, p p= = <0.001). <0.001). Comparing Comparing the the callus callus size size of of the the cohort cohort to to a a location control control group, group, there there was was a a significantly significantly larger larger callus callus in in the the control control group group with with a a mean mean total total callus callus size size of of 25.86mm 25.86mm (anteroposterior (anteroposterior and and medial medial to to lateral lateral combined), combined), compared compared to to the the cohort cohort mean mean total total callus callus 17.7mm 17.7mm (t (t = = -2.38, -2.38, df df = = 15.4, 15.4, p p= = 0.015).

0.015).

CONCLUSIONS CONCLUSIONS

We have have described described a a new new technique technique for for measuring measuring callus callus and and shown shown itit to to be be sensitive sensitive We and reliable. reliable. We We have have shown shown invivo invivo that that use use of of a a single single Poller Poller screw screw provides provides a a and significant significant increase increase in in fracture fracture stability stability and and interfragmentary interfragmentary compression compression at at the the cortex cortex contralateral contralateral to to the the Poller Poller screw screw

38

BTS - 25th Annual Scientific Meeting

PRESENTER PRESENTER

BTS - 25th Annual Scientific Meeting

39

Oral Presentations – Session 6 – Wednesday 4th November Oral Presentations – Session 6 – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR

CO AUTHORS CO AUTHORS

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

40

Abstract 23 Abstract 23

THE VIRTUAL FRACTURE CLINIC: INNOVATION TO OPTIMISE THE VIRTUAL FRACTURE CLINIC: INNOVATION TO OPTIMISE EFFICIENCY WITHIN TRAUMA SYSTEMS EFFICIENCY WITHIN TRAUMA SYSTEMS

Zaamin Hussain Zaamin Hussain Department of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge Department of Trauma Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS&Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ University Hospitals NHS Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ UK UK Kang Niel Niel Kang of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge Department Department of Trauma Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS&Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ University Hospitals NHS Foundation Trust, Box 37, Hills Road, Cambridge, CB2 0QQ UK UK Zaamin Hussain Zaamin Hussain Traditionally, all patients with acute fractures were referred to a fracture clinic soon after Traditionally, with with acute fractures referred to a fracture clinic soon after injury, often toallbepatients confronted long waitingwere times in the clinic and unnecessary injury, visits. often to be confronted with long waiting times in the clinic and unnecessary visits.

Collaboration between our orthopaedic department and the emergency department Collaboration between our orthopaedic the emergency department (ED) has enabled the development of a department redesigned and fracture management pathway.

(ED) allows has enabled the development a redesigned fracture management pathway.for This three possible outcomesofafter visiting ED: leaflet-supported discharge This allows three fractures, possible outcomes visiting ED: Clinic leaflet-supported discharge for minor and stable referral toafter Virtual Fracture (VFC), or immediate minor and stable fractures, to Virtual Fracture Clinicto (VFC), orifimmediate admission.

The VFC allowsreferral consultant orthopaedic opinion decide a patient should admission.

Theon VFC consultant orthopaedic opinion to if a patient should be discharged theallows telephone in a nurse-led consultation, ordecide brought into the face-tobe discharged on the telephone in a nurse-led consultation, or brought into the face-toface fracture clinic: general or subspecialty.

It has the potential to transform patient face fracturereducing clinic: general or subspecialty.

It has the potential to transform patient experience, unnecessary attendance, costs, casting, transport costs and experience, reducing attendance, costs, casting, transport costs and interventions such as unnecessary repeat radiographs. interventions such as repeat radiographs.

The objectives of this study were to assess performance within our system immediately The objectives of this and study to assess performance within our system post-implementation, towere discover and overhaul inefficiencies.

This studyimmediately hopes to post-implementation, andbenefits to discover and trauma overhaulsystems inefficiencies.

This study hopes to transfer the learning and to other nationally. transfer the learning and benefits to other trauma systems nationally.

A retrospective study analysing the pathway taken by 668 patients seen in the VFC at A retrospective study analysing the pathway taken by 668 patients seenFebruary in the VFC Addenbrooke’s Hospital, Cambridge – a major trauma centre, between andat Addenbrooke’s Hospital, Cambridge – a major trauma centre, between February and April 2015.

April 2015.

26% of all cases referred to the VFC were paediatric patients (<16 years old). 68% of 26% of all cases referred to to the VFC were paediatric patients (<16 old).was 68% of all VFC cases were related the upper limb.

The mean number of years referrals all VFC cases wereon related to the upper limb. The number of referrals significantly higher Mondays and Sundays.

90%mean of cases referred to VFCwas were seen significantly Mondays andofSundays.

90% ofmeet casesthe referred to7VFC were seen within 3 dayshigher – the on remaining 10% patients did not BOAST criteria that within 3 days – the remaining 10% of patients didinnot meetclinic the BOAST criteria that suggest patients should be seen within 72 hours a new following7 referral.

34% suggest patients should be seen within 72from hours in and a new referral. 34% of patients were immediately discharged VFC notclinic seenfollowing face-to-face, of patients were immediately discharged from VFC fracture and not seen significantly reducing the patient volume in general clinicsface-to-face, and speciality significantly reducing patient volume in general fracture clinics speciality fracture clinics.

Therethe were no formal written complaints about the and fracture clinic service fracturethis clinics. during time.There were no formal written complaints about the fracture clinic service during this time.

This preliminary assessment demonstrates it is possible to reduce fracture clinic This preliminary assessment demonstrates it is possible reduce fracture clinic attendance by approximately one third with attached costtosavings.

Further evaluation attendance approximately one third with attached cost savings. evaluation should look by at patient satisfaction and outcomes for those patients Further immediately should look at patient satisfaction and provision outcomescan for those patients immediately discharged.

Additionally, appointment be tailored more specifically to the discharged. provision can be tailored more and specifically to the demand - weAdditionally, have since appointment included more clinics targeted at paediatric upper limb demand -We we have have also sinceenabled included more clinics targeted at paediatric and upperdays limb of patients. the clinics to run immediately after the busiest patients. havereducing also enabled thetimes clinics to runpatients immediately afterinthe days of the week,We further waiting before are seen thebusiest VFC. Assessing the week, further reducing waiting times before patients are in the VFC. Assessing performance in this way allows optimisation of systems, in a seen resource-restricted NHS. performance in this way allows optimisation of systems, in a resource-restricted NHS.

BTS - 25th Annual Scientific Meeting

th November Oral Presentations – Session 6 – Wednesday 4th

WAY FORWARD TO EFFICIENT FRACTURE CLINIC

MAIN MAIN AUTHOR AUTHOR

Faiz R Hashmi Warwick Hospital Warwickshire

CO CO AUTHORS AUTHORS

Jafri Mansoor, Ike Nwachukwu Faiz Hashmi

PRESENTER PRESENTER

Abstract 24

OBJECTIVES OBJECTIVES

We present a prospective study to improve the accident and emergency referral to the fracture clinic with a view to improve fracture clinic efficiency Currently referrals to the fracture clinics from emergency department at Warwick hospital are made for the next working day, resulting in significant inappropriate referrals and increased workload.

METHODS METHODS

All the fracture clinics referrals from A & E case notes were prospectively reviewed by one orthopaedic registrar during working days between 9 am to 5 pm over consecutive 38 days period.

Using a set criteria for type of injuries the appointment were rescheduled for the later date or discharge the patients. Patients were then contacted by phone and advised the management plan. Rescheduled patient were issued fresh appointments letters.

RESULTS RESULTS

Total of 229 cases reviewed, 112 (48.90%) patients planned for rescheduling for later clinics, 17 (7.42%) patients planned for discharge and 1 (0.43%) patient called for earlier date clinic.

130 (55.76%) changes were planned. However 33 (14.41%) patients were not reachable over the phone, thus resulting in actual reduction of 97 (42.35%) patients.

Further 21 (9.17%) patients identified which could have been provided with orthotics in emergency department and discharged.

Workload reduction was 42.35%, with potential of 55.76% should all patients were contacted. This resulted in early start of ward rounds and theatres, longer patient – doctor interaction and increased supervision for junior doctors.

CONCLUSIONS CONCLUSIONS

Significant reduction in fracture clinic work load is possible by trauma & orthopaedics registrar review of referral and it will impact and improve the fracture clinic efficiency.

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th Oral Oral Presentations Presentations –– Session Session 6 6 –– Wednesday Wednesday 4 4th November November

Abstract Abstract 25 25

THE THE ASSESSMENT ASSESSMENT AND AND MANAGEMENT MANAGEMENT OF OF DISPLACES DISPLACES SUPRACONDYLAR FRACTURES OF THE HUMERUS SUPRACONDYLAR FRACTURES OF THE HUMERUS IN IN CHILDREN: CHILDREN: AN AN AUDIT OF BOAST GUIDELINE 11 IN A DISTRICT GENERAL HOSPITAL AUDIT OF BOAST GUIDELINE 11 IN A DISTRICT GENERAL HOSPITAL MAIN MAIN AUTHOR AUTHOR

Edward Edward Jenner Jenner Department of of Trauma Department Trauma and and Orthopaedics, Orthopaedics, South South Warwickshire Warwickshire NHS NHS Foundation Foundation Trust Trust (SWFT) (SWFT)

CO CO AUTHORS AUTHORS

Mark Mark Jinks Jinks (SWFT), (SWFT), Farhan Farhan Syed Syed (SWFT), (SWFT), Hope Hope Poole Poole (University (University of of Warwick), Warwick), Faiz Faiz Hashmi (SWFT) Hashmi (SWFT)

PRESENTER PRESENTER

Edward Edward Jenner Jenner

OBJECTIVES OBJECTIVES

Supracondylar Supracondylar fractures fractures of of the the humerus humerus are are common common fractures fractures in in children. children. Displaced Displaced fractures can can cause cause serious fractures serious neurovascular neurovascular complications complications and and their their management management may may be be complex. complex. In In response response to to the the recently recently published published British British Orthopaedic Orthopaedic Association Association Standards Standards for for Trauma Trauma (BOAST) (BOAST) guideline guideline 11 11 we we audited audited the the assessment assessment and and management management of of these these fractures fractures from from presentation presentation in in the the Emergency Emergency Department Department (ED) (ED) to surgical management. to surgical management.

METHODS METHODS

A A retrospective retrospective case case note note review review was was used used to to identify identify children children <16 <16 years years of of age age with with displaced displaced supracondylar supracondylar fractures fractures of of the the humerus humerus (Gartland (Gartland Classification Classification 2&3).

2&3). Three Three years years of of data data was was reviewed reviewed and and audited audited against against BOAST BOAST guideline guideline 11 11 Standards Standards 1,2,4 1,2,4 & & 6.

6.

RESULTS RESULTS

Standard Standard 1 1 Notes were were retrieved Notes retrieved for for 20 20 children. children. 0% 0% (0/20) (0/20) of of children children had had a a complete complete assessment assessment of of both both neurological neurological and and vascular vascular status status documented. documented. A A complete complete vascular vascular examination examination was was performed performed in in three three children children (15%), (15%), a a further further three three (15%) (15%) had had a a documented documented examination examination of of the the radial radial pulse pulse only. only. No No specific specific vascular vascular examination examination was was documented documented for 70% (14/20) of children.

0% (0/20) of children had a complete for 70% (14/20) of children. 0% (0/20) of children had a complete neurological neurological examination documented, documented, one one child child had had a a documented documented examination examination of of the the radial, radial, examination median (excluding (excluding anterior anterior interosseous interosseous nerve) nerve) and and ulnar ulnar nerves nerves and and one one child child had had a a median documented documented examination examination of of the the radial radial and and median median nerves. nerves. No No specific specific neurological neurological examination examination was was documented documented for for 90% 90% (18/20) (18/20) of of children. children.

Standards Standards 2, 2, 4, 4, & &6 6 Twenty-three children Twenty-three children underwent underwent surgery surgery for for displaced displaced supracondylar supracondylar fractures fractures of of the the humerus. 87% 87% (20/23) (20/23) of humerus. of children children underwent underwent surgery surgery within within 24 24 hours hours of of presentation presentation to to ED. ED. Mean Mean time time to to surgery surgery was was 15 15 hours hours (range (range 2 2– – 64 64 hours). hours). 91% 91% (21/23) (21/23) of of children children were were treated treated with with closed closed reduction reduction internal internal fixation fixation with with lateral lateral or or crossed crossed 2mm 2mm K K wires, wires, 9% 9% (2/23) (2/23) of of children children were were treated treated with with open open reduction reduction internal internal fixation fixation with with parallel parallel distal humerus plates. distal humerus plates.

CONCLUSIONS CONCLUSIONS

42

th Oral Presentations – Session 6 – Wednesday 4th November

Abstract 26

REPEAT RADIOGRAPHS FOLLOWING CAST APPLICATION IN CHILDREN WITH FOREARM FRACTURES– AN UNNECESSARY EVIL? MAIN AUTHOR AUTHOR MAIN

Rhodri Gwyn University Hospital of Wales, Cardiff

CO AUTHORS AUTHORS CO

Juliette Lewis, Abdul Gaffar Duddhinwala (UHW, Cardiff) Rhodri Gwyn

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Forearm fractures are very common in children. During the healing process, children will often have repeat XRs to assess fracture position and healing. However, many children also have an immediate repeat XR following cast application – is this useful or an unnecessary evil?

METHODS METHODS

The growth plate to shaft angle (GP-S) is a simple and precise means of calculating deformity following distal forearm injury, such as wrist fracture. Using IMPAX system to search for data. Limited by imaging modality (XR); dates (1st April – 31st December 2013); age of patient (<16y); location (all EU locations) and body part (wrist and forearm). Inclusion criteria- those who had multiple XRs on same day or within same admission. All records initially reviewed by one individual. Images then evaluated using GP-S measurement to assess degree of deformity in distal forearm and compare this with GP-S angle prior to cast

RESULTS RESULTS

53 children had repeat XRs during a single presentation during this 8 month period. 12 had volar angulated fractures 41 had dorsally angulated fractures. The mean angulation in the sagittalplane pre cast application was 17.7. Post cast mean angulation was 14 (p=0.0003) The mean angulation in the coronal plane pre cast was 4.5, post cast mean was 3.7 (p=0.02) In the AP plane 22 had decreased angulation on repeat radiography; 2 had increased and 26 stayed the same. In the coronal plane 13 had decreased angulation, 5 had increased and 32 were unchanged. The mean length of stay in the A&E department was 201 stminutes (3h21) with a range of 60 – 753 minutes (1h00 – 12h33). The mean time to 1st XR was 40 minutes (0h40) with a range of 13 nd minutes to 161 minutes (0h13 – 2h41). The mean time between 1stst and 2nd XR was 104 st minutes (1h44) with a range of 1 – 613 minutes (0h01 – 10h13). The mean time post-1st XR to discharge was 145 minutes 2h25.

CONCLUSIONS CONCLUSIONS

It is not necessary to re-image these fractures following cast application, as the angle is more likely to improve or stay the same rather than worsen. By changing practice and not immediately repeating an XR following cast application, children would be exposed to less radiation and there are significant cost-saving implications of less time spent in A&E.

The The majority majority of of children children presenting presenting with with displaced displaced supracondylar supracondylar fractures fractures of of the the humerus humerus to to our our district district hospital hospital received received prompt prompt and and appropriate appropriate surgical surgical treatment. treatment.

However, However, the the assessment assessment of of the the neurovascular neurovascular status status of of the the injured injured upper upper limb limb on on presentation presentation completely completely failed failed to to meet meet BOAST BOAST guideline guideline standard. standard. This This conclusion conclusion has has also been highlighted by a recent retrospective case series in another NHS Hospital. also been highlighted by a recent retrospective case series in another NHS Hospital.

We believe believe this this shows shows an an urgent urgent need need to to educate educate ED ED clinicians clinicians about about the the importance importance of of We accurate and and specific specific assessment assessment and and documentation documentation of of the the neurovascular neurovascular status status of of accurate the the injured injured upper upper limb limb to to ensure ensure that that indications indications for for urgent urgent surgery surgery are are promptly promptly identified. identified.

BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

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th Oral Oral Presentations Presentations –– Session Session 6 6 –– Wednesday Wednesday 4 4th November November

Abstract Abstract 27 27

COMPLIANCE WITH WITH NICE NICE GUIDELINES GUIDELINES FOR FOR VTE VTE PROPHYLAXIS PROPHYLAXIS FOR FOR COMPLIANCE NON-SURGICALLY TREATED TREATED LOWER LOWER LIMB LIMB INJURIES INJURIES WITH WITH PLASTER PLASTER NON-SURGICALLY CASTS. CASTS. MAIN AUTHOR AUTHOR MAIN CO AUTHORS AUTHORS CO PRESENTER PRESENTER

Oral Presentations – Session 7 – Wednesday 4th November

MAIN AUTHOR

Callum Callum Thomson Thomson (Countess (Countess of of Chester), Chester), Ronan Ronan Banim Banim (Countess (Countess of of Chester) Chester) Rohit Singhal / Dr C Thomson Rohit Singhal / Dr C Thomson PRESENTER

OBJECTIVES OBJECTIVES

To To check check the the compliance compliance with with the the NICE NICE clinical clinical guideline guideline (CG92) (CG92) which which states states that that pharmacological pharmacological thromboprophylaxis thromboprophylaxis should should be be offered offered to to patients patients with with lower lower limb limb plasters after after appropriate appropriate risk risk assessment. assessment. plasters

METHODS METHODS

We We conducted conducted a a retrospective retrospective audit audit including including all all the the patients patients above above the the age age of of 16 16 years, years, treated non non – – surgically surgically for for lower lower limb limb injuries injuries with with plaster plaster casts casts between between the the period period of of treated February 2015 2015 and and March March 2015.

2015.

February

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

A A total total of of 30 30 patients patients met met the the inclusion inclusion criteria criteria with with 14 14 males males and and mean mean age age of of 50.76 50.76 years (range (range 17-83).There 17-83).There were were 21 21 ankle ankle fractures, fractures, 4 4 tendo tendo achilles achilles rupture, rupture, 1 1 distal distal years tibia fracture, fracture, 1 1 foot foot sprain, sprain, one one calcaneal calcaneal fracture fracture one one patellar patellar fracture fracture and and one one base base of of tibia th 5th metatarsal metatarsal fracture. fracture. Backslab Backslab was was applied applied in in 3 3 cases cases whilst whilst in in rest rest of of the the cases cases 5 complete complete cast cast was was applied. applied. All All the the casts casts were were below below knee knee except except one one cylindrical cylindrical cast cast for for conservatively conservatively treated treated patellar patellar fracture. fracture. Amongst Amongst the the below below knee knee plasters plasters ankle ankle was was held in neutral in all except 4 cases of tendo Achilles rupture in which ankle was kept held in neutral in all except 4 cases of tendo Achilles rupture in which ankle was kept in in equines position. position. Six Six out out of of 30 30 cases cases were were allowed allowed to to weight weight bear bear fully fully on on the the affected affected equines limb while while 1 1 patient patient was was allowed allowed to to partially partially weight weight bear. bear. Rest Rest of of the the cases cases (23 (23 out out of of limb 30) were were mobilised mobilised non non weight weight bearingIn bearingIn 13 13 (43.33%) (43.33%) out out of of 30 30 cases cases low low molecular molecular 30) weight weight heparin heparin was was offered offered to to prevent prevent venous venous thromboprophylaxis. thromboprophylaxis. In In 6 6 (20%) (20%) cases cases decision decision was was taken taken not not to to prescribe prescribe pharmacological pharmacological thromboprophylaxis thromboprophylaxis after after risk risk assessment and discussing this with the patients.

In 11 (36.6%) cases, there was assessment and discussing this with the patients. In 11 (36.6%) cases, there was no no documentation with with regards regards to to thromboprophylaxis. thromboprophylaxis. None None of of the the patients patients suffered suffered any any documentation venous thromboembolic thromboembolic phenomena phenomena up up to to the the end end of of their their follow-up. follow-up. venous

PATIENT COMPLIANCE WITH VENOUS THROMBOEMBOLISM PROPHYLAXIS IN TRAUMA AND ORTHOPAEDIC OUTPATIENTS

John R Blackwell

Royal Stoke University Hospital CO AUTHORS

Rohit Singhal Singhal Rohit Countess of of Chester Chester Countess

Abstract 28

OBJECTIVES

Raval, Parag.

Quigley, John P Patel, Amit.

McBride, Donald J. Royal Stoke University Hospital John Blackwell Venous thromboembolic (VTE) disease broadly comprises pulmonary embolism (PE) and deep venous thrombosis (DVT), and cause significant morbidity and mortality, particularly in trauma and orthopaedic patients.

A prevalence of 0.9% for PE and 1.2% for DVT has been reported in this population, with published mortality rates up to 13.8%.

Chemical thromboprophylactic agents such as low molecular weight heparin (LMWH) are considered successful and cost effective in reducing the risk of VTE. The evidence for Aspirin in VTE prophylaxis less convincing but has been investigated as an alternative. There has been no published data on patient compliance with LMWH in trauma outpatients.

We aimed to determine whether trauma outpatients accept LMWH after discussing their VTE risk and the evidence for prophylaxis. For those accepting prophylaxis, we also investigated their compliance with its administration for the duration of immobilisation.

METHODS

Over a 6 month period, at our major trauma centre, those patients with lower limb injuries requiring external immobilisation were included. At the time of removal from their cast, brace or splint they were requested to complete a 17point questionnaire.

Patients who declined an offer of injectable subcutaneous LMWH as prophylaxis were offered Aspirin 75mg as a second line agent.

RESULTS

Seventy-five questionnaires were completed and subsequently five were excluded.

Nineteen of the included 70 patients required surgical intervention for their injury, with the remaining 51 managed non-operatively.

Thirty one patients accepted LMWH and 30 chose Aspirin as an alternative. Nine patients declined or were not commenced on prophylaxis.

VTE prophylaxis prophylaxis was was either either prescribed prescribed or or discussed discussed with with the the patients patients in in 63.33% 63.33% cases. cases.

VTE

Nineteen reported no missed Aspirin doses and 25 reported no missed LMWH doses.

No patients reported missed doses due to pain, side effects or cessation of treatment for another reason. The mean average pain score recorded on the VAS was 3.8, with a mode of 2 and median of 3.

No patients in the study were diagnosed with a VTE. CONCLUSIONS

44

BTS - 25th Annual Scientific Meeting

LMWH is a recognised chemical thromboprophylactic and is well tolerated by patients for VTE risk reduction in lower limb immobilised outpatients. With poor evidence supporting Aspirin as a solo prophylactic agent, our local policy has since withdrawn Aspirin for this purpose.

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Oral Presentations – Session 7 – Wednesday 4th November

MAIN AUTHOR

Abstract 29

VENOUS THROMBOEMBOLISM IN THE TRAUMA AND ORTHOPAEDIC POPULATION

John R Blackwell

Royal Stoke University Hospital CO AUTHORS

PRESENTER OBJECTIVES

Raval, Parag.

Quigley, John P Patel, Amit.

McBride, Donald J. Royal Stoke University Hospital John Blackwell Venous thromboembolism (VTE) is a potentially life threatening complication of both trauma and elective orthopaedics (T&O). Both operative and non-operative patients are at risk owing to immobilisation methods and reduced weight bearing prescribed in treatment protocols.

Many research papers are published reviewing VTE risks for specific procedures and risk reduction strategies (chemical, mechanical, anaesthetic methods, early mobilisation & minimally invasive surgeries), but little data is available documenting the incidence of VTE in the general T&O patient population.

METHODS

Clinical coding provided a list of all patients with a positive scan for deep vein thrombosis (DVT) or pulmonary embolism (PE). These results were cross referenced with those patients who had additional lower limb imaging between 1st August 2013 and 1st August 2014 (all modalities – pelvis and below). This generated a list of 2854 episodes. Non-relevant and duplicate studies were excluded. The resulting 234 patients were manually reviewed via electronic patient notes to identify those treated in an orthopaedic clinic with a subsequent VTE within 6 months.

RESULTS

Forty patients were identified with a ratio 7:33 elective: trauma. Of the trauma patients, seven were high energy and 26 were low energy. Seventeen patients had a DVT, 23 had a PE. Six patients were non-operative. Fifteen patients had a fractured neck of femur (6 DHS, 9 arthroplasty). Five patients had a delay of >8 weeks between admission and VTE diagnosis. Four were frail elderly patients (age range 81-94) with fractured NOF and expected prolonged reduced mobility. The fifth patient was 37years old, having sustained high energy poly trauma with a prolonged intensive care unit stay and delayed mobility.

46

Whilst current strategies are effective in reducing the incidence of VTE, in cases of prolonged reduced mobility, community based assessment may in certain cases reduce the ongoing risk by extending the duration of prophylaxis.

BTS - 25th Annual Scientific Meeting

Abstract Abstract 30 30

VTE PROPHYLAXIS PROPHYLAXIS IN IN PATIENTS PATIENTS WITH WITH ANKLE ANKLE FRACTURES FRACTURES VTE MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

We aimed to assess the overall effectiveness of VTE reduction strategies in T&O patients by determining the demographics of patients diagnosed with VTE during a 1year period in a major trauma centre.

CONCLUSIONS

th Oral Oral Presentations Presentations –– Session Session 7 7 –– Wednesday Wednesday 4 4th November November

Akmal Akmal Turaev Turaev Wrightington, Wrightington, Wigan Wigan and and Leigh Leigh NHS NHS Foundation Foundation Trust Trust

Sahan Sahan Fernando, Fernando, A. A. Fadulelmola, Fadulelmola, Radwane Radwane Faroug, Faroug, R. R. Smith Smith Akmal Turaev Akmal Turaev

OBJECTIVES OBJECTIVES

Determine Determine the the compliance compliance of of Venous Venous Thrombo-Embolic Thrombo-Embolic (VTE) (VTE) prophylaxis prophylaxis against against the the NICE NICE and and Trust Trust guidelines. guidelines.

Determine the incidence of symptomatic DVT or PE’s in patients with ankle fractures.

Determine the incidence of symptomatic DVT or PE’s in patients with ankle fractures.

Determine Determine the the incidence incidence of of complications complications of of VTE VTE prophylaxis prophylaxis in in patients patients with with ankle ankle fractures fractures

METHODS METHODS

Retrospective Retrospective audit audit with with closing closing the the loop. loop. The The sample sample for for this this audit audit included included people people with with ankle ankle fracture fracture between between December December 2012 2012 and and June June 2014 2014 presented presented at at Wrightington, Wrightington, Wigan and Leigh NHS Foundation Trust.

Electronic Patient Records (EPR) and case Wigan and Leigh NHS Foundation Trust. Electronic Patient Records (EPR) and case notes notes were were reviewed reviewed for for documented documented complications complications of of Dalteparin.

Dalteparin. Major Major and and minor minor bleeding reactions, reactions, wound wound haematoma, haematoma, injection injection site site haematoma. haematoma. Picture Picture Archiving Archiving and and bleeding Communication Communication System System (PACS) (PACS) were were reviewed reviewed for for sonographic sonographic and and radiographic radiographic evidence evidence of of DVT DVT and and PE’s.

PE’s. Patients Patients who who were were admitted admitted to to the the children’s children’s ward, ward, on on anticoagulation anticoagulation and and on on external external fixator fixator were were excluded. excluded.

RESULTS RESULTS

We retrospectively retrospectively reviewed reviewed 81 81 patients patients with with ankle ankle fractures fractures from from December December 2012 2012 to to We June 2014.

2014. From From 81 81 patients; patients; 72(88%) 72(88%) of of them them treated treated with with open open reduction reduction and and internal internal June fixation fixation and and the the rest rest treated treated conservatively. conservatively. Patients Patients were were non-weight non-weight bearing bearing from from 2 2 weeks weeks to to 3 3 months. months. 72(88%) 72(88%) patients patients were were for for 6 6 weeks weeks non non weight weight bearing bearing and and all all had had cast for 6 weeks.

3 patients were non-weight bearing for 2 weeks then 4 weeks partial cast for 6 weeks. 3 patients were non-weight bearing for 2 weeks then 4 weeks partial weight weight bearing bearing and and all all had had cast cast for for 6 6 weeks. weeks. One One patient patient was was on on non-weight non-weight bearing bearing for for 8 weeks weeks and and had had cast cast for for 8 8 weeks. weeks. Another Another patient patient was was on on non-weight non-weight bearing bearing for for 3 3 8 months and and had had cast cast for for 3 3 months. months. One One patient patient was was on on non-weight non-weight bearing bearing for for 3 3 weeks weeks months then then partial partial weight weight bearing bearing for for 3 3 weeks weeks and and had had cast cast for for 6 6 weeks. weeks. One One patient patient did did not not require require VTE VTE prophylaxis prophylaxis and and remaining remaining three three patients patients treated treated with with non-weight non-weight bearing bearing with cast for 6 weeks.

We compared our findings against trust and NICE guidelines and with cast for 6 weeks. We compared our findings against trust and NICE guidelines and 1st 1st cycle cycle showed showed 50% 50% compliance compliance with with trust trust guidelines guidelines and and 2nd 2nd cycle cycle showed showed 75%.

75%. In In comparison comparison to to NICE NICE guidelines, guidelines, 1st 1st cycle cycle had had 54% 54% compliance compliance with with NICE NICE guidelines guidelines and 2nd 2nd cycle cycle 100%.

100%. There There were were no no documented documented complications complications of of dalteparin. dalteparin. There There and were were no no documented documented evidence evidence of of DVT DVT or or PE. PE.

CONCLUSIONS CONCLUSIONS

This This retrospective retrospective audit audit demonstrated demonstrated that that there there was was no no single single incidence incidence of of DVT DVT or or PE PE regardless regardless of of their their compliance compliance against against trust trust or or NICE NICE guidelines. guidelines. None None of of the the patients patients had symptomatic symptomatic DVT DVT or or PEs PEs or or documented documented evidence evidence of of complications complications of of Dalteparin.

Dalteparin. had Literature on on DVT DVT and and PE PE and and the the risks risks and and benefits benefits of of thromboprophylaxis thromboprophylaxis in in foot foot and and Literature ankle ankle surgery surgery is is relatively relatively limited, limited, with with little little evidence-based evidence-based guidance. guidance.

BTS - 25th Annual Scientific Meeting

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th Oral Oral Presentations Presentations –– Session Session 7 7 –– Wednesday Wednesday 4 4th November November

Abstract Abstract 31 31

Oral Presentations – Session 7 – Wednesday 4th November Oral Presentations – Session 7 – Wednesday 4th November

MULTI-CENTRE MULTI-CENTRE AUDIT AUDIT OF OF FRACTURE FRACTURE NECK NECK OF OF FEMUR FEMUR MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Ahmed Ahmed Fadulelmola Fadulelmola Wrightington Wigan Wigan and Wrightington and Leigh Leigh NHS NHS trust trust

A. A. Turaev, Turaev, A. A. Abishek, Abishek, K. K. Sigamoney, Sigamoney, A. A. Chitre Chitre Ahmed Fadulelmola Fadulelmola Ahmed

OBJECTIVES OBJECTIVES

To To compare compare presentation, presentation, management management and and outcomes outcomes of of patient patient presented presented with with fracture fracture neck neck of of femur femur in in different different centres, centres, using using one one performa. performa.

METHODS METHODS

As As part part of of multi-centre multi-centre audit audit we we retrospectively retrospectively reviewed reviewed 299 299 patients patients admitted admitted with with fracture fracture neck neck of of femur femur between between the the 1st 1st August August 2013 2013 and and 31st 31st August August 2014, 2014, in in Royal Royal Albert Albert Edward Edward Infirmary Infirmary (RAEI) (RAEI) hospital. hospital. The The other other centre centre is is Preston.

Preston.

RESULTS RESULTS

We We had had 299 299 patients. patients. The The mean mean age age was was 80.96 80.96 years years (range (range 33-100).

33-100). 240 240 (80.3%) (80.3%) had had their their surgery surgery in in less less than than 36 36 hours hours from from admission. admission. In In hospital hospital mortality mortality was was 23 23 (7.7%).

Causes of the fracture; 284 (95%) due to mechanical fall and 15 (5%) (7.7%). Causes of the fracture; 284 (95%) due to mechanical fall and 15 (5%) were were due due to to medical medical related related falls. falls. Radiological Radiological assessment assessment showed showed that that 143 143 (47.8%) (47.8%) were were intraintracapsular capsular and and 156 156 (52.2%) (52.2%) were were extraextra- capsular. capsular. 125 125 (41.8%) (41.8%) of of the the patients patients had had Dynamic Dynamic Hip Hip screw screw and and same same number number (125) (125) had had hemiarthoplasty hemiarthoplasty of of the the hip hip as as the the method method of of fixation. fixation. 23 23 (7.7%) (7.7%) were were managed managed by

by Intra-Medullary Intra-Medullary nail, nail, 14 14 (4.7%) (4.7%) had had total total hip hip replacement, replacement, 8 8 (2.7%) (2.7%) fixed fixed with with cannulated cannulated hip hip screws screws and and 4 4 managed managed nonnonoperatively.

Most of the patients presented to our unit have high ASA grades: 213 operatively. Most of the patients presented to our unit have high ASA grades: 213 (71.2%) (71.2%) were were grade grade 4, 4, 55 55 (18.4) (18.4) were were grade grade 3, 3, 21 21 (7%) (7%) were were grade grade 2, 2, 9 9 (3%) (3%) were were grade grade 1, 1, and and 1 1 (0.3%) (0.3%) was was not not recorded. recorded. Delayed Delayed discharge discharge was was due due to to social social reasons reasons for for 2 2 patients, patients, medical medical causes causes for for 65 65 (21.7%), (21.7%), combined combined medical medical and and social social for for 167 167 (55.9%) (55.9%) and and 65 65 (21.7%) (21.7%) patients patients were were discharged discharged without without delay. delay.

CONCLUSIONS CONCLUSIONS

48

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

PREDICTORS OF RETURN TO PRE-MORBID LEVEL OF MOBILITY AND PREDICTORS OF RETURN TO PRE-MORBID LEVEL OF MOBILITY AND RESIDENCE AFTER HIP FRACTURE: A RETROSPECTIVE COHORT RESIDENCE AFTER HIP FRACTURE: A RETROSPECTIVE COHORT ANALYSIS ANALYSIS Mr Benjamin D Chatterton Mr Benjamin D Chatterton Royal Shrewsbury Hospital Royal Shrewsbury Hospital Salar O, Baker PN, Hutchinson C, Meyer CER, Thomas OL, Ford DJ Salar O, Baker PN, Hutchinson C, Meyer CER, Thomas OL, Ford DJ Mr Omer Salar Mr Omer Salar

OBJECTIVES OBJECTIVES

It is unclear what happens to hip fracture patients after acute hospital discharge. This It is unclear happens to hip after acute hospital discharge.

This study aimed what to assess the level of fracture mobility patients and place of residence for patients for up to study to assess theand level of mobility and place of residence patients for up to a yearaimed after hip fracture, identify predictors of failure to return for to the patient’s prea yearlevel afterofhip fracture, and identify predictors of failure to return to the patient’s preinjury mobility or place of residence. injury level of mobility or place of residence.

METHODS METHODS

A retrospective cohort analysis of a prospectively collated database of all hip fractures A retrospective cohort analysis prospectively collated database all hip fractures admitted from December 2007oftoa December 2012 to our hospitalofwas undertaken. admitted from 2007 to December to our or hospital was undertaken.

Within this all December patients undergoing Dynamic 2012 Hip Screw hemiarthroplasty were Within thisPlace all patients undergoing Dynamic Screwneeds or hemiarthroplasty identified. of residence and mobility statusHip including of use of aid (s) were were identified.

Place of residence and mobility status including needs of use of aid (s) recorded pre-operatively and at day 30, 120 and day 365 post-operatively were were recorded pre-operatively and and at day 30, 120 and day were recorded. Descriptive statistics regression analysis was 365 used post-operatively to analyse the data. recorded. Descriptive statistics and regression analysis was used to analyse the data.

RESULTS RESULTS

1225 patients were identified (335 males [27.3%], mean age 83.5 ± 7.6 years), of whom 1225 patients were identified (335 malesand [27.3%], mean age 83.5 ± 7.6hemiarthroplasty. years), of whom 666 (54%) underwent internal fixation, 559 (45.6%) underwent 666 (54%) underwent internal fixation, and 559 (45.6%) underwent hemiarthroplasty.

The majority of patients were ASA category 3 (633 [51.7%]) and were admitted from The of patients were ASA category (633 [51.7%]) and walked were admitted their majority own home (901 [73.6%]).

Pre-injury, 5083 (41.5%) of patients without from aids their ownwhereas home (901 Pre-injury, patients walked indoors, 301[73.6%]).

(24.6%) walked with508 one(41.5%) aid, andof301 (24.6%) withwithout 2 aids aids or a indoors, whereas 301 (24.6%) walked with one aid, and 301 (24.6%) with 2 aids or a frame. Patients aged over 90 at time of operation were significantly less likely to return frame.

Patients aged over 90 at time of operation were significantly less likely to return to their preoperative residence at 120 days postoperatively (odds ratio [OR] 0.44, 95% to their preoperative residence at 0.78), 120 days postoperatively (odds ratio [OR] 95% confidence interval [95%CI] 0.25, as were those in ASA categories 4/5 0.44, (OR 0.55, confidence interval [95%CI] 0.25, 0.78), as were those in ASA categories 4/5 (OR 0.55, 95%CI 0.36, 0.84), and those who walked with one aid indoors preoperatively (OR 95%CI 0.36, 0.40, 0.84),0.88). and those who walked preoperatively (OR 0.60, 95%CI Patients who walkedwith withone oneaid aidindoors outdoors were significantly 0.60, 95%CI Patients who walked one aidatoutdoors were significantly less likely to 0.40, return0.88). to their preoperative level with of mobility 120 days postoperatively less return0.21, to their preoperative level of mobility at 120 (OR likely 0.41, to 95%CI 0.81).

At 365 days, only 38.5% (347) of days thosepostoperatively admitted from (OR 0.41,home 95%CI 0.81).home.

At 365 days, only 38.5% (347) of those admitted from their own had0.21, returned their own home had returned home.

CONCLUSIONS CONCLUSIONS

From these results it is possible to identify patients at risk of a poor functional outcome From these results Patients it is possible identify at risk co-morbidities of a poor functional outcome after hip fracture. agedtoover 90,patients with multiple and who use after hip fracture.

Patients aged over 90, with multiple co-morbidities and who use mobility aids preoperatively should be targeted for early multidisciplinary discharge mobility be targeted for early discharge planning aids and preoperatively rehabilitation, should in an effort to optimise their multidisciplinary functional outcomes and planning rehabilitation, in an effort to optimise their functional outcomes and dischargeand destination. discharge destination.

The The author author concluded concluded that that 80.3 80.3 % % of of the the patient patient had had surgery surgery within within 36 36 hours hours of of admission. admission. In In hospital hospital mortality mortality was was 7.7%.

7.7%. Medical Medical optimization optimization is is recommended recommended to to decrease decrease the the lengths lengths of of stay stay after after NOF. NOF. A A further further re-audit re-audit is is scheduled scheduled after after receiving receiving the the results results from from the the other other centre centre the the to to ensure ensure the the higher higher standards standards are are maintained maintained and and to to see see ifif further further improvements improvements may may be be made made to to the the pathway pathway

BTS - 25th Annual Scientific Meeting

Abstract 32 Abstract 32

BTS - 25th Annual Scientific Meeting

49

BRITISH BTS - 25th Annual Scientific Meeting

CIETY SO

50

AUMA TR

www.bts-org.co.uk

th November Oral Presentations – Session 1 – Thursday 5th

Abstract 33

A 7-YEAR PROSPECTIVE EPIDEMIOLOGICAL STUDY OF ACUTE ELBOW ADMISSIONS TO A TRAUMA UNITY MAIN MAIN AUTHOR AUTHOR MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Alexander Bolt Royal Shrewsbury Hospital Siddartha Govilkar, John Blackwell, Stuart Hay Royal Shrewsbury Hospital Alexander Bolt

th November Oral Presentations – Session 1 – Thursday 5th

Faiz R Hashmi Warwick Hospital

CO CO AUTHORS AUTHORS

Professor Dr. Edgar Mayr, Klinikum Augsburg, Germany Faiz R Hashmi

OBJECTIVES OBJECTIVES OBJECTIVES OBJECTIVES

This prospective study identifies the epidemiology of the acute elbow admitted to an acute trauma unit over a 7-year period in order to increase awareness of the prevalence of the acute elbow and its impact upon services.

METHODS METHODS

An admissions database was collated over a 7-year period with all acute elbows identified and categorised into “Fractures/dislocations, painful elbows, soft tissue trauma or re-admission”. The fractures/dislocations were then sub classified into bones involved through radiographic evaluation and data was collected on operative management.

RESULTS RESULTS

In total 746 admissions were included in this study including 453 admissions with fractures/dislocations, 184 painful elbows, 84 cases of soft tissue trauma and 25 readmissions.

The most common reason for paediatric admission was supracondylar fracture accounting for 100 admissions, the majority occurred in Spring with only half as many in Winter.

In adults the most common fracture was the olecranon accounting for 89 admissions with an equivalent number managed with tension band wiring or locking plate.

A NEW NAIL WITH A LOCKING BLADE FOR THE COMPLEX PROXIMAL HUMERAL FRACTURES

MAIN MAIN AUTHOR AUTHOR

PRESENTER PRESENTER

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Abstract 34

Displaced proximal humeral fractures management shows consistently term of pain relief and functional range of motion.

Currently operative treatment appears to be the preferred method these fractures. We present our results of new locked blade nail with distally inserted locked blade for medial support and locking screws.

inferior result in of treatment of straight design,

This prospective study included a series of 63 patients with displaced proximal humeral fractures with age above 65 years. They were followed over a twelve months period.

This study included a series of 63 patients with acute proximal humeral fractures. The mean age of the patients was 67.5years (53-90) among 90% of those older than 65years. Out of sixty-five patients 13 were male and fifty were female. All fracture were treated using the locking blade nail with straight design and has proximal and distal locking screws. The one locking blade for calcar support locked into position on the nail distally and proximally .

At one year mean constant score was 84.2. All fractures had united, range of elevation was 112. And range of abduction was 94. Head shaft angle was 130. Pain Visual analogue score was 1.6 Locking blade nail offers stiff triangular fixation of the head fragment and support of the important medial calcar region to prevent secondary varus collapse.

There were 49 simple and 40 complex elbow dislocations. In 14 of the 15 paediatric complex dislocations there was a fracture of the medial epicondyle. In adults the most common fracture in a complex elbow dislocation was of the radial head. The majority of paediatric complex dislocations were acutely stabilised however this only occurred in less than half of adult cases. No simple dislocations were stabilised acutely.

Eighty-four patients were admitted following soft tissue trauma to the elbow and of these 77 required surgical wound management.

A variety of equipment was necessary in the management of these injuries including 101 K-wires, 90 locking plates, 23 headless compression screws, 11 radial head replacements and 3 acute total elbow replacements.

Olecranon bursitis was the most common reason for admission amongst the nontraumatised elbows.

CONCLUSIONS CONCLUSIONS

52

In conclusion this data allows us to identify common fracture patterns in elbow injuries and common presentations of the acute elbow. In addition, the equipment/fixation utilised helps to inform both inventory and numbers when making provision for the acute elbow in a district general trauma unit.

BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

53

Oral Presentations – Session 1 – Thursday 5th November

MAIN AUTHOR

Abstract 35

ALTERNATIVE TENSION BAND TECHNIQUE FOR OLECRANON FRACTURES; A BIOMECHANICAL STUDY

PRESENTER

OBJECTIVES

METHODS

Jan Kuiper – Keele University, Abol Behzadian – Keele University, T Madhusudhan – Glan Clwyd Hospital, Amit Sinha –Glan Clwyd Hospital Sanjit Singh To investigate whether an alternative tension band wire technique will produce greater compression and less displacement at olecranon (elbow) fracture sites compared to a standard figure of eight tension band technique. Olecranon fractures are commonly treated with tension band wiring using stainless steel wire in a figure of eight configuration. Tension band wiring is intended to produce compression across the fracture even during active flexion and extension of the elbow thus allowing early rehabilitation of the injured elbow. However recently published studies have raised doubts over the validity of the tension band concept proving that the standard figure of eight configuration does not provide fracture compression when the elbow is flexed. We propose an alternative tension band technique where the figure of eight is applied in a modified configuration.

An artificial elbow joint was simulated using artificial forearm (ulna) and arm (humerus) bones. The design simulated the action of the muscles around the elbow joint to produce flexion and extension. An intra-articular fracture was created in the ulna with a saw. Two 1.6mm Kirshner wires were inserted to hold the reduced fracture fragments.

This was followed by application of the tension band. There are two arms to this investigation.

(1) Standard tension band wire configuration with stainless steel (2) Modified tension band wire configuration with stainless steel The simulated elbow was put through a range of movement and sensors measured the compression at the fracture site. Measurements were taken for compression both at the articular and the non-articular aspect of the fracture. Three different weights were applied to challenge both the techniques of tension band wiring.

RESULTS

Measurements from the non-articular surface of the fracture demonstrated greater compression with alternative tension band technique. However it was not statistically significant (ANOVA). Compression at the articular surface of the fracture exhibited statistically significant (p<0.05) greater compression with the alternative technique.

Neither technique produced greater compression during flexion of the simulated elbow.

CONCLUSIONS

The alternative tension band wiring technique proved superior in providing greater compression over the fracture site and smaller displacement. Clinical studies required to investigate whether this translates into higher union rates and lower metal work loosening.

54

ABSTRACT TITLE ABSTRACT TITLE

Sanjit Singh

Glan Clwyd Hospital, Rhyl CO AUTHORS

Oral Presentations – Session 1 - Thursday 5th November Oral Presentations – Session 1 - Thursday 5th November

BTS - 25th Annual Scientific Meeting

Abstract 36 Abstract 36

ELASTIC TITANIUM NAILING FOR METACARPAL FRACTURES - OUR ELASTIC TITANIUM NAILING FOR METACARPAL FRACTURES - OUR RESULTS RESULTS

MAIN AUTHOR MAIN AUTHOR MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

Ankit Desai Ankit Desai Ashford and St. Peters Hospital, Chertsey, United Kingdom Ashford and St. Peters Hospital, Chertsey, United Kingdom John Afolayan, William Wynterbee, Kevin Newman John Afolayan, William Wynterbee, Kevin Newman Ankit Desai Ankit Desai

OBJECTIVES OBJECTIVES

Metacarpal fractures are common injuries whose management is still debated. Many of Metacarpal fractures common injuries whose management is still debated. of these fractures can beare treated non-operatively, however, fractures with over 30Many degrees these fractures be treated non-operatively, however, fractures with over 30 degrees of angulation orcan rotational deformity are considered for operative fixation.

Operative of angulation or plate rotational deformity are considered forpinning. operative fixation. options include osteosynthesis or percutaneous Our centre Operative previously options include plate osteosynthesis percutaneous pinning.

Our centre previously published a technique for insertion ofor antegrade Titanium Elastic Nails (TENS) for published a technique for insertion antegrade Titanium Elastic Nails (TENS) for stabilisation of these fractures.

We of followed up patients who underwent operative stabilisation fractures. followed up patients who underwent fixation with of thisthese technique and We review their functional outcome from ouroperative single centre. fixation with this technique and review their functional outcome from our single centre.

METHODS METHODS

Retrospective review of patients who underwent fixation with TENS nail were reviewed Retrospective review of patients who underwent fixation with TENS were reviewed rediologically and a DASH questionnaire were taken to assess their nail functional rediologically outcomes. and a DASH questionnaire were taken to assess their functional outcomes.

RESULTS RESULTS

A total of 33 patients were identified to have the TENS nailing procedure. They on A total ofhad 33 patients were identified to have theand TENS nailing procedure.

They on average 49.2 degrees of dorsal angulation 34.5 degrees of coronal angulation average had 49.2They degrees of dorsal 34.5 degrees of coronal prior to surgery. had the TENSangulation nail in situ and for an average of 7.9 weeks.angulation They had prior to surgery.

They had thefracture TENS nail situ for an average of 7.9 weeks. had improved the position of their withinan average of 26.7 degrees and 22They degrees improved the position of their fracture an average of 26.7 degrees and 22with degrees improvement in the sagittal plane and with coronal plane respectively.

16 patients an improvement theofsagittal plane and coronal patients with an a average followinup 15.8 months (range 3-45)plane were respectively. reviewed and16asked to complete average follow up of 15.8 3-45) were reviewed and asked to had complete a DASH questionnaire.

Theymonths had an(range average DASH score of 2.19±1.99.

They a DASH They(average had an average DASH score of 2.19±1.99. They had a medianquestionnaire. of 2 days off work 14.2, range 0-128). median of 2 days off work (average 14.2, range 0-128).

CONCLUSIONS CONCLUSIONS

Operative fixation of metacarpal fractures with Titanium Elastic Operative fixationallowing of metacarpal with Titanium Elastic operative option patientsfractures to rehabilitate quickly and our operative option allowing patients term. to rehabilitate quickly and our shows good results in the medium shows good results in the medium term.

BTS - 25th Annual Scientific Meeting

Nails is a successful Nails is a case successful on-going series on-going case series

55

th Oral Oral Presentations Presentations –– Session Session 2 2 –– Thursday Thursday 5 5th November November

Abstract Abstract 37 37

THE THE USE USE OF OF INTRA-ARTICULAR INTRA-ARTICULAR DYE DYE TO TO ASSESS ASSESS INJURY INJURY TO TO & & REDUCTION REDUCTION OF OF THE THE SYNDESMOSIS SYNDESMOSIS – – THE THE ’CHERTSEY’ ’CHERTSEY’ TEST TEST MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS

Robert Robert Boyd Boyd St St Peter’s Peter’s Hospital, Hospital, Chertsey Chertsey

Zuhair Zuhair Nawaz Nawaz -- St St Peter’s Peter’s Hospital, Hospital, Chertsey Chertsey Arshad Khaleel Arshad Khaleel -- St St Peter’s Peter’s Hospital, Hospital, Chertsey Chertsey

PRESENTER PRESENTER

Robert Robert Boyd Boyd

OBJECTIVES OBJECTIVES

Many Many syndesmotic syndesmotic fixations fixations demonstrate demonstrate malreduction malreduction of of the the syndesmosis. syndesmosis. If If a a syndesmosis syndesmosis injury injury is is not not detected detected or or not not treated treated itit can can lead lead to to pain pain and and arthritis. arthritis.

Various techniques have been described to assess the presence or absence of Various techniques have been described to assess the presence or absence of a a syndemosis syndemosis injury. injury. If If concern concern is is raised raised regarding regarding malreduction, malreduction, the the most most recognised recognised way of of checking checking accuracy accuracy of way of the the reduction reduction (of (of the the fibula fibula into into the the incisura) incisura) is is bilateral bilateral postoperative ankle ankle CT CT scans. scans. This This not not only only exposes exposes the postoperative the patient patient to to further further radiation, radiation, but but can can only only be be done done once once the the surgery surgery is is completed completed and and so so ifif adjustment adjustment is is needed, needed, this this requires requires a a further further operation, operation, (encompassing (encompassing further further surgical surgical risks risks such such as as infection) infection) to to rectify rectify the the situation. situation.

We developed a simple test, which both gives accurate intra-operative assessment We developed a simple test, which both gives accurate intra-operative assessment of of injury to to the the syndesmosis syndesmosis ligaments ligaments and and also also can can check check how how well well the the fibula fibula has has been been injury reduced (if (if required), required), without without the the need need for for further further radiological radiological investigation investigation or or surgical surgical reduced intervention. intervention.

The The objectives objectives were were to to test test how how easy easy itit was was to to perform perform the the test test and and apply apply itit to to a a number number of of different different ankle ankle fractures fractures

METHODS METHODS

Peri-operatively, Peri-operatively, 2-5mls 2-5mls of of contrast contrast medium medium was was injected injected into into the the ankle ankle joint joint in in cases cases where there there was was concern where concern about about injury injury to to the the syndesmosis. syndesmosis. If If there there was was a a ‘positive’ ‘positive’ test, test, and and a a ‘blush’ ‘blush’ of of dye dye leaked leaked into into the the surrounding surrounding soft soft tissues, tissues, then then fixation fixation of of the the syndesmosis syndesmosis was was performed performed (as (as per per the the surgeon’s surgeon’s preferred preferred technique). technique). After After fixation fixation was completed, a further injection of contrast medium was injected to see if the fibular was completed, a further injection of contrast medium was injected to see if the fibular had had been been anatomically anatomically reduced reduced into into its its incisura. incisura. The The test test was was performed performed on on 15 15 ankles. ankles.

RESULTS RESULTS

There There were were no no difficulties difficulties in in performing performing the the test test and and no no complications complications reported. reported. The The test test clearly clearly demonstrated demonstrated where where there there had had been been an an injury injury to to the the syndesmosis syndesmosis and and also also confirmed confirmed the the ‘accurate ‘accurate reduction reduction of of the the fibula fibula when when there there had had been been stabilisation stabilisation of of the the syndesmosis. syndesmosis.

CONCLUSIONS CONCLUSIONS

This This has has proved proved to to be be an an easy easy and and reliable reliable adjunct adjunct to to ankle ankle fixation fixation surgery. surgery. Further Further work work is is needed needed in in validating validating the the test. test.

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BTS - 25th Annual Scientific Meeting

th Oral Oral Presentations Presentations –– Session Session 2 2 –– Thursday Thursday 5 5th November November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Abstract Abstract 38 38

SENSITIVITY OF OF MAGNETIC MAGNETIC RESONANCE RESONANCE IMAGING IMAGING IN IN DETECTING DETECTING SOFT SOFT SENSITIVITY TISSUE TISSUE INJURIES INJURIES OF OF THE THE KNEE KNEE

Jonathan Jonathan Yates Yates Aintree Aintree University University Hospital Hospital

Tom Tom Jamieson, Jamieson, William William Bosswell, Bosswell, Cronan Cronan Kerin, Kerin, Aintree Aintree University University Hospital Hospital Jonathan Yates Jonathan Yates

OBJECTIVES OBJECTIVES

Magnetic Magnetic resonance resonance imaging imaging (MRI) (MRI) is is a a routine routine investigation investigation for for traumatic traumatic soft soft tissue tissue knee injuries. injuries. It It is is less less invasive invasive and and carries carries a a lower lower risk risk of of morbidity morbidity than than other other imaging imaging knee and can can help help determine determine whether whether surgery surgery is is appropriate. appropriate. Compared Compared to to arthroscopy, arthroscopy, MRI MRI and has has a a sensitivity sensitivity of of around around 90% 90% in in detecting detecting anterior anterior cruciate cruciate ligament ligament (ACL) (ACL) and and meniscal meniscal injuries. injuries. It It appears appears less less effective effective in in detecting detecting focal focal cartilage cartilage lesions lesions of of the the femur, but limited data is available.

We set out to determine our own local MRI femur, but limited data is available. We set out to determine our own local MRI sensitivities to utilise alongside these figures. sensitivities to utilise alongside these figures.

METHODS METHODS

We selected selected data data from from three three knee knee surgeons, surgeons, between between June June 2013 2013 and and June June 2014.

2014. We We We identified identified knee knee arthroscopy arthroscopy cases cases from from operating operating theatre theatre records. records. Clinic Clinic letters letters and and operative operative notes notes were were retrospectively retrospectively analysed analysed through through the the electronic electronic patient patient record record system. system.

RESULTS RESULTS

There were were 88 88 cases cases and and 46 46 (52%) (52%) had had undergone undergone pre-operative pre-operative MRI MRI (reported (reported by by a a There musculoskeletal radiologist). radiologist). The The average average age age of of these these patients patients was was 47 47 (range (range 16-68) 16-68) musculoskeletal with with an an equal equal male-to-female male-to-female ratio. ratio. 44 44 (96%) (96%) of of these these were were day day cases. cases. MRI MRI was was found found to to have have a a sensitivity sensitivity of of 82% 82% for for ACL ACL pathology, pathology, 91% 91% for for meniscal meniscal pathology pathology and and 92% 92% for focal cartilage lesions of the femur. for focal cartilage lesions of the femur.

CONCLUSIONS CONCLUSIONS

MRI, combined combined with with specialist specialist reporting, reporting, provides provides effective effective data data for for use use in in pre-operative pre-operative MRI, planning planning for for soft soft tissue tissue knee knee injuries. injuries. Locally Locally produced produced data data adds adds greater greater precision precision and and improves improves conclusion conclusion validity. validity. We We recommend recommend that that similar similar studies studies be be conducted conducted in in other other Trusts, to produce local sensitivities to guide and enhance service provision.

Trusts, to produce local sensitivities to guide and enhance service provision.

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th Oral Presentations – Session 2 – Thursday 5th November

Abstract 39

MOTOCROSS BIKING FOR COMPETITION AND FOR RECREATION: - A PROSPECTIVE ANALYSIS OF FOUR HUNDRED AND TWENTY THREE (423) INJURED RIDERS

Oral Presentations – Session 2 – Thursday 5th November

Abstract 40

Oral Presentations – Session 2 – Thursday 5th November

Abstract 40

MAIN AUTHOR

ANKLE SYNDESMOSIS FIXATION, VARIATIONS IN PRACTICE AND PROTOCOL FOR A TRAINEE LED, REGIONAL,IN MULTI-CENTRE ANKLE SYNDESMOSIS FIXATION, VARIATIONS PRACTICE AND RANDOMISED TRIAL. PROTOCOL FOR A TRAINEECONTROLLED LED, REGIONAL, MULTI-CENTRE RANDOMISED CONTROLLED TRIAL.Research NETwork) Steve Borland, on behalf of CORNET (Collaborative Orthopaedic

MAIN MAIN AUTHOR AUTHOR

Rohit Singh Royal Shrewsbury Hospital

MAIN AUTHOR

CO AUTHORS AUTHORS CO

AK Hamad (Royal Shrewsbury Hospital), SM Hay (Royal Shrewsbury Hospital) Rohit Singh

CO AUTHORS

Northern Deanery Patrick Williams

CO AUTHORS PRESENTER

Patrick Williams Williams Patrick

PRESENTER

Patrick Williams

Motocross biking for Competition and for Recreation: – A Prospective analysis of Four Hundred and Twenty three (423) injured riders.

OBJECTIVES

Motocross is a form of motorcycle racing held on established off-road circuits and has been a recreational and competitive sport across the world for over 100 years. In the UK alone, motocross has grown into a phenomenally ambitious and popular franchise.

There are over 200 motocross clubs across the country, permitting over 900 events annually. The aim of this study is to categorise and quantify the magnitude of motocross injury and its associated morbidity.

Fixation of the ankle syndesmosis is usually performed using screws or a tightrope fixation. examined variations in ispractice proposeusing a multi centre Fixation We of the ankle syndesmosis usuallyand performed screws or randomised a tightrope controlledWe trialexamined (RCT) to compare of different fixation. variationsthe in outcomes practice and proposetechniques. a multi centre randomised

METHODS

PRESENTER PRESENTER

ABSTRACT TITLE TITLE ABSTRACT OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

OBJECTIVES

controlled trial (RCT) to compare the outcomes of different techniques.

METHODS

Data was collected prospectively over 4 years (from 2010 to 2014) at our unit. All injuries caused by motocross biking that were referred to our trauma and orthopaedic department were included in this study, regardless of whether the rider was performing the sport competitively or recreationally.

During the period studied (four years), 423 patients were included with a total of 485 injuries, ranging from one to six injuries per patient. The patient’s age range was from 4-73 years, with most of the injuries being sustained within the early spring and summer months representing the start of the motocross season. 216 patients required hospital admission, with 205 (48%) requiring operative intervention.

We present the first epidemiological study of motocross injuries in the UK. Within the growing culture of ‘adrenaline sports’, motocross has become an exhilarating and extremely fashionable pastime. This study has identified and categorized the spectrum of associated injuries, some of which are serious and may cause significant morbidity and possible mortality. These injuries could have significant resource implications, especially for smaller rural hospitals as illustrated by the number of injuries doubling in the last four years.

Steve Borland, on behalf of CORNET (Collaborative Orthopaedic Research NETwork) Northern Deanery

The collaborative orthopaedic research network (CORNET) is a trainee led organisation designed to facilitate cooperation between trusts(CORNET) to produceisclinical trials, data The collaborative orthopaedic research network a trainee ledexamine organisation and produce better quality research.

Through this to network weclinical carriedtrials, out aexamine retrospective designed to facilitate cooperation between trusts produce data audit of regional We looked at all fractures undergoing operative and produce better practice. quality research.

Through thisankle network we carried out a retrospective intervention in 7 units in the We Northern region, 2 major trauma centres, over a audit of regional practice. looked at allincluding ankle fractures undergoing operative 12 month period.

We used andincluding radiographs to isolate those undergoing intervention in 7 units in theoperation Northernnotes region, 2 major trauma centres, over a syndesmosis stabilisation, documenting of fixation, used and 12 month period.

We used operation notesthe andmethod radiographs to isolateimplant those undergoing removal of hardware. syndesmosis stabilisation, documenting the method of fixation, implant used and removal of hardware.

RESULTS RESULTS

880 ankle fractures underwent fixation. The mean number of surgeries per unit was 125 (65-180) major underwent trauma units performing more.number 194 patients underwent syndesmosis 880 anklewith fractures fixation.

The mean of surgeries per unit was 125 stabilisation.

194 trauma patientsunits 81%performing had fixation using194 screws and underwent 19% had fixation using (65-180) withOf major more. patients syndesmosis tightrope.

If screws used81% 63%had patients had fixation using a single screw whileusing 37% stabilisation.

Of 194were patients fixation using screws and 19% had fixation patients fixationwere usingused 2 screws.

3.5mm had fully fixation threaded cortical screws were used in tightrope.had If screws 63% patients using a single screw while 37% 94.4% cases.

In 5%, 4mm fully threaded screws werescrews used and a single patientsofhad fixation using 2 screws.

3.5mmcancellous fully threaded cortical wereinused in case 4.5mm fully threaded screw was used. In 64.3%were tricortical was 94.4%a of cases.

In 5%, 4mm cortical fully threaded cancellous screws used purchase and in a single employed and fully in 35.7%% cases four screw cortices were crossed.

Post operatively 40.7%was case a 4.5mm threaded cortical was used.

In 64.3% tricortical purchase patients had removal of screws. did not.were Of those whoPost had operatively screw removal 79.7% employed and in 35.7%% cases 59.3% four cortices crossed.

40.7% were routine planned of cases and 59.3% 20.3% did were removed due to had complication. patients had removal screws. not.

Of those who screw removal 79.7% were routine planned cases and 20.3% were removed due to complication.

CONCLUSIONS CONCLUSIONS

We found a large variation in practice throughout the region. Some units use exclusively screw fixation.

One unit used tightropes for most cases.

Practice was alsouse variable with We found a large variation in practice throughout the region.

Some units exclusively regard to number and of tightropes screw used, of cortices crossed and variable routine screw screw fixation.

One unittype used fornumber most cases.

Practice was also with removal. present, to promote the use of one method ofscrew regard to At number andthere typeisoflimited screw evidence used, number of cortices crossed and routine fixation over another.

A recent RCT has been published showing better outcome scores removal. At present, there is limited evidence to promote the use of one method of which approached, butA did not achieve, significance.

The CORNET group fixation over another. recent RCT has statistical been published showing better outcome scores plans to run a multi but centre RCT to look significance. for a difference in CORNET outcomesgroup with which approached, did pragmatic not achieve, statistical The screw versus andpragmatic with removal screws. Patient recorded plans to run a tightrope, multi centre RCTortoretention look for aofdifference in outcomes with outcome scores looking and for awith clinically significant difference will be collected at regular screw versus tightrope, removal or retention of screws.

Patient recorded intervals.

Patients would also receive long term follow-up to look for progression of post outcome scores looking for a clinically significant difference will be collected at regular traumatic arthritis would also receive long term follow-up to look for progression of post intervals. Patients traumatic arthritis

58

BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

59

Oral Presentations – Session 3 – Thursday 5th November th Oral Oral Presentations Presentations –– Session Session 3 3 –– Thursday Thursday 5 5th November November

Abstract Abstract 41 41

th

Oral Presentations – Session 3 – Thursday 5 November

A A DISTRICT DISTRICT GENERAL GENERAL HOSPITALS’ HOSPITALS’ EXPERIENCE EXPERIENCE OF OF DISTAL DISTAL BICEP BICEP REPAIRS; REPAIRS; A TEN TEN YEAR YEAR ANALYSIS. ANALYSIS. A MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

MAIN AUTHOR

Paul Paul Brewer Brewer Barnsley Barnsley District District General General Hospital Hospital

Noman Noman Saghir, Saghir, Daniel Daniel Wilson, Wilson, Hany Hany IsmaielIsmaiel- Barnsley Barnsley District District General General Hospital Hospital Paul Brewer Paul Brewer

MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

OBJECTIVES OBJECTIVES

This follow follow up up study study aimed aimed to to investigate investigate the the functional functional outcomes outcomes of of all all consecutive consecutive This patients who who had had a a distal distal biceps biceps repair repair during during the the last last 10 10 years years using using the the Manchester Manchester patients 2 DASH score score (M (M2-DASH).

-DASH).

DASH

METHODS METHODS

All All patients patients who who had had a a primary primary distal distal biceps biceps repair repair from from January January 2004 2004 2to to March March 2015 2015 were were included. included. A A case case note note review review was was completed completed alongside alongside the the M M2-DASH -DASH score. score.

Statistical significance significance was was taken taken as as p<0.05. p<0.05.

Statistical

RESULTS RESULTS

Five Five surgeons surgeons operated operated upon upon 65 65 consecutive consecutive distal distal bicep bicep ruptures. ruptures. We We had had a a 91% 91% follow follow up. up. Mean Mean follow follow up up was was 49 49 months months (three (three to to 103).

103). One One patient patient re-ruptured; re-ruptured; this this patient was a habitual anabolic steroid abuser and therefore excluded. patient was a habitual anabolic steroid abuser and therefore excluded.

We found a 100% male and 61% dominant hand preponderance.

Mean age 46 (±7.34) We found a 100% male and 61% dominant hand preponderance. Mean age 46 (±7.34) with Mean Mean M2 M2 DASH DASH score score 8.45 8.45 (±10.96). (±10.96). Analysis Analysis comparing comparing patients patients <45 <45 (n=27) (n=27) vs vs with >45 (n=32), (n=32), dominant dominant (n=34) (n=34) vs vs non non dominant dominant hand hand (n=25), (n=25), single single (n=57) (n=57) vs vs double double >45 incision incision (n=2) (n=2) showed showed no no statistical statistical significance. significance. However, However, younger younger patients patients with with dominant dominant side side surgery surgery tended tended to to report report less less disability. disability.

CONCLUSIONS CONCLUSIONS

Biotenodeis is is a a more more commonly commonly published published technique technique for for repair repair and and our our cohort cohort were were Biotenodeis mainly repaired repaired using using a a single single incision, incision, corkscrew corkscrew anchor anchor technique; technique; our our results results are are mainly comparable to to the the already already published published literature literature further further supporting supporting this this technique technique for for comparable repairing repairing distal distal bicep bicep rupture rupture repair. repair. The The technique technique is is reproducible reproducible in in the the hands hands of of more more than than one one surgeon surgeon (i.e. (i.e. not not only only the the main main surgeon surgeon in in this this series). series).

The The DASH DASH scores scores were were similar similar to to that that of of the the general general population population with with good good to to excellent excellent overall outcomes. outcomes. overall This study study shows shows the the distal distal biceps biceps repairs repairs at at our our centre centre do do extremely extremely well well and and return return to to This their social social and and work work activities activities with with few few problems. problems. their

OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

60

BTS - 25th Annual Scientific Meeting

Abstract 42 Abstract 42

REFRACTURE RATES IN PAEDIATRIC FOREARM FRACTURES: IS PROLONGED IMMOBILISATION THE ANSWER? REFRACTURE RATES IN PAEDIATRIC FOREARM FRACTURES: IS PROLONGED IMMOBILISATION THE ANSWER? Christie Brennan Royal Victoria Infirmary, Newcastle-upon-Tyne, England Christie Brennan Mark McMullan, Mukesh Newcastle-upon-Tyne, Madhavan, Philip Henman, Royal Victoria Infirmary, England Royal Victoria Infirmary, Newcastle-upon-Tyne, England Mark McMullan, Mukesh Madhavan, Philip Henman, Christie Brennan Royal Victoria Infirmary, Newcastle-upon-Tyne, England Christie Brennan Radial and ulna shaft fractures account for around 10% of all paediatric fractures.

Despite their prevalence there are no published or universally agreed guidelines for the Radial and ulna shaft fractures account The for around 10% remodelling of all paediatric fractures. management of these types of injuries. substantial potential of Despite their prevalence there are no published universally agreed for the paediatric bone means standard practice favoursorclosed reduction withguidelines immobilisation management of these types of injuries.

The substantial remodelling potential of on average for 4-6 weeks in cast. Anecdotally we have observed relatively high paediatric bone in means standard practice favours closed de reduction withFrançaise immobilisation refracture rates this population.

The 2005 Le congrès la Société de on average for 4-6 weeks cast. Anecdotally we have observed high study Chirurgie Orthopédique et in Traumatologique (SOFCOT), publishedrelatively a prospective refracture ratesainre-fracture this population.

2005 congrèsinjuries de la Société Française de demonstrating rate ofThe 3.1% andLe identified occurred within 3-18 Chirurgie Orthopédique et Traumatologique (SOFCOT), a prospective study month period of initial injury and after only minor trauma.published We used this as our standard demonstrating a re-fracture rate ofrates 3.1% identified injuries occurred within 3-18 and aimed to examine refracture in and our paediatric population to determine if the month period approach of initial injury and in after minor trauma. We used this as our standard conservative adopted theonly UK was optimal. and aimed to examine refracture rates in our paediatric population to determine if the conservative approach the patient UK wasdatabases optimal. to identify 1030 paediatric This retrospective case adopted analysis in used patients either admitted to Orthopaedics or attending the Emergency department (ED) This case analysis used patient to identify 1030 paediatric at theretrospective Royal Victoria Infirmary (RVI) over a 12databases month period with a forearm fracture. Xpatients to Orthopaedics or refracture attending the Emergency departmentof(ED) Rays andeither clinicadmitted notes were used to identify patients, their mechanism at the Royal Victoria Infirmary (RVI) over a 12 month period with a forearm fracture. Xinjury and initial and subsequent management.

Rays and clinic notes were used to identify refracture patients, their mechanism of injury initial and subsequent Of 290and diaphyseal fractures 6.6%management. (n=19) were refractures. Range of time from initial

injury to refracture was 1–69 months. However, the majority (68%, n=13) occurred with Of 290 and diaphyseal 6.6% were84% refractures.

Range of timehad frominitially initial 1 year 69% of fractures these in the first(n=19) 6 months. of refracture patients injury to refracture was 1–69 months.

However, the immobilisation majority (68%, period n=13) occurred with been managed by closed reduction with an average of 5 weeks in 1 year20% and(n=4) 69% of in the first 6 months.

84% ofclosed refracture patients initiallytime cast. of these the refracture patients underwent reduction forhad a second rd been by (n=2) closedwent reduction with an immobilisation period of 5 weeks in and ofmanaged these 50% on to have a 3average refracture. cast. 20% (n=4) of the refracture patients underwent closed reduction for a second time rd and these 50% wenttoon have than a 3 that refracture.

Our of refracture rate(n=2) appears betohigher reported during the SOFCOT congress. This is likely due to differences between France and the UK of initial Our refractureofrate appearsfractures. to be higher than that reported during the fixation SOFCOT management paediatric Initial management with internal may be congress. between France and the initial are at associatedThis withisa likely lowerdue risk to of differences refracture. Furthermore patients whoUK do of refracture management Initial with internal fixation may be increased riskofofpaediatric recurrent fractures. fractures at that management site and should subsequently be managed associated with a lower of More refracture.

Furthermore patients who do refracture are at operatively to reduce thisrisk risk. research on the optimal management of paediatric increased of recurrent fractures at thatparents site andand should subsequently managed diaphysealrisk fractures is required to enable guardians to makebe informed operatively to reduce this risk.

More research onnon-operative the optimal management of paediatric decisions when considering both operative and management. diaphyseal fractures required to to enable parents and guardians to make informed Consideration shouldisbe given as possibility of prolonged immobilisation following decisions when considering both and non-operative management. closed reduction to reduce the riskoperative of refracture by allowing sufficient cortical Consideration remodelling to should occur. be given as to possibility of prolonged immobilisation following closed reduction to reduce the risk of refracture by allowing sufficient cortical remodelling to occur.

BTS - 25th Annual Scientific Meeting

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th Oral Oral Presentations Presentations –– Session Session 3 3 –– Thursday Thursday 5 5th November November

Abstract Abstract 43 43

INNOVATIVE INNOVATIVE USE USE OF OF SINGLE SINGLE INCISION INCISION INTERNAL INTERNAL FIXATION FIXATION LATERAL LATERAL THIRD THIRD CLAVICLE CLAVICLE FRACTURES FRACTURES AUGMENTED AUGMENTED WITH WITH FIBERWIRE. FIBERWIRE. MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Rajpal Rajpal Nandra Nandra University University Hospital Hospital Birmingham, Birmingham, Queen Queen Elizabeth Elizabeth Hospital Hospital Simon Simon Maclean, Maclean, Daniel Daniel Thurston, Thurston, Socrates Socrates Kalogrianitis Kalogrianitis Rajpal Nandra Rajpal Nandra

The The management management of of unstable unstable lateral lateral one-third one-third clavicle clavicle fractures fractures remains remains controversial, controversial, particularly particularly in in younger younger patients patients where where there there is is no no consensus consensus as as to to which which surgical surgical intervention leads to maximum functional outcomes.

Non-operative treatment intervention leads to maximum functional outcomes. Non-operative treatment is is frequently chosen chosen in in elderly elderly low low demand demand patients patients with with equivocal equivocal long-term long-term outcomes outcomes in in frequently literature literature to to date, date, however however acromio-clavicular acromio-clavicular joint joint (ACJ) (ACJ) arthritis arthritis is is a a concern concern and and one one third third of of cases cases progress progress to to non-union. non-union. We We report report an an innovative innovative surgical surgical technique technique augmenting augmenting plate plate fixation fixation with with tightrope tightrope through through a a single single incision. incision.

METHODS METHODS

We We assessed assessed the the union union rate rate and and postoperative postoperative shoulder shoulder function function in in 7 7 patients patients treated treated acutely at our institution by the senior author.

The procedure uses a pre-contoured acutely at our institution by the senior author. The procedure uses a pre-contoured claviclular claviclular plate plate and and coracoclavicular coracoclavicular augmentation augmentation using using a a cortical cortical button. button. Patients Patients adhered adhered to to a a standardised standardised rehabilitation rehabilitation protocol protocol and and clinical clinical review review assessing assessing time time to to union, complications and Oxford Shoulder Scores. union, complications and Oxford Shoulder Scores.

RESULTS RESULTS

7 7 patients patients have have been been treated treated to to date date within within 14 14 days days of of injury injury (mean (mean 8 8 days). days). Patient Patient aged 19 to 73 years (mean 41 years).

According to Neer 2 patients had type aged 19 to 73 years (mean 41 years). According to Neer 2 patients had type 2a 2a injuries, injuries, 2 2 had had type type 2b 2b and and 3 3 patients patients had had type type 5 5 injuries. injuries. All All patients patients went went onto onto clinical clinical and and radiological radiological union union with with no no soft soft tissue tissue complications. complications. Data Data regarding regarding functional functional outcome outcome is being collated prospectively. is being collated prospectively.

CONCLUSIONS CONCLUSIONS

The procedure procedure is is safe, safe, time time and and cost cost efficient. efficient. The The technique technique does does have have a a learning learning The curve, curve, although although upper upper limb limb surgeons surgeons will will be be familiar familiar with with techniques. techniques. We We advocate advocate the the use use of of this this technique technique as as an an alternative alternative to to hook hook plate plate fixation fixation in in high high demand demand young young patients or those fractures likely to progress to non union. patients or those fractures likely to progress to non union.

62

BTS - 25th Annual Scientific Meeting

Oral Presentations – Session 3 – Thursday 5th November

Abstract 44

ULTRASOUND GUIDED INTERSCALENE BRACHIAL PLEXUS BLOCKS IN SHOULDER SURGERY

MAIN AUTHOR

Kelly Jones

CO AUTHORS

The Department of Trauma & Orthopaedic Surgery at The Norfolk & Norwich University Hospital, Norwich, Norfolk, United Kingdom Prakash Jayakumar, Sonali Polakhare, Amratlal Patel (The Norfolk & Norwich University Hospital, Norwich, Norfolk, United Kingdom) Kelly Jones

PRESENTER

OBJECTIVES

To investigate the use of interscalene brachial plexus blocks (ISB) in both elective and trauma shoulder surgery and assess departmental current practice and mode of administration in relation to a set gold standard of ‘awake ultrasound (US) guided single injection ISB prior to induction of general anaesthetic (GA)’.

METHODS

A consecutive series of patients undergoing both elective and trauma shoulder surgery performed by two leading upper limb surgeons (Mr AD Patel and Mr P Hallam) over the course the year 2014 were retrospectively analysed, with data obtained from departmental electronic databases. 250 patients were identified (mean age 52 years, age range 18 to 91 years) undergoing a variety of shoulder procedures (204 elective cases and 46 trauma cases). Operative records were assessed for mode of regional and general anaesthetic delivery.

RESULTS

72 (29%) of all surgical procedures performed complied with the set gold standard. Of the total number of ISBs performed, 95 (38%); most were conducted with the patients awake using US guidance. A small proportion 7 (3%) in total, additionally used NS. A small proportion of ISBs were conducted under US guidance after administration of GA, 16 (6%).

CONCLUSIONS

Best practice gold standard for regional upper limb blockade in shoulder surgery based on the current evidence base was not followed in the majority of cases. The gold standard offers safe and effective anaesthesia and analgesia under most conditions and provides optimal patient satisfaction. This should be further endorsed to improve current best evidence based practice.

BTS - 25th Annual Scientific Meeting

63

Oral Presentations – Session 4 – Thursday 5th November

Abstract 45

Oral Presentations – Session 4 – Thursday 5th November Oral Presentations – Session 4 – Thursday 5th November

FRACTURED NECK OF FEMURS: ARE CLINICAL COMMISSIONING GROUPS SPOILING YOUR FIGURES MAIN AUTHOR

MAIN AUTHOR MAIN AUTHOR

Martin Sharrock University Hospital South Manchester

CO AUTHORS

Ronnie Davies, Philomena Smith, Martyn Lovell

PRESENTER

Martin Sharrock

OBJECTIVES

Background: Hip fractures are a common problem in the UK, particularly in the frail and elderly population. Most patients are treated with surgery. The average length of hospital stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be.

METHODS

RESULTS

CONCLUSIONS

64

We analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust’s catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS. 1847 patients were identified. After excluding mortalities and missing data, 1603 were included in the analysis. The median LOS varied from 14.9 to 23.8 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient’s own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery.

We have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust’s performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS.

BTS - 25th Annual Scientific Meeting

CO AUTHORS CO AUTHORS

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Abstract 46 Abstract 46

COMPLIANCE OF HEMOCUE USAGE AMONG HIP FRACTURE PATIENTS: COMPLIANCE OF HEMOCUE USAGE AMONG HIP FRACTURE PATIENTS: A RETROSPECTIVE STUDY A RETROSPECTIVE STUDY

Shazali Sulieman Shazali Sulieman James Cook University Hospital, Middlesbrough James Cook University Hospital, Middlesbrough William Eardley William Eardley James Cook University Hospital, Middlesbrough James Cook University Hospital, Middlesbrough Paul Baker Paul Baker James Cook University Hospital, Middlesbrough James University Hospital, Middlesbrough ShazaliCook Sulieman Shazali Sulieman

Anaemia is common among patients with hip fracture and may contribute to increased Anaemia is this common amongTo patients withassessment hip fractureand andearly may contribute to increased mortality in population. aid in the management of mortality aid in the assessment of anaemia,ina this pointpopulation. of care toolTo( ‘Hemocue’) is availableand andearly was management recently introduced as anaemia, a pointinofour care ( ‘Hemocue’) available introduced routine practice hiptool fracture patients.isThe aim of and this was workrecently was to assess the as routine practice in peri our hip fractureusage patients.

The aim of work wasunit to assess compliance of the operative of Hemocue by this hip fracture nurses. the In compliance the peri operative usage of Hemocue by hip fracture nurses. addition, weof aimed to check whether a Full Blood Count (FBC) was unit taken in the In event addition, we Hemocue aimed to check whether a Full Blood Count (FBC) was taken in the event of abnormal readings. of abnormal Hemocue readings.

A retrospective study was conducted following institutional clearance over a five month A retrospective study was clearance over a five month period on a hip fracture unitconducted in a Majorfollowing Trauma institutional Centre. Point of care (Hemocue) period ontaken a hip as fracture in a Major Trauma Centre. Point of care (Hemocue) readings part ofunit normal practice were recorded: preoperative readings on the readings taken as part normal practice were recorded: preoperative on the morning of surgery andofpostoperative readings on return from theatre inreadings the evening. morning of surgery and postoperative readings (<100 on return from theatre in the For patients with abnormal Hemocue readings g/l for preoperative andevening. < 80 g/l For patients with abnormal Hemocue readings (<100 for preoperative and < if80a g/l for postoperative), the hospital laboratory system wasg/l interrogated to establish for postoperative), laboratory system was interrogated to establish if a check venous FBCthe washospital obtained. check venous FBC was obtained.

104 consecutive hip fracture admissions were included. Preoperatively, 73 (70.2 %) 104 consecutive hip fracture were 73showed (70.2 %) patients had a Hemocue test admissions performed on theincluded. ward. 14 Preoperatively, (19.2%) patients patients a Hemocue performed (19.2%) abnormalhad readings (rangetest between 69 toon 98the g/l).ward.

Only14 6 (42.9 %) patients of those showed abnormal abnormal readings (range between to 98 g/l).

Only 6 (42.965 %)(62.5%) of thoseout abnormal readings had a follow up formal FBC69taken.

Postoperatively, of 104 readings hadtheir a follow up formal FBC taken.

Postoperatively, (62.5%) readings out of 104 patients had Hemocue readings recorded.

7 (10.8%) had65 abnormal patients had their67Hemocue recorded.

(10.8%) had abnormal readings (range between to 76 g/l).readings 3 (42.9%) of those7had a venous FBC taken. (range between 67 to 76 g/l). 3 (42.9%) of those had a venous FBC taken.

Compliance with ward based point of care perioperative haemoglobin assessment is Compliance with ward based point In of care perioperative haemoglobin is poor in our hip fracture population. addition to incomplete use of theassessment tool, more than poor our hip fracture population.

In addition incomplete the tool, more than half ofinpatients with abnormal readings did notto have a formaluse FBCoftaken. half of patients with led, abnormal readings did not care have is a utilised formal FBC taken. healthcare.

Increasingly, nurse protocol driven patient throughout Increasingly, led, protocol driven patient patient centred care is utilised throughout healthcare.

While having nurse huge promise to improve management, these systems While to improve patient centred management, systems requirehaving robusthuge auditpromise as we have demonstrated significant concerns in these their use in hip require audit ascare. we have demonstrated significant concerns in their use in hip fracturerobust perioperative fracture perioperative care.

BTS - 25th Annual Scientific Meeting

65

Oral Presentations – Session 4 – Thursday 5th November

Abstract 47

Oral Presentations – Session 4 – Thursday 5th November

Abstract 47

MAIN AUTHOR MAIN AUTHOR CO AUTHORS PRESENTER CO AUTHORS PRESENTER ABSTRACT TITLE ABSTRACT TITLE OBJECTIVES OBJECTIVES METHODS METHODS RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

66

INTERNAL FIXATION OF INTRACAPSULA NECK OF FEMUR FRACTURES – DYNAMIC HIP SCREW OR CANNULATED HIP SCREWS? Simon WoodsFIXATION OF INTRACAPSULA NECK OF FEMUR FRACTURES INTERNAL DYNAMIC HIP SCREW OR CANNULATED HIP SCREWS? Hull Royal–Infirmary Simon Woods Ivan Vidakovic, Alloush Al-Mothenna, Reza Mayahi Hull Royal Infirmary Simon Woods Ivan Vidakovic, Alloush Al-Mothenna, Reza Mayahi

Simon Woods Internal Fixation of Intracapsular Neck of Femur Fractures – two-hole Dynamic Hip Screw or Cannulated Hip Screws?

Internal Fixation of Intracapsular Neck of Femur Fractures – two-hole Dynamic Hip When of femur fractures are amenable to internal fixation there are Screw Intracapsular or Cannulatedneck Hip Screws? two main treatment options: dynamic hip screw (DHS); or cannulated hip screws (CHS).

In this Intracapsular retrospective study wefemur compare the outcomes with these two fixation methods at When neck of fractures are amenable to internal fixation there are our two institute. main treatment options: dynamic hip screw (DHS); or cannulated hip screws (CHS).

In this retrospective study we compare the outcomes with these two fixation methods at We institute. identified 161 patients with intracapsular fracture treated with internal fixation over a our 5 year period. The clinical notes and imaging of these cases were reviewed to complete a database examining several were then statistically analysed.

We identified 161 patients withwhich intracapsular fracture treated with internal fixation over a 5 year period. The clinical notes and imaging of these cases were reviewed to complete Ninety-three patients were treated 68 treated with CHS. The a database examining several whichwith wereDHS thencompared statisticallytoanalysed. mean age of the DHS group was 75 years, compared to 67 for our CHS group. The age Ninety-three patients a were treated compared to 68 to treated CHS. The of patients suffering failure was with not DHS significantly different thosewith undergoing a mean age oftreatment the DHS group was 75 67 for our CHS group. age successful regardless of years, fixationcompared method. toThe length of stay for The patients of patients failure was not 4.7 significantly different to those undergoing a treated with suffering CHS wasaalso on average days shorter than those treated with DHS successful (p<0.01). treatment regardless of fixation method. The length of stay for patients treated with rate CHSwas washigher also on averagein 4.7 days shorter treatedthan with those DHS The failure (p<0.05) patients treated than with those DHS (18%) (p<0.01). treated with CHS (7%). The DHS group was subdivided by the use of derotation screw The failure analysed. rate was higher (p<0.05) in patients treated DHS (18%) than those and further Insertion of a derotation screw with awith two-hole DHS reduced the treated CHS (7%). group wasthe subdivided by the use difference of derotation screw rate of with failure from 24%The to DHS 9%, nullifying significance of the in failure and analysed.

Insertion a derotation screw with a two-hole reducedofthe ratesfurther between DHS and CHS. of This gives a number needed to treat DHS for insertion a rate of failure from 24% to 9%, nullifying the significance of the difference in failure derotation screw of 6.42. rates between DHS and CHS. This gives a number needed to treat for insertion of a derotation of 6.42.lower failure rate for CHS compared to two-hole DHS. When a We found ascrew significantly two-hole DHS is used in combination with a derotation screw the difference in failure rate between DHS and CHS is failure large nullified.

We found a significantly lower rate for CHS compared to two-hole DHS. When a two-hole DHS is used in combination with a derotation screw the difference in failure rate between DHS and CHS is large nullified.

BTS - 25th Annual Scientific Meeting

Oral Presentations – Session 4 – Thursday 5th November Oral Presentations – Session 4 – Thursday 5th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Abstract 48 Abstract 48

PREDICTING THE LENGTH OF LAG AND LOCKING SCREWS FROM THE PREDICTING THE LENGTH OFA LAG AND LOCKINGCASE SCREWS FROM THE LENGTY OF GAMMA NAILS: RETROSPECTIVE SERIES STUDY LENGTY Rhys Morris OF GAMMA NAILS: A RETROSPECTIVE CASE SERIES STUDY Rhys Morris College of Medicine, Swansea University, SA2 8PP College of Medicine, Swansea University, SA2 8PP Ian Pallister (Morriston Hospital, Swansea, SA6 6NL) Ian Pallister (Morriston Hospital, Swansea, SA6 6NL) Rhys Morris Rhys Morris

Gamma nails are widely used intramedullary devices for intertrochanteric and Gamma nails are widely neck usedfractures. intramedullary devices for intertrochanteric andtheir use subtrochanteric femoral With an increasing elderly population subtrochanteric femoral fractures.

With increasing elderly their useof is likely to grow due to a neck greater incidence of an fragility fractures.

Thepopulation component parts is likely to nail groware due a greater incidence fragility fractures.

Thescrewscomponent parts of a gamma thetonail, lag screwused of proximally, and locking inserted a gamma nail are theare nail,packaged lag screwused proximally, locking screws- inserted distally.

These items separately and are and retrieved intra-operatively distally. items are packaged andcreates are retrieved intra-operatively followingThese measurements.

However, separately this approach more theatre traffic, entering following measurements.

However, thisinfection approach creates more assesses theatre traffic, entering and exiting, which can mean a greater risk.

This study whether and exiting, which can mean a greater risk. Thisfrom studythe assesses whether lengths of the component parts can be infection reliably predicted nail lengths alone to lengths of thetheatre component help reduce traffic.parts can be reliably predicted from the nail lengths alone to help reduce theatre traffic.

Trauma theatre logbook records for a teaching hospital were reviewed from June the Trauma records for a teaching hospital were reviewed from June the 29th 2014theatre to Julylogbook the 14th 2015 inclusive.

Exclusion criteria were:intramedullary th 29 2014 to July thethan 14thgamma 2015 inclusive.

Exclusion criteria intramedullary femoral nails other nails, and cases where thewere:lengths of component parts femoral other than gamma nails, and cases the lengths component parts were notnails recorded.

Following exclusion, cases to where be included in the of study were were not recorded.

Following exclusion, cases to in the study evaluated for demographic details and lengths of be theincluded component parts of awere gamma nail. evaluated for demographic detailsinand lengths of theifcomponent partsexisted of a gamma nail.

Statistical testing was performed SPSS to assess any correlation between Statistical was performed SPSS to assess any correlation existed between lengths of testing the component parts ofingamma nails, and ifthe strength of any correlation. lengths of the component parts of gamma nails, and the strength of any correlation.

In total 126 intramedullary femoral nails were placed during the study period. Following In total 126 intramedullary femoral nails were during study period. exclusion criteria, 104 patient records with 105placed gamma nailsthe (one patient had Following bilateral exclusion criteria, patient records with64 105 gammaand nails patient had bilateral gamma nails) were104 reviewed.

There were females 40(one males with 58 nails on the gamma nails) reviewed.

There were and males with was 58 nails on the left and 47 on were the right.

The mean ratio of 64 nailfemales length to lag40 screw length 4.11:1, left on the right. The mean ratioratio of nail length to lag length was 4.11:1, andand nail 47 length to locking screw length was 8.14:1, andscrew the lag screw length to and nailscrew lengthlength to locking length ratio was 8.14:1, and the lag screw length to locking ratio screw was 1.98:1. locking screwdata length ratio was 1.98:1.

All recorded was entered into SPSS and Shapiro-Wilk testing revealed the data All recorded datadistributed was entered into SPSS and Shapiro-Wilk revealed the data was not normally and therefore Spearman’s rank testing correlation co-efficient (r) was normallyFor distributed and therefore Spearman’s rank co-efficient (r) was not calculated. the nail length to lag screw correlation r=correlation 0.417, for nail length to was calculated.

For the nail length to lag r= 0.417, for rnail length to locking screw length r=0.580, and for lag screw screw correlation length to locking length = 0.337 locking length r=0.580, and for lag screw length to locking length r = 0.337 (p<0.05screw for each of these correlations.) (p<0.05 for each of these correlations.)

This study confirms a significant correlation between lengths of the component parts of This studynail confirms a significant correlation of the component parts of a gamma and the lag and locking screwbetween lengths, lengths which can be reliably estimated by a gammabynail and8the lag and locking screw lengths, whichtocan be reliably estimated dividing 4 and respectively.

This knowledge is useful surgeons to help predict by dividing byscrew 4 andused 8 respectively.

This knowledge is thereby useful toreducing surgeons to helptraffic. predict lengths of with the gamma nail system theatre lengths of screw used with the gamma nail system thereby reducing theatre traffic.

BTS - 25th Annual Scientific Meeting

67

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th Oral Oral Presentations Presentations –– Session Session 5 5 –– Thursday Thursday 5 5th November November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS

Abstract Abstract 49 49

PREDICTING INTRA-OPERATIVE INTRA-OPERATIVE PERIPROSTHETIC PERIPROSTHETIC FRACTURE FRACTURE DURING DURING PREDICTING UNCEMENTED UNCEMENTED HEMIARTHROPLASTY HEMIARTHROPLASTY FOR FOR INTRACAPSULAR INTRACAPSULAR NECK NECK OF OF FEMUR FEMUR FRACTURES FRACTURES

Harpal Uppal Uppal Harpal Alexandra Hospital, Hospital, Redditch, Redditch, UK UK Alexandra

Anil Dhadwal Dhadwal (Alexandra (Alexandra Hospital), Hospital), Chris Chris Downam Downam (University (University Hospital Hospital Coventry Coventry and and Anil Warwickshire), Ben Ben Dean Dean (Nuffield (Nuffield Orthopaedic Orthopaedic Centre), Centre), Partha Partha Bose Bose (Oxford (Oxford Warwickshire), Statistical Statistical Counselling), Counselling), Adnan Adnan Saithna Saithna (University (University Hospital Hospital Coventry Coventry and and Warwickshire) Warwickshire)

PRESENTER PRESENTER

Mr Mr Anil Anil Singh Singh Dhadwal Dhadwal

BACKGROUND BACKGROUND

Current guidelines guidelines recommend recommend cemented cemented over over uncemented uncemented hemiarthroplasty hemiarthroplasty for for Current intracapsular intracapsular neck neck of of femur femur fractures. fractures. However, However, the the use use of of uncemented uncemented implants implants remains remains prevalent. prevalent. This This in in part part is is due due to to their their user user “friendly “friendly nature”, nature”, the the avoidance avoidance of of polymethyl polymethyl methacrylate methacrylate complications complications and and shorter shorter operating operating times. times. However, However, uncemented implants are associated with an increased risk of periprosthetic fracture uncemented implants are associated with an increased risk of periprosthetic fracture particularly particularly in in severely severely osteoporotic osteoporotic patients. patients. Osteoporosis Osteoporosis is is associated associated not not only only with with proximal femoral femoral cortical cortical thinning thinning but but also also increased increased marrow marrow star star volume. volume. The The proximal hypothesis of of this this study study was was that that simple simple measurements measurements of of femoral femoral canal canal diameter diameter could could hypothesis provide provide a a surrogate surrogate marker marker for for these these more more elaborate elaborate measurements measurements and and therefore therefore provide provide useful useful information information to to assist assist in in predicting predicting the the risk risk of of intra-operative intra-operative fracture. fracture.

OBJECTIVES OBJECTIVES

The The objective objective of of this this study study was was to to develop develop a a simple simple tool tool to to be be used used at at the the pre-operative pre-operative planning stage stage to to assess assess patients patients for for the the risk risk of of intra-operative intra-operative fracture. fracture. planning

METHODS METHODS

A A retrospective retrospective review review of of a a 3-year 3-year cohort cohort of of neck neck of of femur femur patients patients (n=235) (n=235) was was conducted. conducted. Radiographic Radiographic measurements measurements of of the the width width of of the the intramedullary intramedullary canal canal of of the the proximal femur were compared in a bootstrapping analysis between patients who proximal femur were compared in a bootstrapping analysis between patients who experienced an an intra-operative intra-operative fracture fracture (n=13) (n=13) and and those those who who did did not. not. experienced

RESULTS RESULTS

Kolmogorov Kolmogorov Smirnov Smirnov two-sample two-sample analysis analysis demonstrated demonstrated that that the the population population of of patients patients who who sustained sustained an an intra-operative intra-operative fracture fracture were were significantly significantly different different to to those those who who did did not by virtue of the fact that they had larger measurements of the intramedullary not by virtue of the fact that they had larger measurements of the intramedullary canal. canal.

Intra-operative fracture is significantly more likely in those patients who have Intra-operative fracture is significantly more likely in those patients who have an an intramedullary canal canal upper upper lesser lesser trochanter trochanter width width and and a a lower lower lesser lesser trochanter trochanter width width intramedullary of greater greater than than 38.5mm 38.5mm and and 26mm 26mm respectively. respectively. of

CONCLUSIONS CONCLUSIONS

Simple Simple measurements measurements of of canal canal width width are are easily easily obtained obtained on on calibrated calibrated films films and and can can help help identify identify patients patients at at high high risk risk of of intra-operative intra-operative fracture. fracture. Clinicians Clinicians should should consider consider using a cemented prosthesis for those patients whose measurements exceed using a cemented prosthesis for those patients whose measurements exceed the the recommended values. values. recommended

72

BTS - 25th Annual Scientific Meeting

th Oral Presentations – Session 5 – Thursday 5th November

Abstract 50

PERIPROSTHETIC LOWER LIMB FRACTURES; 10 YEARS EXPERIENCE MAIN MAIN AUTHOR AUTHOR

Rhodri Gwyn Royal Gwent Hospital

CO CO AUTHORS AUTHORS

Sanjit Singh – Royal Gwent Hospital, Ashok Mukherjee – Royal Gwent Hospital Rhodri Gwyn

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

We aim to classify type of fractures encountered, the mortality rate associated with these fractures and the treatment methods used.

METHODS METHODS

We identified a cohort of 108 patients who sustained periprosthetic fractures around knee and hip arthroplasty prosthesis from a prospective database of all admissions to our unit over a 10 year period. Fractures were classified according to the Vancouver, Lewis and Rorabeck and Felix and associates classification systems

RESULTS RESULTS

70 (65%) of patients were female. Average age at fracture was 77 years. The mean time from index operation to fracture was 6 years. Minimum follow up was 1 year. 4 were high energy injuries, 96 were low energy injuries and 8 were unknown.

69 patients had fractures associated with femoral components of hip arthroplasty. 4 had Vancouver type A, 26 Vancouver B1, 18 Vancouver B2, 6 Vancouver B3 and 15 Vancouver C. 38 patients fracture around total knee replacements. 4 had Lewis and Rorabeck type1, 26 had Type 2 and 2 had type 3. 5 patients suffered a Felix and associates type 2 and 2 patients suffered a type 3.

57 patients underwent ORIF, 17 patients a revision, 19 patients a manipulation and plaster application, 5 were treated with and IM nail and 19 treated non operatively.

At 30 days the overall mortality rate was 4%. After 1 year the overall mortality rate was 18%.

CONCLUSIONS CONCLUSIONS

Periprosthetic fractures carry a high 1 year mortality rate (18%) This risk is significantly higher than for elective revision arthroplasty surgery and native bone fracture fixation.

The mortality rate is slightly lower but comparable to neck of femur fractures (20-35%).

BTS - 25th Annual Scientific Meeting

73

th 5th

Oral Presentations – Session 5 – Thursday 5 November

Abstract 51

Oral Presentations – Session 5 – Thursday 5th November Oral Presentations – Session 5 – Thursday 5th November

COMPARATIVE OUTCOME OF ISOLATED HIP FRACTURES AND HIP FRACTURES IN PATIENTS WITH SIMULTANEOUS UPPER LIMB INJURY MAIN MAIN AUTHOR AUTHOR

CO AUTHORS AUTHORS CO

Atanu Bhattacharjee The Robert Jones and Agnes Hunt Orthopaedic Hospital and Wrexham Maeolar Hospital Razi Bashir, Ibrahim Malek, Asad Syed

PRESENTER PRESENTER

Atanu Bhattacharjee

OBJECTIVES OBJECTIVES

Compare the outcome of patients with concurrent upper limb injury(ULI) and simultaneous hip fractures with patients presenting with isolated hip fractures(NOF)

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

74

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER

A retrospective analysis of 260 patients with hip fractures with/ without upper limb injury was undertaken from the local hip fracture data base. The nature of upper limb injury was evaluated by reviewing radiographs and case-notes of the patients. The following outcome was assessed from the studyPrimary outcome was to evaluate 30 days and 365 days mortality in patients with isolated NOF and ULI with NOF. Secondary outcome was to identify the discharge destination following admission from their own home and also ascertain the length of hospital stay in both groups of patients.

A total 243 patients (93.5%) had isolated hip fractures (NOF) and only17 patients (6.5%) had concurrent upper limb injury (ULI) with NOF. There was no statistically significant difference in patient’s age (p-value-0.7) and Abbreviated Mental Test Score (p-value-0.29) between the two groups of patients. The median ASA grade of patients with isolated NOF was 3 and NOF with concurrent ULI was 2.

The 30 day mortality of patients with NOF and ULI (0.6%) is significantly less than patients with isolated NOF (9%, p-value<0.05). However, 1 year mortality was significantly higher in patients with ULI and NOF (29%) in comparison to isolated NOF (15%, p-value-<0.05). Moreover, significantly longer inpatient hospital stay was observed in patients with ULI and NOF (46 days) in comparison to isolated NOF (32 days). Furthermore, patients with ULI and NOF had significantly higher rate of returning to their own home (11 out of 12) in comparison to isolated NOF (129 out of 175) following admission from their own home.

Patients with ULI and NOF are more fit and have no difference in age or Abbreviated Mental State Score in comparison to patients with isolated NOF. The 30 days mortality in patients with simultaneous ULI is significantly low in comparison to patients with isolated NOF, indicating their pre-morbid fitness. The 1- year mortality trend is reversed in this group of patients potentially by the added morbidity from upper limb injury which increases their length of hospital stay and period of rehabilitation.

BTS - 25th Annual Scientific Meeting

PRESENTER OBJECTIVES OBJECTIVES METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Abstract 52 Abstract 52

DOES LAMINAR FLOW VENTILAION REDUCE INFECTION RATE? AN OBSERVATIONAL STUDY OFREDUCE TRAUMAINFECTION IN ENGLAND DOES LAMINAR FLOW VENTILAION RATE? AN OBSERVATIONAL STUDY OF TRAUMA IN ENGLAND

Elizabeth Pinder Elizabeth ColchesterPinder General Hospital

Colchester Hospital A Bottle (DrGeneral Foster Unit, Imperial College), P Bottle Aylin (Dr A (DrFoster FosterUnit, Unit,Imperial ImperialCollege), College), M Aylin Loeffler P (Dr(Colchester Foster Unit,General ImperialHospital) College), Elizabeth M LoefflerPinder (Colchester General Hospital) Elizabeth Pinder To determine whether there is any difference in infection rate at 90 days between trauma operations performed laminar flow and pleniumrate ventilation and between whether To determine whether there isinany difference in infection at 90 days infectionoperations risk is altered followingin thelaminar installation laminar flow. ventilation and whether trauma performed flowofand plenium infection risk is altered following the installation of laminar flow.

All hospitals with an orthopaedic trauma theatre were contacted to determine which type of ventilation was usedtrauma during theatre the period April 2008 – March 2013: always All hospitals with system an orthopaedic were contacted to determine which laminar flow, neversystem laminarwas flow, installed flowApril during study period2013: (subdivided type of ventilation used duringlaminar the period 2008 – March always into before, and after installation), and unknown. each operation, age, laminar flow, during never laminar flow, installed laminar flow duringFor study period (subdivided gender, comorbidity, deprivation, number of previous trauma into before, during andsocio-economic after installation), and unknown.

For each operation, age, operations and surgicalsocio-economic site infection within 90 days were extracted from England’s gender, comorbidity, deprivation, number of previous trauma national administrative database, Statistics. and operationshospital and surgical site infection within Hospital 90 days Episode were extracted fromCrude England’s adjusted ratios were used to database, compare ventilation hierarchical logistic national odds hospital administrative Hospital groups Episodeusing Statistics.

Crude and regression.

Sub-analysis performed for ventilation hip hemiarthroplasties. adjusted odds ratios werewas used to compare groups using hierarchical logistic regression. Sub-analysis was performed for hip hemiarthroplasties.

During the study period, 803,065 trauma operations were performed. Laminar flow was installed in study 19 hospitals thistrauma time, 124 alreadywere had laminar flow,Laminar 13 had flow plenium During the period,during 803,065 operations performed. was ventilation 28 were unknown. characteristics similar the installed in and 19 hospitals during thisPatient time, 124 already had were laminar flow,between 13 had plenium groups.

Infection rates within 90 days were similar for “always laminar flow” and ventilation and 28 were unknown. Patient characteristics were similar between the plenium Infection ventilation (2·7within and 2·4%).

Forwere hip hemiarthroplasties, infection rates were groups. rates 90 days similar for “always laminar flow” and significantly higher for flow compared with plenium ventilation (3·8 andwere 2·6%, plenium ventilation (2·7laminar and 2·4%).

For hip hemiarthroplasties, infection rates OR 1·45, p=0·001).

Hospitals laminarwith flowplenium did notventilation see any statistically significantly higher for laminar installing flow compared (3·8 and 2·6%, significant change inHospitals infection installing rates either for theflow whole for hip OR 1·45, p=0·001). laminar did population not see anyorstatistically hemiarthroplasties. significant change in infection rates either for the whole population or for hip hemiarthroplasties.

It appears equally safe to perform orthopaedic trauma surgery including implant surgery in appears laminar equally flow and ventilation.

Theatre laminar flow may It safeplenium to perform orthopaedic traumasuites surgerywithout including implant surgery continue to perform implant and Theatre non-implant trauma surgery. in laminar flow andorthopaedic plenium ventilation. suites without laminar flow may continue to perform orthopaedic implant and non-implant trauma surgery.

BTS - 25th Annual Scientific Meeting

75

Oral Presentation –Session 5 – Thursday 5th November Oral Presentation –Session 5 – Thursday 5th November

ABSTRACT TITLE ABSTRACT TITLE MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS

PRESENTER PRESENTER OBJECTIVES OBJECTIVES METHODS METHODS RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

76

Abstract 53 Abstract 53

ADEQUACY OF HIP FRACTURE RADIOGRAPHS IN EMERGENCY ADEQUACY OF HIP FRACTURE IN EMERGENCY DEPARTMENT ANDRADIOGRAPHS IT'S IMPLICATIONS Al-Mothenna AlloushDEPARTMENT AND IT'S IMPLICATIONS Al-Mothenna Alloush Tamas Kobezda Hull and east Yorkshire hospitals NHS trust Tamas Kobezda and east Yorkshire hospitals NHS trust Michael MokawemHull Hull and east Yorkshire hospitals NHS trust Michael Mokawem Hull and Yorkshire hospitals NHSNHS trusttrust Najarajan MuthuKumar Hull east and east Yorkshire hospitals Najarajan MuthuKumar east Yorkshire hospitals NHS trust Dr Craig Moore, PhysicistHull andand Radiation Protection Advisor Dr Craig Moore, Physicist and Radiation Protection Advisor Al-Mothenna Alloush Al-Mothenna Alloush

The study aimed to establish the adequacy of hip radiographs in patient admitted with The study aimed to establish the to adequacy of hip radiographs patientwith admitted with fracture neck of femur in addition the implication of inadequateinx-rays regards to fracture of femur additioncost to the implication of inadequate x-rays with regards to radiationneck exposure andinfinancial radiation exposure cost Retrospective studyand of financial the AP (antero-postero) and lateral x-rays of 100 consecutive Retrospective study theroyal AP infirmary (antero-postero) andoflateral of The 100 radiographs consecutive patients admitted to of Hull with neck femur x-rays fracture. patients admitted to Hull with neck of femur fracture.

The radiographs were assessed against theroyal trustinfirmary protocol(HEYRAD12) of referral criteria and standards were assessed against the trust protocol(HEYRAD12) of referral criteria and standards of adequate x-ray. of adequate x-ray.

Only 9% of the patients had 100% compliant AP and lateral radiographs with the trust Only 9% of 44% the patients hadpelvis 100%x-rays compliant lateral radiographs with the trust standards. of the AP wereAP notand compliant with the trust standards. standards. of view the AP pelvis werewith notthe compliant with the trust 48% of the44% lateral were not x-rays compliant trust standards.

19% standards. of the AP 48% the lateral and view5% were not lateral compliant with trusthad standards.

19% oftothe AP pelvisofradiographs of the views of the hip to be repeated allow pelvis radiographs 5% of the lateral views of the hip had to be repeated to allow treatment decisionsand to be made. treatment made.

Significantdecisions number toofbethe AP pelvis and lateral hip views taken in emergency Significant of the and lateral hip views in emergency department number for fracture neckAP of pelvis femur were inadequate as pertaken the trust criteria. A department for fracture were inadequate as perdefinite the trust criteria.

A significant number >20%neck had of to femur be repeated prior to making decision with significant number >20% had financial to be repeated priortotothemaking with regards to treatment.

This has implications trust asdefinite the costdecision of repeating regards to treatment.was Thisestimated has financial implications theradiation trust as the cost repeating the 24 radiographs at 1,426 pounds to with dose of of0.145 mSv the 24 radiographs was estimated at 1,426 pounds with radiation dose of 0.145 mSv per x-ray. per x-ray.

BTS - 25th Annual Scientific Meeting

Oral Presentations – Session 6 – Thursday 5th November

MAIN AUTHOR

CO AUTHORS

Abstract 54

EPIDEMIOLOGY OF ACETABULAR FRACTURES IN THE NORTH WEST OF ENGLAND

Suran De Almeida

Royal Albert Edward Infirmary, Wigan, Wrightington and Leigh NHS Foundation Trust, Wigan Pratima Khincha Bishoy Youssef N Birkett E R Street A D Clayson Nikhil Shah Henry Wynn Jones – Royal Albert Edward Infirmary, Wigan, Wrightington and Leigh NHS Foundation Trust, Wigan

PRESENTER

Suran De Almeida

OBJECTIVES

To report the epidemiology of acetabular fractures occurring in the North West of England; including incidence, mechanism of injury, modes of treatment, associated injuries and mortality.

METHODS

305 adults who suffered an acetabular fracture were identified from a prospectively maintained database of all pelvic and acetabular fractures referred for management opinion to the North West Pelvic and Acetabular Service (NWPAS). This is the only unit treating these patients in the Greater Manchester (GM) and Lancashire regions. Period of study was from September 2009 to April 2013. The fracture incidence rate was calculated (referrals from outside GM and Lancashire excluded). Fractures were classified using the AO system. Information regarding the mechanism, associated injuries and treatment methods were analysed. The mortality at 3, 6 and 12 months was recorded using the National Hospital Episode Statistics database.

RESULTS

The mean incidence was 1.4/100000/ year. 50.16% resulted from high energy injuries with 55.56% resulting from road traffic collisions and 44.44% from falls from a height.

48.8% fractures resulted from low energy injuries, of which the majority (60%) were from simple falls from a standing height. High energy injuries showed a bimodal distribution with peaks at 21-30 and 51-60 years, and were more common in males.

Low energy injuries showed a peak at 71-80 years, and had similar trends in both males and females. Associated injuries were present in 29.8% of all patients and 56.2% of patients with high energy injuries. Distribution of fracture pattern according to the AO classification was Type A = 47.9%, Type B = 21.4% and Type C = 30.7%. Operative management was performed in 47% of patients with high energy injury whilst 91.9% of low energy injuries were managed non operatively. Late conversion to hip arthroplasty was seen in 2.7% of patients following conservative management and 5.9% following surgical fixation. There were no deaths recorded in the operative group, and in those managed non operatively, the mortality rate was 9.9% at 12 months.

CONCLUSIONS

The study identified a slight upward trend in the incidence of these rare fractures and analysis of the mechanism of injury revealed a decline in high energy injuries. Whilst these high energy fractures are commonly associated with additional injuries, despite the additional morbidity and a higher percent undergoing operative intervention mortality was zero at 12 months. The majority of the low energy injuries can be successfully managed non operatively with a low conversion rate to arthroplasty.

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November Oral Presentations – Session 6 – Thursday 5th Oral Presentations – Session 6 – Thursday 5th November

Abstract 55 Abstract 55

Oral Presentations – Session 6 – Thursday 5th November Oral Presentations – Session 6 – Thursday 5th November

A BIOMECHANICAL STUDY TO DETERMINE THE OPTIMUM METHOD OF A BIOMECHANICAL STUDY DETERMINE OPTIMUM METHOD OF FIXATION FORTO DISTAL TIBIALTHE FRACTURES FIXATION FOR DISTAL TIBIAL FRACTURES MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS

PRESENTER PRESENTER

OBJECTIVES OBJECTIVES

METHODS METHODS

Ashwin Unnithan Ashwin Unnithan Royal Surrey County Hospital Royal Surrey County Hospital Zhaochen Shan (University College London) Zhaochen Shan (University College London) Camilla Halewood (University College London) Camilla Halewood (University CollegeHospitals) London) Arshad Khaleel (Ashford & St Peter’s Arshad Khaleel (Ashford & St Peter’s Hospitals) Professor Andrew Amis (University College London) Professor Andrew Amis (University College London) Claire Richards Claire Richards

A number of different methods of fixation for distal tibial fractures are used in clinical A numberincluding of different methods of (IM) fixation for distal clinical practice intramedullary nailing, distaltibial tibialfractures locking are plateused andinexternal practice There including intramedullary (IM) nailing, distal istibial locking plate andand external fixation. is currently no consensus as to which the optimum method if this fixation.

There is currently as toofwhich is the optimum methodofand this should vary depending on no theconsensus exact location the fracture.

The objective thisif pilot should vary depending ontothe of the fracture.

Thein objective this pilot biomechanical study was testexact theselocation three methods of fixation saw boneofmodels to biomechanical was to test these meaningful three methods fixationcould in saw models see if it would study be possible to obtain dataof which bebone extended to to a see if it would be possible to obtain meaningful data which could be extended to a larger study and subsequently inform clinical practice. larger study and subsequently inform clinical practice.

Six fourth generation composite tibial saw bone models (Sweden, model 3402) had Six fourth generation composite tibial saw bone (Sweden, model 3402) had oblique fractures created at 3cm or 5 cm from themodels distal end.

The fractures were then oblique fractures created at 3cmnail or 5orcm from the distal end.plate, The fractures were fixed with either an IM (Expert) a distal tibial locking both tested at then 3cm fixed with either IM (Expert) distal tibial locking plate, both were testedtested at 3cm and 5cm, and ananexternal fixatornail of or twoa different configurations which at and and an and external twostability different configurations which were was tested at 5cm 5cm, only (Hybrid olive fixator wires). of The of the different configurations then 5cm only (Hybrid olive wires).

The stability of theUK) different configurations then tested using the and Instron® 8874 (High Wycombe, axial-torsion servo was hydraulic tested using Instron® 8874 (High UK)axial axial-torsion servo for hydraulic testing systemthe using a maximum torqueWycombe, of 25Nm and load of 1000N 5,000 testing using a maximum torque of 25Nm axial load 1000N for 5,000 cycles. system The three dimensional displacement of theand fracture was of measured using a cycles.

The three dimensional digital camera tracking system. displacement of the fracture was measured using a digital camera tracking system.

RESULTS RESULTS

The IM nail provided the best stability (1.531±0.052mm displacement) at the fracture The IM nail the provided the fracture 3cm from distal the endbest of stability the tibia(1.531±0.052mm and the plate displacement) provided the atbest stability 3cm from the distal end of at thethetibia and 5cm the plate provided the best stability (0.836±0.31mm displacement) fracture from the distal end.

Although the (0.836±0.31mm displacement) at the 5cm from the than distaleither end. Although the displacement was much greater withfracture the external fixator of the other displacement wasit much greater thetorsional externalstability. fixator than either of the other constructs at 5cm provided much with greater constructs at 5cm it provided much greater torsional stability.

CONCLUSIONS CONCLUSIONS

The IM nail provided more stability than the other constructs when the fracture was 3cm The IM provided stability than the other constructs thestability fracturewhen was 3cm from thenail distal end. more The distal tibial locking plate provided when greater the from thewas distal end.

The platehad provided the fracture 5cm from thedistal distaltibial end.locking The frame much greater greater stability torsionalwhen stability fracture the distal The frame much stability than the was other5cm two from constructs.

Theend. limitation of thishad study wasgreater that thetorsional constructs need than other constructs.

The of this study that are the worthy constructs need to bethe tested in two a greater number of limitation models however thesewas results of further to be tested in a greater of to models however results worthy of further investigation and have thenumber potential change clinical these practice in theare future. investigation and have the potential to change clinical practice in the future.

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MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS CONCLUSIONS CONCLUSIONS

Abstract 56 Abstract 56

BILATERAL SPONTANEOUS BISPHOSPHONATE INSUFFICIENCY FRACTURES BILATERAL SPONTANEOUS BISPHOSPHONATE INSUFFICIENCY FRACTURES OF THE PROXIMAL TIBIA AND UNILATERAL DISTAL FEMUR: A CASE REPORT OF THE PROXIMAL TIBIA AND DISTAL FEMUR: A CASE REPORT ANDUNILATERAL RECOMMENDATION AND RECOMMENDATION Zaid Al-Wattar Zaid Al-Wattar Maidstone and Tunbridge Wells NHS Trust Maidstone and Tunbridge Wells NHS Trust Kasetti Ravikumar Kasetti Ravikumar Zaid Al-Wattar Zaid Al-Wattar To raise awareness among trauma and orthopaedic surgeons about these rare To raise and awareness among andanyorthopaedic these rare fractures recommend MRItrauma scan in patient withsurgeons long-termabout bisphosphonate fractures in the anyknee. patient with long-term bisphosphonate treatment and arecommend new onset ofMRI painscan around treatment and a new onset of pain around the knee.

We present a 77 years old Caucasian female with spontaneous onset of pain in both We present a 77 years Caucasian female withcasualty spontaneous onset pain inclinic. both knees for several days old before presenting to the then to our of fracture knees for several days before presenting casualty then to our fracture There was no history of trauma.

The patienttois the known to have Rheumatoid arthritisclinic.

There history trauma.

The patient is known to have (Alendronate) Rheumatoid arthritis for overwas 30 no years and of has been on Bisphosphonate treatment for over for over 30 following years andthe has been onof Bisphosphonate (Alendronate) for over 12 months diagnosis osteoporosis bytreatment DEXA scan.

Plain radiographs 12 months following diagnosis of osteoporosis DEXA scan.tibiae.

Plain Magnetic radiographs showed subtle linearthe areas of sclerosis bilaterally inbyher proximal showed subtle linearconfirmed areas of sclerosis bilaterally in her proximal tibiae. resonance imaging the presence of extra-articular linear highMagnetic signal intensity resonance imaging confirmed the presence of extra-articular high signal intensity change on T1, T2 with surrounding marrow edema consistent linear with insufficiency change T2 areas with surrounding marrow consistent insufficiency fractureson inT1, these as well as her right edema distal femur.

Thesewith fractures were treated fractures in these areas as well as herand righta distal TheseThere fractures treated successfully with activity modification hinge femur. knee brace. are were very few successfully with activity modification andinvolving a hinge knee brace. There very few reports of atyipcal insufficiency fractures the proximal tibia inare patients on reports of bisphosphonate atyipcal insufficiency fractures involving thetoproximal tibiadocumented in patients on long-term therapy and this appears be the third bilateral long-term bisphosphonate therapy and this appears to be theand third documented bilateral case involving the metaphyseal regions of the proximal tibia distal right femur. case thewere metaphyseal of the with proximal tibiamodification and distal right femur.

Theseinvolving fractures treated regions successfully activity and a weight These were treated successfully with activity modification and a weight bearing fractures hinge knee brace for 8 weeks. bearing hinge knee brace for 8 weeks.

This rare presentation in a rheumatoid patient with osteoporosis and long-term This rare presentation a rheumatoid patient with osteoporosis long-term bisphosphonate treatmentinhighlights the importance of being vigilant andand having a high bisphosphonate treatment highlights thefractures importance of being high index of suspicion for these atypical around the vigilant knees and having not to arelate index of suspicion for these process atypical or fractures the knees and not to relate symptoms to the inflammatory synovitisaround associated with rheumatoid arthritis. symptoms to the inflammatory process or synovitis associated withunder rheumatoid arthritis.

We think that these insufficiency fractures around the knees are diagnosed and We that these fractures around knees under awareness diagnosed and oftenthink confused with insufficiency the rheumatoid process.

We the would likeare to raise often confused theinrheumatoid We would like to raise treatment awareness and recommend MRIwith scan any patientprocess. with long-term bisphosphonate and a recommend in the anyknee. patient with long-term bisphosphonate treatment and a new onset of MRI pain scan around new onset of pain around the knee.

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th Oral Oral Presentations Presentations –– Session Session 6 6 –– Thursday Thursday 5 5th November November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Abstract Abstract 57 57

DEDICATED DEDICATED ANAESTHETIC ANAESTHETIC TEAMS TEAMS FOR FOR TRAUMA TRAUMA – – OPTIMISING OPTIMISING FRACTURE FRACTURE NECK NECK OF OF FEMUR FEMUR PATIENT PATIENT CARE CARE AND AND THE THE ADDITIONAL ADDITIONAL BENEFIT BENEFIT TO TO IMPROVED IMPROVED BEST BEST PRACTICE PRACTICE TARIFF TARIFF (BPT) (BPT) – –A A DISTRICT DISTRICT GENERAL GENERAL HOSPITAL HOSPITAL (DGH) (DGH) EXPERIENCE EXPERIENCE

Sushil Sushil Manohar Manohar Sandwell Sandwell and and West West Birmingham Birmingham NHS NHS (SWBH (SWBH NHS) NHS) Trust Trust

Atul Atul Malik Malik (SWBH (SWBH NHS); NHS); Syeda Syeda Naqvi Naqvi (SWBH (SWBH NHS); NHS); Martin Martin Beard Beard (SWBH (SWBH NHS); NHS); Subhash Subhash Sivasubramanium Sivasubramanium (SWBH (SWBH NHS); NHS); Ram Ram Ponnuru Ponnuru (SWBH (SWBH NHS); NHS); Pragnesh Pragnesh Raj Raj (SWBH (SWBH NHS); NHS); Aun Aun Shaun Shaun Thein Thein (SWBH (SWBH NHS) NHS) Sushil Sushil Manohar Manohar As As per per NICE NICE guidelines; guidelines; in in addition addition to to Orthogeriatrician Orthogeriatrician (OG) (OG) & & Orthopaedic Orthopaedic teams teams jointly jointly treating treating patients patients with with neck neck of of femur femur fractures; fractures; anaesthetists anaesthetists participate participate in in the the multidisciplinary multidisciplinary team team (MDT) (MDT) of of NOF NOF fracture fracture patients. patients. In In addition; addition; a a rota rota of of dedicated dedicated Anaesthetists Anaesthetists with with an an interest interest in in Trauma Trauma can can provide provide many many benefits. benefits. OG OG team team input input has has been been complimented complimented and and perioperative perioperative care care has has improved. improved. This This is is visible visible from from increased increased percentage of patients operated within 36 hours of admission.

Having a named percentage of patients operated within 36 hours of admission. Having a named anaesthetist anaesthetist on on a a rolling rolling rota rota in in parallel parallel to to the the trauma trauma team team has has allowed allowed a a named named specialist specialist for for pre-operative pre-operative optimisation optimisation which which includes includes precluding precluding delays delays by by optimal optimal investigation. investigation.

METHODS METHODS

A A departmental departmental database database is is maintained maintained for for patients patients admitted admitted with with fracture fracture neck neck of of femur. femur. This This is is maintained maintained by by a a surgical surgical care care practitioner practitioner (SCP) (SCP) who who along along with with the the OG OG monitors monitors such such patients patients over over the the perioperative perioperative period. period. A A designated designated orthopaedic orthopaedic lead lead consultant consultant oversees oversees the the progression progression of of care care along along with with them them with with monthly monthly meetings meetings outlining outlining any any issues issues or or specific specific concerns concerns with with regards regards to to delays delays – – clinical clinical or or logistical. logistical.

RESULTS RESULTS

In In our our small small district district general general hospital hospital we we annually annually receive receive approximately approximately 420 420 patients patients sustaining sustaining neck neck of of femur femur fractures fractures undergoing undergoing operative operative management. management. To To improve improve the the time-to-theatre time-to-theatre from from admission admission various various measures measures were were adopted. adopted. Over Over a a year year ago, ago, the the dedicated dedicated trauma trauma anaesthetists anaesthetists with with an an interest interest in in trauma trauma surgery surgery became became part part of of the the perioperative perioperative team. team. .. Each Each anaesthetist anaesthetist was was available available for for a a whole whole week. week. This This meant meant ease ease of of accessibility accessibility of of a a named named specialist specialist for for pre-operative pre-operative review, review, drawing drawing of of structured structured plans plans for for optimisation optimisation as as well well as as pre-empting pre-empting investigations investigations toward toward clearance clearance for operative fitness.

It also brought reliability causing fewer cancellations from the for operative fitness. It also brought reliability causing fewer cancellations from the trauma trauma list. Hence, list. Hence, the the number number of of patients patients with with such such injuries injuries undergoing undergoing definitive definitive surgery surgery in in the the 24 24 hours hours following following the the injury injury has has improved improved from from 62.7% 62.7% patients patients before before the the change change in in schedule schedule to to 79%.

79%. Other Other variables variables improved improved such such as as mental mental status status assessment (from 95.6% to 98.8%) while the department gained from an improvement assessment (from 95.6% to 98.8%) while the department gained from an improvement in in the the BPT BPT (for (for qualifying qualifying patients) patients) from from 74.3% 74.3% to to 75.8%.

75.8%.

CONCLUSIONS CONCLUSIONS

80

Timely Timely optimisation optimisation of of patients patients with with neck neck of of femur femur fractures fractures for for surgical surgical management management has has been been improved improved by by having having a a rota rota of of anaesthetists anaesthetists in in parallel parallel to to the the orthopaedic orthopaedic team. team.

This has improved the perioperative care of these patients having a direct This has improved the perioperative care of these patients having a direct bearing bearing on on their postoperative rehabilitation.

Improvements from such changes have not only had their postoperative rehabilitation. Improvements from such changes have not only had a a positive positive bearing bearing on on clinical clinical outcomes outcomes but but also also economic economic benefits benefits (through (through the the BPT) BPT) by by adhering adhering to to the the guidelines. guidelines.

BTS - 25th Annual Scientific Meeting

Oral Presentations – Session 6 – Thursday 5th November Oral Presentations – Session 6 – Thursday 5th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Abstract 58 Abstract 58

THE OUTCOME AFTER OPERATIVE AND NON-OPERATIVE MANAGEMENT OF SCAPULAR FRACTURES: SYSTEMATIC REVIEW. THE OUTCOME AFTER OPERATIVE ANDA NON-OPERATIVE Sudhir Kannan MANAGEMENT OF SCAPULAR FRACTURES: A SYSTEMATIC REVIEW. Sudhir Kannan University Hospitals of Leicester University HP Singh, Hospitals R Pandeyof Leicester HP Singh, R Pandey Sudhir Kannan Sudhir Kannan

Scapular fractures account for 0.4%-1% of all injuries and 3-5% of shoulder injuries (Gosens et al). There is nofor agreement regarding management these Scapular fractures account 0.4%-1% inof literature all injuries and 3-5% of shoulderofinjuries fractures. aim our studyinis literature was to carry out amanagement systematic review to (Gosens etThe al).primary There is noofagreement regarding of these compare of operative andstudy non-operative of scapular review fractures. fractures. the Theresults primary aim of our is was tomanagement carry out a systematic to We collected the data of both and modalities of treatment and categorized in to compare the results of operative non-operative management of scapularthem fractures. according in tothe different regions of Weand nextcategorized analysed the datainand We collected data anatomical of both modalities of scapula. treatment them to compared in these results anatomical with results regions of otherofcomparative After comparing according to different scapula. Westudies. next analysed the data and validating our results wewith finally could provide guidelinesstudies. for the After management of and the compared these results results of other comparative comparing scapular validatingfractures. our results we finally could provide guidelines for the management of the scapular fractures.

The search was conducted in multiple medical databases like MEDLINE, EMBASE, and PUBMED. terms ‘Scapula And fractures’, Glenoid And fractures’.

The searchThe wasprimary conducted in were multiple medical databases like MEDLINE, EMBASE, The and literature search in thisterms systematic review was conducted Glenoid according the PRISMA PUBMED. The primary were ‘Scapula And fractures’, Andtofractures’.

The protocol. search in this systematic review was conducted according to the PRISMA literature All the studies in literature till February 2014 on scapular fractures that reported an protocol. outcome of treatment were included in the2014 study.onCase seriesfractures less thanthat 7 patients, case All the studies in literature till February scapular reported an reports, review articles, articles without studies, without outcome of treatment were included in theabstract,obervational study. Case series less than 7papers patients, case results and papers dealing with fractures following reverse shoulder arthroplasty were reports, review articles, articles without abstract,obervational studies, papers without excluded. results and papers dealing with fractures following reverse shoulder arthroplasty were excluded.

There were 32 studies which met the inclusion criteria, Majority of the included studies were studies (20) 8 studies wereMajority prospective series, one Thereretrospective were 32 studies which metstudies, the inclusion criteria, of thecase included studies was aretrospective cohort study.studies These studies were used for thewere collection of evidence.

There was were (20) studies, 8 studies prospective case series, one a metanalysis and 2These systematic reviews whichforwere used to check the validity of was our was a cohort study. studies were used the collection of evidence.

There results .In these studies therewhich were were 1315 used patients who the underwent either a metanalysis andincluded 2 systematic reviews to check validity of our conservative (804)included or operative management (511) for scapular results .In these studies there were 1315 patients fractures. who underwent either conservative (804) or operative management (511) for scapular fractures.

100 % scapular body fractures in literature managed non-operatively have satisfactory results, hence the nonfractures operativeinmanagement might result in satisfactory The 100 % scapular body literature managed non-operatively haveoutcome satisfactory literaturehence review that management operative management displaced glenoid results, the suggests non operative might result of in satisfactory outcomefossa The fractures have functional our review we found glenoid the 94.7% of literature reviewbetter suggests that outcome. operative Inmanagement of have displaced fossa scapular neck displaced <10mmInhave satisfactory outcome nonfractures have fractures better functional outcome. our review we have foundfollowing the 94.7% of operative management; the <10mm non-operative management might be preferred in scapular neck fractures hence displaced have satisfactory outcome following nonthese fractures.

Our analysis on the displaced scapularmanagement neck fractures(>10mm)showed operative management; hence non-operative might be preferredthat in they have better functional following operative management, this prompted these fractures.

Our analysisoutcome on displaced scapular neck fractures(>10mm)showed that us to have conclude these fractures could have better management, outcome following operative they betterthat functional outcome following operative this prompted management .There is not fractures enough evidence for better coracoid fractures to compare the us to conclude that these could have outcome following operative results of both .There treatment modalities management is not enough evidence for coracoid fractures to compare the results of both treatment modalities

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BRITISH BTS - 25th Annual Scientific Meeting

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AUMA TR

www.bts-org.co.uk

Poster Presentations – Wednesday 4th November th November Poster Presentations – Wednesday 4

th Poster Poster Presentations Presentations –– Wednesday Wednesday 4 4th November November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

Poster Poster 1 1

ANALYSIS ANALYSIS OF OF POST-OPERATIVE POST-OPERATIVE THROMBOPROPHYLAXIS THROMBOPROPHYLAXIS INSTRUCTIONS INSTRUCTIONS AT AT A A MAJOR MAJOR TRAUMA TRAUMA CENTRE: CENTRE: A A CLOSER CLOSER LOOK LOOK AT AT THE OPERATION THE OPERATION NOTE NOTE

Leslie Leslie Ing Ing Orthopaedic Orthopaedic Surgery, Surgery, King's King's College College Hospital Hospital

Saif Saif Sait, Sait, Kirsty Kirsty Drew, Drew, Kumar Kumar Kunasingam Kunasingam (Orthopaedic (Orthopaedic Surgery, Surgery, King's King's College College Hospital) Hospital) Dr Saif Sait Dr Saif Sait

OBJECTIVES OBJECTIVES

Post-operative Post-operative instructions instructions documented documented in in operation operation notes notes are are an an important important means means of of communication communication between between operating operating surgeons surgeons and and ward-based ward-based junior junior doctors doctors receiving receiving patients from theatre.

Our aim was to review the precision of VTE prophylaxis patients from theatre. Our aim was to review the precision of VTE prophylaxis instructions instructions left left in in the the operation operation notes notes by by operating operating orthopaedic orthopaedic surgeons surgeons and and the the effect effect this this has has on on ward-based ward-based care. care.

METHODS METHODS

A A total total of of 231 231 cases cases were were reviewed reviewed retrospectively retrospectively over over a a one one month month period. period. Data Data collected collected included included VTE VTE prophylaxis prophylaxis instructions, instructions, operation operation type, type, patient patient confounding confounding factors for VTE prophylaxis, and adverse outcomes.

A questionnaire was also factors for VTE prophylaxis, and adverse outcomes. A questionnaire was also completed completed by by junior junior doctors doctors to to assess assess their their knowledge knowledge of of the the recommended recommended VTE VTE prophylaxis prophylaxis according according to to operation operation type, type, and and also also their their confidence confidence in in prescribing prescribing this this using using the the Likert Likert scale. scale.

RESULTS RESULTS

Of Of the the 231 231 cases, cases, only only 15% 15% had had a a specific specific VTE VTE prophylaxis prophylaxis instruction instruction documented documented in in the the post-operative post-operative instructions. instructions. 59% 59% had had no no VTE VTE prophylaxis prophylaxis instruction instruction and and 26% 26% had had a a non-specific instruction, the most common being "prescribe as per protocol".

A total of non-specific instruction, the most common being "prescribe as per protocol". A total of 10 FY1s filled out questionnaires.

They revealed that none were confident in 10 FY1s filled out questionnaires. They revealed that none were confident in prescribing prescribing VTE VTE prophylaxis prophylaxis post-operatively, post-operatively, with with only only 3 3 able able to to accurately accurately recall recall the the recommended recommended VTE VTE prophylaxis prophylaxis for for different different orthopaedic orthopaedic procedures. procedures.

CONCLUSIONS CONCLUSIONS

The The frequency frequency with with which which precise precise instructions instructions for for VTE VTE Prophylaxis Prophylaxis were were documented documented was was disappointing. disappointing. Furthermore, Furthermore, there there was was a a significant significant lack lack of of confidence confidence among among the the junior doctors doctors in in prescribing prescribing VTE VTE prophylaxis prophylaxis for junior for different different orthopaedic orthopaedic procedures. procedures.

Frequently, Frequently, this this led led to to a a delay delay in in prescribing prescribing VTE VTE prophylaxis prophylaxis as as juniors juniors would would need need to to consult consult with with the the operating operating surgeon surgeon before before prescribing. prescribing. As As the the junior junior doctors doctors are are the the ones ones who implement post-operative plans for patients coming back from surgery, the lack of who implement post-operative plans for patients coming back from surgery, the lack of confidence confidence and and clear clear knowledge knowledge highlights highlights an an area area of of concern. concern. Comments Comments left left by by juniors juniors expressed expressed that that some some of of the the confusion confusion has has stemmed stemmed from from discrepancy discrepancy between between surgeons, who may advise differing VTE prophylaxis regimens for similar orthopaedic surgeons, who may advise differing VTE prophylaxis regimens for similar orthopaedic procedures. procedures. Furthernore, Furthernore, they they expressed expressed a a need need for for better better education education in in this this area area and and for for the the development development of of trust-wide trust-wide guidelines. guidelines.

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MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Poster 2 Poster 2

MORTALITY ARISING FROM DIABETIC NECK OF FEMUR FRACTURE MORTALITY ARISING FROM DIABETIC PATIENTSNECK OF FEMUR FRACTURE PATIENTS Onn Shaun Thein

Onn Shaun Thein Sandwell and West Birmingham Hospitals NHS Trust Sandwell and West Birmingham Hospitals NHS Trust Emma Hirons, Sandwell and West Birmingham Hospitals NHS Trust Emma KishoreHirons, Dasari,Sandwell Sandwelland andWest WestBirmingham BirminghamHospitals HospitalsNHS NHSTrust Trust Kishore Dasari, Sandwell and West Birmingham Hospitals NHS Trust Onn Shaun Thein Onn Shaun Thein Due to an ageing population, the incidence of neck of femur fractures in the UK is Due to an ageing population, the aincidence neck of femur fractures in the UK is increasing.

Diabetes has become common ofco-morbidity in patients presenting with increasing.

Diabetes has Diabetic become apatients common co-morbidity in patients with neck of femur fractures. may pose a higher risk ofpresenting post-operative neck of femur fractures.

Diabetic patients may a higher risk of post-operative mortality and morbidity due to diabetic control andpose microand macrovascular effects of mortality and There morbidity dueprevious to diabetic controldetailing and microthe disease. is little literature this.and macrovascular effects of the disease. There is little previous literature detailing this.

We aimed to assess mortality of all operated diabetic neck of femur fracture patients We to assess mortalityand of all operated diabetic neck of femur fracture patients overaimed six months in Sandwell West Birmingham NHS Trust over six months in Sandwell and West Birmingham NHS Trust 6 months of operations identified 43 diabetic patients. Diabetic control (HbA1c) and 6 months of operations patients.respiratory, Diabetic control (HbA1 c) and comorbidities (generallyidentified classified43 to diabetic cardiovascular, vascular, neurology, comorbidities (generally classified to cardiovascular, respiratory, gastrointestinal, renal, ophthalmological, and malignancies) werevascular, recorded.neurology, gastrointestinal, renal,from ophthalmological, Complications arising the operation and and malignancies) mortality at 30 were days,recorded.

3 months, 6 months Complications from the operation and mortality at 30 days, 3 months, 6 months and 12 monthsarising were recorded. and 12 months were recorded.

30-day mortality rates were equal between non-diabetic and diabetic patients (9.3%), 30-day mortality were equal between non-diabetic and diabetic patients but slightly aboverates the national average (8.2%).

1-year mortality was higher in (9.3%), the nonbut slightly above the national average to (8.2%).

1-yearpopulation mortality was higherNo in the nondiabetic population (30.2%) compared the diabetic (11.6%). diabetic population the diabetic population (11.6%). There No was a significant different (30.2%) betweencompared number oftoco-morbidities or age of patients. significant co-morbidities or age of patients.

There was a significant different differencebetween in renalnumber functionof(creatinine) between diabetic and non-diabetic significant difference in renal function between diabetic and non-diabetic deaths (mean non-diabetic 88, diabetic(creatinine) 115, p=0.007).

There was no difference deaths (mean non-diabetic diabetic 115, p=0.007). was nonon-diabetic difference recorded for different types 88, of prosthesis used between There diabetic and recorded different types of prosthesis usedwere between diabetic anddiabetic non-diabetic patients. for Complications arising from surgery not higher in the population. patients. Complications arising from surgery were not higher in the diabetic population.

Diabetic patients who died had a significantly higher age than those who survived Diabetic patients had a significantly higher agewas thanno those who survived (mean alive 76.2,who deaddied 91.3, p=0.027).

However, there significant difference in (mean alive 76.2, dead 91.3, p=0.027).

However, there was no significant difference in co-morbidities (p=0.656), HbA1 c (p=0.123), or renal function (p=0.193). co-morbidities (p=0.656), HbA1c (p=0.123), or renal function (p=0.193).

Diabetic patients are not at higher risk of mortality compared to non-diabetic patients in Diabetic patientsHowever, are not atelderly higher diabetic risk of mortality to risk non-diabetic patients this population. patientscompared are more at of mortality, and in this population. diabetic patients more at risk of mortality, therefore should However, be closelyelderly monitored.

There was aare significant difference in the and renal therefore closely monitored.

There was a significant in thethat renal function ofshould deathsberecorded in diabetic vs non-diabetic patients. difference This suggests function of deaths recorded in diabetic vs non-diabetic Thisofsuggests that is these patients have less functional reserve and regularpatients. observation renal function these patients have less functional reserve and regular observation of renal function is necessary. necessary.

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November Poster Presentations – Wednesday 4th Poster Presentations – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

Poster 3 Poster 3

FEMORAL AND TIBIAL NAILING IN 2014, IS FOLLOW UP NECESSARY? FEMORAL AND TIBIAL NAILING IN 2014, IS FOLLOW UP NECESSARY?

Andrew Swali Andrew Swali University Hospital of South Manchester University Hospital of South Manchester Mr Martyn Lovell - University Hospital of South Manchester Mr Martyn Lovell - University Hospital of South Manchester Oluwatomisin Ashiru - University Hospital of South Manchester Oluwatomisin Ashiru - University Hospital of South Manchester Oluwatomisin Ashiru Oluwatomisin Ashiru

OBJECTIVES OBJECTIVES

Tibial and femoral fractures are serious injuries associated with extensive trauma, with Tibial and femoral fractures are serious injuries associated with extensive trauma, with risk of subsequent lifelong impairment. Hence, follow-up of such patients is essential to risk of subsequent lifelong impairment. Hence, follow-up of such patients is essential to preventing or managing post-operative complications. This audit aimed to assess preventing or managing post-operative complications. This audit aimed to assess outcomes of femoral and tibial intramedullary (IM) nailing at the University Hospital of outcomes of femoral and tibial intramedullary (IM) nailing at the University Hospital of South Manchester (UHSM) in 2014.

South Manchester (UHSM) in 2014.

METHODS METHODS

Retrospective analysis of patient’s radiographic imaging and clinical correspondence Retrospective analysis of patient’s radiographic imaging and clinical correspondence was utilised to obtain the incidence of post-operative complications over a 1 year was utilised to obtain the incidence of post-operative complications over a 1 year period. Complications such as malalignment, hardware failure, infection, non-union, period. Complications such as malalignment, hardware failure, infection, non-union, neurovascular injury, joint pain and iatrogenic fractures were selected for follow up. neurovascular injury, joint pain and iatrogenic fractures were selected for follow up.

Follow-up rates were also investigated.

Follow-up rates were also investigated.

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

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Poster Presentations – Wednesday 4th November Poster Presentations – Wednesday 4th November

79 patients underwent IM nailing of the lower limb (65 femoral and 14 tibial nails). The 79 patients underwent IM nailing of the lower limb (65 femoral and 14 tibial nails). The following incidence rates were found: 27.8% malalignment, 7.7% hardware failure, following incidence rates were found: 27.8% malalignment, 7.7% hardware failure, 0.0% infection, 3.8% non-union, 1.3% neurovascular injury, 17.7% joint pain and 0.0% 0.0% infection, 3.8% non-union, 1.3% neurovascular injury, 17.7% joint pain and 0.0% iatrogenic fractures. Of the patients with femoral nails 26% received no follow-up, 15% iatrogenic fractures. Of the patients with femoral nails 26% received no follow-up, 15% were seen within a different speciality and 59% of patients were followed up within the were seen within a different speciality and 59% of patients were followed up within the orthopaedic department. Of the patients with tibial nails 8% received no follow-up and orthopaedic department. Of the patients with tibial nails 8% received no follow-up and 92% of patients were to be followed up within the orthopaedic department, but 3 did not 92% of patients were to be followed up within the orthopaedic department, but 3 did not attend. In total 22% received no follow-up, 12% were followed up within a different attend. In total 22% received no follow-up, 12% were followed up within a different speciality and 66% were seen within the orthopaedic department. 21.5% of patients had speciality and 66% were seen within the orthopaedic department. 21.5% of patients had no post-operative imaging. no post-operative imaging.

The follow-up rate at UHSM was higher for tibial nailing (mean patient age 48 years) The follow-up rate at UHSM was higher for tibial nailing (mean patient age 48 years) compared to femoral nails (mean patient age 66 years); perhaps showing that age compared to femoral nails (mean patient age 66 years); perhaps showing that age influences decisions regarding follow-up. No national/international guidelines were influences decisions regarding follow-up. No national/international guidelines were found during our literary search on the follow-up of IM nailing. One manufacturer stated found during our literary search on the follow-up of IM nailing. One manufacturer stated in their manual that radiographs should be taken at 6-8 weeks to assess callus in their manual that radiographs should be taken at 6-8 weeks to assess callus formation for weight-bearing. Similar studies in the literature followed up patients for at formation for weight-bearing. Similar studies in the literature followed up patients for at least 6 months. 34% of patients had no follow up by UHSM’s orthopaedic department. least 6 months. 34% of patients had no follow up by UHSM’s orthopaedic department.

In allowance for the apparent lack of follow-up with clinical review and imaging, the In allowance for the apparent lack of follow-up with clinical review and imaging, the majority of femoral and tibial nails performed were successful with no patients requiring majority of femoral and tibial nails performed were successful with no patients requiring secondary revision nailing. We suggest further study is recommended to observe secondary revision nailing. We suggest further study is recommended to observe follow-up rates in patients having IM nailing, thereby assessing the value and need for follow-up rates in patients having IM nailing, thereby assessing the value and need for the length of post-operative clinical review and imaging. the length of post-operative clinical review and imaging.

BTS - 25th Annual Scientific Meeting

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Poster 4 Poster 4

A UHSM AUDIT: HOW MANY TRAUMA CALLS ARE POTENTIALLY A UHSM AUDIT: HOW MANY TRAUMA CALLS ARE POTENTIALLY AVOIDABLE? AVOIDABLE? Rory Grinsill Rory Grinsill Manchester Medical School Manchester Medical School Martyn Lovell, Ronnie Davies, University Hospital South Manchester Martyn Lovell, Ronnie Davies, University Hospital South Manchester Martyn Lovell Martyn Lovell

This study aims to analyse data held for trauma patients seen at University Hospital This aims to between analyse data for trauma University Hospital Southstudy Manchester 1 Aprheld 14 and 31 Marpatients 15. Theseen auditat specifically looks at South Manchester between 1 Apras 14those and 31 Mar 15.

The audit specifically looks at major trauma patients, identified patients requiring trauma team activation. major trauma purpose patients,isidentified as the those patients trauma team activation.

The primary to assess number of requiring patients for whom trauma team The primary is to assess the isnumber of patients for using whomInjury trauma team activation waspurpose unnecessary.

Trauma commonly classified Severity activation was Major unnecessary.

Trauma is commonly classified using NHS Injuryguidelines Severity Scores (ISS). trauma can be defined as an ISS >15, whilst Scores Major trauma be defined as an >15, whilst NHS guidelines suggest (ISS). that any patients withcan a score >8 should be ISS classified as a ‘candidate major suggest thatthat anyapatients withshould a score >8 should be classified a ‘candidate trauma’ and trauma call correctly be made in these as cases.

ISS is a major score trauma’ and that a trauma call should correctly be made in these cases.

ISS is a score that can only be assigned retrospectively and so trauma tools must instead be used to that can only be patients assignedrequire retrospectively and activation. so trauma tools must instead be used to determine which trauma team determine which patients require trauma team activation.

In total 257 major trauma patients were identified, 129 of which were reported to the In total 257 trauma patients were identified, 129 of which reportedoftolocal the Trauma Auditmajor Research Network (TARN) with the remainder foundwere on analysis Trauma Audit Research Network ISS (TARN) with found ontoanalysis of other local trauma records.

TARN provides values forthe theremainder patients reported them and trauma TARNlocally. providesThe ISSISS values for the patients themthe andvalues other patientsrecords. were scored values were then reported comparedto with patients wereto scored The ISSidentified values were thentrauma compared with the values given above identify locally. those incorrectly as major patients given above to identify those incorrectly identified as major trauma patients . .Analysis of both local and TARN data found that 136 of the 257 major trauma patients Analysis of both local and found22% that scoring 136 of the trauma patients (53%) had ISS values <9,TARN with data a further <16257 as major required in the strict (53%) hadof ISS values <9, with a further <16 required in patients the strictit definition major trauma.

As the focus of22% this scoring audit was on as major trauma definition of major trauma.

As the focus of this audit was on major trauma patients has not been possible to accurately estimate the number of patients undertriaged in thisit has time.not been possible to accurately estimate the number of patients undertriaged in this time.

This clearly demonstrates that a large proportion of trauma patients are in fact being This clearly demonstrates that a large proportion of trauma patients arecosts. in fact being overtriaged, resulting in potentially avoidable financial and manpower As a overtriaged, resulting in recommendations potentially avoidable manpower costs.

As a result of these findings are financial made forand further research into trauma result of to these findings recommendations are madeofforpatients further being research into trauma patients more accurately assess the proportion undertriaged in patients morepatient accurately theany proportion patients being in order to to ensure safetyassess prior to changes ofbeing made, and undertriaged also to assess order patient safety to any changes being made, and to assess ways to in ensure which overtriage can prior be reduced, potentially examining the also validity of the ways in which be reduced, individual triage overtriage tool criteria can for major trauma. potentially examining the validity of the individual triage tool criteria for major trauma.

BTS - 25th Annual Scientific Meeting

87

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MAIN MAIN AUTHOR AUTHOR PRESENTER PRESENTER

Poster Poster 5 5

THE ROLE ROLE OF OF CT CT SCANNING SCANNING IN IN HUMERAL HUMERAL HEAD HEAD FRACTURES FRACTURES THE

Alistair jones jones Alistair Worcestershire Royal Royal Hospital Hospital Worcestershire

MAIN AUTHOR MAIN AUTHOR

Alistair Jones Jones Alistair

OBJECTIVES OBJECTIVES

To To assess assess the the rate rate of of humeral humeral head head fracture-dislocations fracture-dislocations that that are are missed missed by

by XRay XRay alone. alone.

METHODS METHODS

All All CT CT scans scans of of the the shoulder shoulder over over a a 4-year 4-year period period were were accessed accessed on on the the hospital hospital radiology radiology viewing viewing system. system. Those Those performed performed for for fracture fracture were were included. included. The The corresponding radiographs were then accessed and the radiologists’ reports corresponding radiographs were then accessed and the radiologists’ reports were were compared.

The CTs and XRays were categorised as either “fracturedislocation” compared. The CTs and XRays were categorised as either “fracture- dislocation” or or “simple fracture”. fracture”. 4-part 4-part fractures fractures with with subluxed subluxed humeral humeral heads heads were were included included in in the the “simple “simple fracture” fracture” group. group. “simple

RESULTS RESULTS

33 33 CT CT scans scans were were performed performed over over 4 4 years years for for fracture fracture of of the the humeral humeral head. head. Of Of these, these, 4 4 had had associated associated true true dislocation dislocation of of the the glenohumeral glenohumeral joint joint reported reported on on CT. CT. Of Of these these 4, 4, 2 2 were identified on plain XRay and 2 were not. were identified on plain XRay and 2 were not.

CONCLUSIONS CONCLUSIONS

50% of of the the fracture fracture dislocations dislocations of of the the humeral humeral head head identified identified on on CT CT scanning scanning were were 50% missed missed on on plain plain radiographs. radiographs. These These were were 4 4 part part fractures fractures of of the the humeral humeral head head and and therefore therefore interpretation interpretation was was more more challenging. challenging. The The recent recent PROFHER PROFHER Trial Trial shows shows there there is no benefit to operative management over non-operative management in humeral is no benefit to operative management over non-operative management in humeral head head fractures, fractures, and and the the likely likely trend trend will will now now be be to to treat treat more more humeral humeral head head fractures fractures non-operatively. Where Where there there is is a a simple simple fracture fracture this this approach approach is is acceptable, acceptable, but but in in the the non-operatively. presence of of glenohumeral glenohumeral dislocation dislocation a a good good outcome outcome is is difficult difficult to to achieve achieve with with nonnonpresence operative operative management. management. Performing Performing CT CT scans scans for for 4-part 4-part humeral humeral head head fractures fractures routinely routinely would would minimise minimise the the risk risk of of dislocations dislocations being being missed missed and and change change management, thereby improving patient outcomes. management, thereby improving patient outcomes.

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Poster Presentations – Wednesday 4th November Poster Presentations – Wednesday 4th November

BTS - 25th Annual Scientific Meeting

CO AUTHORS CO AUTHORS PRESENTER PRESENTER

Poster 6 Poster 6

IMPROVING THE CARE AND SAFE MOVEMENT OF PATIENTS WITH IMPROVING THE CARE AND SAFE MOVEMENT OF PATIENTS WITH PELVIS FRACTURES BY DEVELOPING A LOCAL GUIDELINE AT A LEVEL PELVIS FRACTURES BY DEVELOPING A LOCAL GUIDELINE AT A LEVEL 1 MAJOR TRAUMA CENTRE 1 MAJOR TRAUMA CENTRE

Jessica Lunn Jessica Lunn Kings College Hospital, London, England Kings College Hospital, London, England Abigail Clark-Morgan, Paul Harnett, Matthew Gee – Kings College Hospital Abigail Clark-Morgan, Paul Harnett, Matthew Gee – Kings College Hospital Jessica Lunn Jessica Lunn

OBJECTIVES OBJECTIVES

1. To establish whether healthcare staff were aware of any available movement 1. To establish whether healthcare staff were aware of any available movement restriction guidelines in patients with pelvic fractures. restriction guidelines in patients with pelvic fractures.

2. To generate and make a readily known and accessible hospital guideline to aid 2. To generate and make a readily known and accessible hospital guideline to aid healthcare staff and improve the care and safety of this group of patients. healthcare staff and improve the care and safety of this group of patients.

METHODS METHODS

A review was undertaken of online hospital reference material and ward references.

A review was undertaken of online hospital reference material and ward references.

Using the keywords pelvis, fracture, movement, rolling, restrictions, guideline and Using the keywords pelvis, fracture, movement, rolling, restrictions, guideline and management we sought to find any existing guidelines. Alongside this, a sample of 20 management we sought to find any existing guidelines. Alongside this, a sample of 20 ITU and trauma staff completed a verbal questionnaire assessing knowledge of existing ITU and trauma staff completed a verbal questionnaire assessing knowledge of existing protocols, whether such a guide would be useful and what it should include. Using all protocols, whether such a guide would be useful and what it should include. Using all areas of feedback a one-page guideline was developed and rolled out to relevant staff. areas of feedback a one-page guideline was developed and rolled out to relevant staff.

After two weeks, practice was re-audited through questionnaires assessing knowledge After two weeks, practice was re-audited through questionnaires assessing knowledge of the guideline, its contents, usefulness and effectiveness. of the guideline, its contents, usefulness and effectiveness.

RESULTS RESULTS

No staff knew of any guideline already in use. No such protocol was found within No staff knew of any guideline already in use. No such protocol was found within hospital reference material. Sitting up and rolling angles, end of the bed raising and hospital reference material. Sitting up and rolling angles, end of the bed raising and traction were identified as essential points to include in a one side A4 size sheet that traction were identified as essential points to include in a one side A4 size sheet that could be filed easily with the patient notes. Explanatory points would be appreciated could be filed easily with the patient notes. Explanatory points would be appreciated alongside the guideline to improve overall understanding. alongside the guideline to improve overall understanding.

Completion of the audit cycle revealed a user-friendly and pertinent protocol had been Completion of the audit cycle revealed a user-friendly and pertinent protocol had been achieved. Staff reported the topics covered to be relevant and in sufficient detail. Of achieved. Staff reported the topics covered to be relevant and in sufficient detail. Of particular benefit to the nursing staff the idea of a combined sitting up angle particular benefit to the nursing staff the idea of a combined sitting up angle incorporating raising the end of the bed proved a hugely useful practical point for incorporating raising the end of the bed proved a hugely useful practical point for patient positioning. patient positioning.

CONCLUSIONS CONCLUSIONS

Introducing the pelvis fracture rolling restrictions has improved understanding Introducing the pelvis fracture rolling restrictions has improved understanding confidence in the care of this group of patients by the multidisciplinary team. It confidence in the care of this group of patients by the multidisciplinary team. It forms an integral part of their workup on admission and subsequent care. forms an integral part of their workup on admission and subsequent care.

BTS - 25th Annual Scientific Meeting

and and now now

89

th Poster November Poster Presentations Presentations –– Wednesday Wednesday 4 4th November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Poster Poster 7 7

INCIDENTAL INCIDENTAL FINDINGS FINDINGS ON ON WHOLE WHOLE BODY BODY COMPUTERISED COMPUTERISED TOMOGRAPHIC TOMOGRAPHIC SCANNING SCANNING IN IN A A TERTIARY TERTIARY TRAUMA TRAUMA CENTRE. CENTRE.

Emma Emma Merrick Merrick Aintree University University Hospital Aintree Hospital

Sumita Sumita Chawla, Chawla, John John Taylor: Taylor: Aintree Aintree University University Hospital Hospital Emma Merrick Merrick Emma Whole Whole body body CT CT (WBCT) (WBCT) scans scans have have become become a a standard standard assessment assessment in in the the assessment assessment of of major major trauma trauma patients. patients. As As well well as as trauma trauma related related findings findings inevitably inevitably there will will be be significant there significant incidental incidental clinical clinical findings findings which which may may require require further further investigation investigation of of intervention. intervention. Previous Previous reviews reviews have have shown shown significant significant incidental incidental findings findings (IF) (IF) in in up up to to 8% 8% of of patients patients however however we we are are not not aware aware of of a a similar similar review review in in a a UK UK major major trauma trauma population. population.

METHODS METHODS

A A radiology radiology database database search search was was conducted conducted using using the the key key phases phases CHNTPC CHNTPC and TRAUMA and TRAUMA to to identify identify any any WBCT WBCT scans scans performed performed on on trauma trauma patients patients during during a a9 9 month month period period September September 2014 2014 to to February February 2015.

2015. Scans Scans that that were were WBCT WBCT and and performed performed at at first first presentation presentation of of trauma trauma were were included. included. The The written written radiology radiology report report was was then then assessed assessed to to identify identify IF. IF. IF were grouped into 3 categories: Category 1, benign findings of no clinical IF were grouped into 3 categories: Category 1, benign findings of no clinical significance; significance; Category Category 2, 2, findings findings of of minor minor clinical clinical significance significance which which may may require require future future investigations dependant dependant on on symptoms symptoms or or clinically clinically significant significant findings findings that that were were investigations already already known; known; Category Category 3, 3, previously previously unknown unknown clinically clinically significant significant findings findings that that require require further further investigations. investigations. The The prevalence prevalence of of IF IF in in these these categories categories was was then then compared with patient age. compared with patient age.

All All patients patients with with Category Category 3 3 findings findings discharge discharge summaries summaries were were assessed assessed to to see see ifif follow follow up up had had been been arranged arranged or or they they had had been been investigated. investigated.

CONCLUSIONS CONCLUSIONS

90

Poster 8

FRACTURE CLINIC SERVICE EFFICIENCY MAIN AUTHOR

Amanda King Huddersfield Royal Infirmary

OBJECTIVES OBJECTIVES

RESULTS RESULTS

Poster Presentations – Wednesday 4th November

97 97 patients patients fit fit the the criteria criteria and and were were investigated. investigated. Overall Overall there there were were 119 119 IF IF in in 65 65 patients. patients. Therefore Therefore 67% 67% of of patients patients had had an an IF. IF. Age group 0-40 34% of patients had an IF; 40-65 53% had an IF and 65-100 Age group 0-40 34% of patients had an IF; 40-65 53% had an IF and 65-100 90% 90% had had IF. IF. 17.5% of of patients patients had had a a category category 3 3 finding, finding, 17 17 findings findings in in total. total. In In age age group group 0-40 0-40 1 1 17.5% category 3 3 IF IF which which equates equates 2.7% 2.7% patients. patients. In In 40-65 40-65 6 6 category category 3 3 IF IF in in 16.6% 16.6% patients. patients. category And And finally finally in in the the 65-100 65-100 10 10 category category 3 3 IF IF in in 25.8 25.8 % % of of patients. patients.

Of Of the the 17 17 Category Category 3 3 IF. IF. 4 4 findings findings the the patient patient died died soon soon after after admission. admission. 6 6 findings findings appropriate follow-up arranged and 7 findings no note on appropriate follow-up arranged and 7 findings no note on the the discharge discharge summary summary and and no follow up arranged.

In summary 41% no documentation of any follow up no follow up arranged. In summary 41% no documentation of any follow up for for the the IF IF and GP not informed on discharge summary. and GP not informed on discharge summary.

We We found found a a significantly significantly higher higher rate rate of of IF IF particularly particularly in in the the older older population population which which although although may may be be explained explained by by the the trauma trauma population population profile profile in in the the UK. UK. The The majority majority of of incidental findings may prove benign but there needs to be improved systems incidental findings may prove benign but there needs to be improved systems to to ensure ensure appropriate follow up. appropriate follow up.

Word Count Count 393 393 Word

BTS - 25th Annual Scientific Meeting

CO AUTHORS

Alex Feben, Asim Siddiqui, Ben Brooke, Bob Metcalf, Guy McWilliams

PRESENTER

Amanda King

OBJECTIVES

The British Orthopaedic Association Standards for Trauma (BOAST) 7 fracture clinic services guidelines suggest that patients with an acute soft tissue or bone injury should be seen in a new fracture clinic within 72 hours of presentation to an emergency department. We retrospectively audit the time from referral to the initial fracture clinic appointment to determine whether our department is meeting this national standard.

We also evaluate the number of referrals and the number of appointments available on each day of the week with the aim of improving efficiency.

METHODS

Data obtained from the Hospital’s Informatics Service was used to assess the time between referral and initial appointment, and patient notes were reviewed to confirm attendance. Patients referred for follow-up following attendance or surgery at another institution were excluded.

RESULTS

The highest average number of referrals were made on Mondays and Fridays (21 patients per day), followed by Tuesdays and Sundays (19 patients per day), then on Thursdays and Saturdays (17 patients per day), and on Wednesdays (16 patients).

The highest average number of patients seen in fracture clinic was on a Thursday (53 patients), followed by 48 patients on a Monday, 29 patients on a Wednesday, 25 patients on a Tuesday and 6 patients on a Friday. Of the 548 patients, only 176 (32%) were seen in fracture clinic within 72 hours of presentation to the emergency department. The average length of time from referral to fracture clinic was 4.4 (range 0-18) days.

CONCLUSIONS

Only 32% of patients were seen within the 72 hour guideline recommended by the BOAST with an average of 4.4 days from referral to fracture clinic. On average, the fewest number of patients were seen on a Friday. To distribute referrals effectively and improve efficiency, one solution would be to aim to see patients at 48 hours following referral. Referrals from Saturday would be seen on a Monday and Sunday’s referrals on a Tuesday etc with the exception of Friday’s, which would get seen on a Monday.

Availability would meet demand if some of Thursday’s appointments were transferred to a Friday. If further audit over a 12 month period demonstrates a similar trend in the number of referrals and fracture clinic availability, enforcing this referral system and adjusting the workforce may help us achieve the national guidelines.

BTS - 25th Annual Scientific Meeting

91

Poster Presentations – Wednesday 4th November

Poster 9

th Poster November Poster Presentations Presentations –– Wednesday Wednesday 4 4th November

ANTIBIOTIC PROPHYLAXIS FOR HIP FRACTURE SURGERY MAIN AUTHOR

Amanda King Huddersfield Royal Infirmary

CO AUTHORS PRESENTER

OBJECTIVES

METHODS

Jan Marciniak, Chris Lewis, Gareth Wells, Sudhi Ankarath, Aneil Shenolikar, Simon Sturdee Amanda King

The aim of antibiotic surgical prophylaxis is to reduce rates of surgical site and healthcare-associated infections and thereby reduce surgical morbidity and mortality. In order to comply with the Scottish Intercollegiate Guidelines Network (SIGN) guidance, April 2014 they should be administered in theatre, given as a bolus <30mins prior to tourniquet inflation and skin incision, and should be documented in the 'once only' section of the drug chart. Terminology for our hip fracture prophylaxis was deemed to be confusing, leading to uncertainty regarding appropriate antibiotics i.e. surgery with an implant or open surgery for closed fracture? We investigate the rationale behind trust departmental antibiotic prophylaxis guidelines and review departmental prophylaxis given for hip fracture surgery during September and October 2014 with existing guidelines and again following implementation of new guidelines during March and April 2015.

The medical notes of patients who underwent hip fracture surgery during September and October 2014 were obtained from the audit department by clinical coding and cross-checked with hip fracture patient admission data from the trauma co-ordinators.

Anaesthetic and drug charts were reviewed and the antibiotics prescribed documented and checked against the guidelines. New guidelines were implemented in December 2014 and displayed on posters in anaesthetic rooms. The medical notes for re-audit during March and April were obtained in the same way and the antibiotics prescribed checked against the new guidelines.

RESULTS

During September and October 2014, 53 patients underwent hip fracture surgery.

There was poor compliance with existing guidance. Only 85% of patients were prescribed the correct antibiotic prophylaxis pre-operatively and only 7% of these were prescribed post-operative antibiotics (if indicated) in the 'once only' section of drug chart. During March and April 2015, 41 patients underwent hip fracture surgery and 89% of these were prescribed the correct antibiotic prophylaxis pre-operatively. Only one patient required post-operative antibiotic but these were not prescribed. One patient did not have any antibiotic prophylaxis prescribed with no clear reason why it was not given.

CONCLUSIONS

There was poor compliance with existing guidance and despite implementation of posters in anaesthetic rooms displaying new guidelines, compliance only improved by 4%. Every effort so be made to ensure antibiotic prophylaxis is given. In an attempt to further improve compliance we suggest that this is checked and read against the guidelines when the WHO checklist is performed prior to surgery.

92

BTS - 25th Annual Scientific Meeting

MAIN MAIN AUTHOR AUTHOR MAIN AUTHOR AUTHOR MAIN CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Poster Poster 10 10

CORRELATION CORRELATION BETWEEN BETWEEN FOREARM FOREARM TO TO DISTAL DISTAL INTERPHALANGEAL INTERPHALANGEAL JOINT JOINT OF OF LITTLE LITTLE FINGER FINGER AND AND FEMORAL FEMORAL NAIL NAIL LENGTH LENGTH

Uthman Uthman Alao Alao Dept T&O, T&O, Aintree Aintree University Dept University Hospital, Hospital, Liverpool.

Liverpool. United United Kingdom.

Kingdom.

Jonathan Jonathan Yates, Yates, Cronan Cronan Kerin.

Kerin. Dept Dept T&O, T&O, Aintree Aintree University University Hospital, Hospital, Liverpool.

Liverpool.

Uthman Alao Alao // Jonathan Jonathan Yates Yates Uthman

OBJECTIVES OBJECTIVES

To To determine determine whether whether there there is is a a correlation correlation between between the the length length of of forearm forearm to to the the distal distal interphalangeal interphalangeal joint joint (DIPJ) (DIPJ) of of the the little little finger finger and and length length of of antegrade antegrade intramedullary intramedullary (IM) (IM) femoral femoral nails nails in in adults. adults.

METHODS METHODS

Measurements Measurements from from the the tip tip of of the the olecranon olecranon to to the the DIPJ DIPJ of of the the ipsilateral ipsilateral upperlimb upperlimb was was taken taken in in 30 30 patients patients undergoing undergoing antegrade antegrade IM IM femoral femoral nails. nails. The The length length of of the the IM IM nails nails inserted inserted was was determined determined by by intra-operative intra-operative measurements measurements using using a a guide guide wire. wire. The The two two measurements measurements were were analysed analysed for for correlation correlation and and mean mean difference. difference.

RESULTS RESULTS

The The mean mean forearm forearm to to DIP DIP of of little little finger finger length length was was 38.86 38.86 with with a a standard standard deviation deviation of of 2.83.

2.83. The The mean mean IM IM length length and and standard standard deviation deviation were were 38.56 38.56 and and 2.77 2.77 respectively. respectively.

The The difference difference between between the the two two means means 0.3 0.3 (95% (95% CI).

CI). Correlation Correlation testing testing between between the the two two variables variables shows shows a a positive positive relationship relationship (Pearson (Pearson Correlation Correlation factor factor of of 1).

1). The The scatter plot shows a positive linear relationship scatter plot shows a positive linear relationship

CONCLUSIONS CONCLUSIONS

Length Length of of the the forearm forearm form form the the tip tip of of the the olecranon olecranon to to the the DIP DIP joint joint of of the the little little finger finger represents represents the the ideal ideal length length of of IM IM nail nail for for the the femur. femur. It It can can be be readily readily performed performed with with the the use use of of a a tape tape measure measure and and can can serve serve as as a a useful useful adjunct adjunct to to determining determining ideal ideal length length in in cases where the contralateral femur cannot be used. cases where the contralateral femur cannot be used.

BTS - 25th Annual Scientific Meeting

93

Poster Presentations – Wednesday 4th November

Poster 11

Poster Presentations – Wednesday 4th November

THE MANAGEMENT OF SEGMENTAL TIBIAL SHAFT FRACTURES: A SYSTEMATIC REVIEW MAIN AUTHOR

CO AUTHORS

Zoe Little

ARTHROSCOPY FOR LATERAL EPICONDYLITIS: DOES PRE-OPERATIVE MRI SCANNING ACCURATELY PREDICT THE FINDINGS AT ARTHROSCOPY?

Jonathan Yates

Warrington and Halton Hospitals

St George’s Hospital, London, England

CO AUTHORS

Harry Casserley (Same institution)

Samuel McMahon, Royal Victoria Hospital, Belfast, Northern Ireland Toby O Smith, University of East Anglia, Norwich, England Alex Trompeter, St George’s Hospital, London, England Caroline Hing, St George’s Hospital, London, England

PRESENTER

Jonathan Yates

OBJECTIVES

This work explores the relationship between observations made from elbow magnetic resonance imaging (MRI), and at arthroscopy, for lateral epicondylitis (LE). Patientreported outcome measures (PROMS) were also obtained.

METHODS

Patient records were examined of consecutive primary elbow arthroscopies for the treatment of LE performed by one surgeon over a four year period. All patients had a pre-operative MRI scan which was analysed for correlation with arthroscopy findings.

Post-operative Oxford elbow scores were recorded.

RESULTS

A total number of 55 patients were identified for study with a mean age of 48.5 (38-64 years) and a mean follow up of 28 months (10-59 months). 52% of the patients were male. 39 patients had both MRI and arthroscopy reports available with 28 (72%) demonstrating features consistent with LE on both. Nine (23%) had isolated radial head wear seen only at MRI whilst the remaining two had other features of LE only present on MRI. Post-operative PROM data showed a mean Oxford elbow total score of 37.2 (12-48) with sub-domain scores as follows; pain 74.8, function 82.7 and socialpsychological 74.4. There was an overall revision rate of 1.8% with no other complications.

CONCLUSIONS

This study shows that treating LE with arthroscopy leads to satisfactory PROMS with low complication rates. MRI is useful in backing up a clinical diagnosis of LE prior to surgery. Arthroscopy has the crucial advantage of facilitating assessment of the radiocapitellar joint. However, neither the MRI nor operative findings appear to have an affect on the functional outcome post surgery.

PRESENTER

Zoe Little

OBJECTIVES

This study aimed to identify the most effective method of treating segmental tibial fractures. These complex injuries, commonly associated with significant soft tissue damage, pose difficult treatment questions.

METHODS

A systematic review of the literature was conducted. Studies investigating the management of segmental tibial fractures by intramedullary nail fixation, open reduction and internal fixation or circular external fixation were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. No randomized controlled trials were identified; therefore, a narrative review of the thirteen included studies was undertaken.

RESULTS

Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then circular external fixation. Overall, the rate of deep infection was highest following intramedullary nail (3%) or open reduction internal fixation (3%) and was slightly lower following circular external fixation (2%). However, some studies reported particularly high rates of infection following intramedullary nailing for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a markedly higher rate of deformity (20%) following intramedullary nailing, compared to open reduction and internal fixation (13%) and circular external fixation (9%). Three studies included patient reported outcome measures. These did not include intramedullary nailing. Different scoring systems were used, with results ranging from ‘excellent’ to ‘fair’. The available evidence was of a poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available. The studies tended to be well structured; however, the lack of control groups, standardised management protocols and the heterogeneous nature of the data reported made comparison challenging.

CONCLUSIONS

Intramedullary nailing has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests circular external fixation provides the most satisfactory results; however, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomized controlled study to further investigate this challenging problem.

94

MAIN AUTHOR

Poster 12

BTS - 25th Annual Scientific Meeting

BTS - 25th Annual Scientific Meeting

95

th Poster Poster Presentations Presentations –– Wednesday Wednesday 4 4th November November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

OBJECTIVES OBJECTIVES

Poster Poster 13 13

DISTAL FEMORAL FEMORAL OBLIQUE OBLIQUE FRACTURE FRACTURE IN IN A A YOUNG YOUNG MALE MALE SOLDIER: SOLDIER: DISTAL AN UNUSUAL UNUSUAL PRESENTATION PRESENTATION AN

Hesham Hesham Al-Khateeb Al-Khateeb King King Hamad Hamad University University Hospital, Hospital, Bahrain Bahrain Hussain Hussain Al Al Omar, Omar, David David Cohen, Cohen, King King Hamad Hamad University University Hospital, Hospital, Bahrain Bahrain David Cohen Cohen David

Femoral Femoral fractures fractures often often require require significant significant force, force, particularly particularly in in young, young, healthy healthy individuals. individuals. Injuries Injuries in in this this demographic demographic usually usually follow follow high-energy high-energy trauma, trauma, road road traffic traffic accidents and high velocity injuries. accidents and high velocity injuries.

RESULTS RESULTS

The The patient patient had had an an uneventful uneventful post-operative post-operative recovery recovery and and was was mobilised mobilised non-weight non-weight bearing bearing on on crutches crutches on on day day one. one. Post-operative Post-operative radiographs radiographs confirmed confirmed anatomical anatomical reduction and the patient was allowed passive range of movement on day reduction and the patient was allowed passive range of movement on day three. three. At At latest followup, followup, the the patient patient achieved achieved a a range range of of movement movement of of 0 0 to to 100 100 degrees degrees and and the the latest fracture was was uniting uniting radiologically. radiologically. fracture

CONCLUSIONS CONCLUSIONS

To To our our knowledge, knowledge, there there have have been been no no reported reported cases cases of of distal distal femoral femoral fractures fractures after after non-traumatic non-traumatic military military exercises. exercises. The The majority majority of of injuries injuries are are related related to to stress stress fractures. fractures.

This case should be of interest to the Orthopaedic community as well as military This case should be of interest to the Orthopaedic community as well as military doctors. doctors.

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MAIN MAIN AUTHOR AUTHOR

BTS - 25th Annual Scientific Meeting

Rana Rana Q QH H Mehdi Mehdi Cumberland Cumberland Infirmary, Infirmary, Carlisle, Carlisle, England, England, UK UK

Soliman Soliman Noureldin, Noureldin, Ramasubramanian Ramasubramanian Dharmarajan, Dharmarajan, Manjula Manjula Meda, Meda, Michael Michael Orr, Orr, Biju Biju Sankar, Timothy Timothy Petheram Petheram Sankar, Orthopaedic Department, Department, Cumberland Cumberland Infirmary, Infirmary, Carlisle, Carlisle, England, England, UK UK Orthopaedic

PRESENTER PRESENTER

Rana Rana Q QH H Mehdi Mehdi

OBJECTIVES OBJECTIVES

We would would like like to to present present the the early early result result of of our our study study using using Leucocyte Leucocyte Esterase Esterase We Reagent Reagent (LER) (LER) strips strips to to diagnose diagnose Prosthetic Prosthetic Joint Joint Infection Infection (PJI).

(PJI). Diagnosing Diagnosing acute acute PJI PJI is is challenging. challenging. Traditionally Traditionally gram gram stain stain has has been been the the gold gold standard; standard; however, however, sensitivity sensitivity has been reported as low as 17% in some studies. has been reported as low as 17% in some studies.

METHODS METHODS

39 consecutive consecutive patients patients with with prosthetic prosthetic joint joint infections infections clinically clinically suspected suspected to to have have PJI PJI 39 were were reviewed reviewed over over a a2 2 year year period. period. All All patients patients had had joint joint aspirates aspirates which which were were tested tested for for LER LER and and synovial synovial white white cell cell count. count. The The patients patients also also had had WBC, WBC, CRP, CRP, ESR ESR or or Plasma Plasma viscosity. viscosity. 11 11 Bloodstained Bloodstained sampled sampled were were excluded excluded from from the the study study as as LER LER could could not be identified on these aspirates.

PJI was confirmed by positive microbiology not be identified on these aspirates. PJI was confirmed by positive microbiology in in direct and and enrichment enrichment cultures. cultures. The The LER LER results results were were interpreted interpreted as as negative, negative, +1, +1, +2 +2 or or direct +3. +3.

RESULTS RESULTS

28 28 remaining remaining samples samples were were included included in in the the study; study; 13 13 samples samples tested tested negative negative or or +1 +1 on on LER, LER, and and none none of of them them grew grew any any organisms organisms in in extended extended cultures. cultures. 15 15 samples samples tested tested positive for LER and were either +2 or +3, 10 of these grew organisms and five did not. positive for LER and were either +2 or +3, 10 of these grew organisms and five did not.

Therefore sensitivity sensitivity of of this this test test is is 100% 100% and and specificity specificity is is 72.22%.

72.22%. The The negative negative Therefore predictive value value of of LER LER is is 100% 100% and and the the positive positive predictive predictive value value is is 66.67%.

66.67%. The The predictive inflammatory inflammatory markers markers were were raised raised in in all all patients patients who who had had positive positive bacteriology bacteriology and and a a corresponding corresponding synovial synovial white white cell cell count count of of more more than than 4000 4000 cells/ml. cells/ml. The The Musculoskeletal Infection Society derived a 3 part criteria to identify the presence of Musculoskeletal Infection Society derived a 3 part criteria to identify the presence of joint joint infection. infection. To To confirm confirm presence, presence, at at least least three three separate separate positive positive cultures cultures must must be be isolated, in in conjunction conjunction with with positive positive inflammatory inflammatory markers markers or or the the presence presence of of a a sinus sinus isolated, tract. Isolating Isolating multiple multiple joint joint samples samples using using separate separate sterile sterile equipment equipment can can be be tract. complicated complicated by by cross cross contamination. contamination. This This creates creates a a false false positive positive diagnosis diagnosis and and can can complicate complicate management. management. LER LER provides provides an an instant instant indicator indicator for for the the presence presence of of infection. infection. Our Our study study further further shows shows a a strong strong correlation correlation between between a a positive positive LER LER result result and raised inflammatory markers, indicating the accuracy of this test.

Thus, LER can and raised inflammatory markers, indicating the accuracy of this test. Thus, LER can direct initiation initiation of of treatment, treatment, and and prevent prevent unnecessary unnecessary use use of of antimicrobial antimicrobial agents. agents. direct

CONCLUSIONS CONCLUSIONS

LER LER is is a a highly highly sensitive sensitive test test for for PJI; PJI; a a negative negative or or + + 1 1 LER LER in in our our study study virtually virtually excludes excludes infection. infection. A A +2 +2 or or +3 +3 result result is is highly highly suggestive suggestive of of a a PJI. PJI. LER LER can can therefore therefore be used reliably to exclude infection in a timely and cost efficient manner.

However, be used reliably to exclude infection in a timely and cost efficient manner. However, LER cannot cannot be be utilised utilised in in a a blood blood stained stained aspirate. aspirate. The The study study continues. continues.

LER

The The patient patient presented presented with with a a history history of of severe severe pain pain and and deformity deformity in in the the distal distal femur femur and inability inability to to weight weight bear bear following following a a sharp sharp turn turn whilst whilst marching. marching. On On examination, examination, and there was was an an obvious obvious deformity deformity and and swelling swelling in in the the left left distal distal femur femur with with no no there neurovascular compromise. compromise. Plain Plain radiographs radiographs revealed revealed an an oblique oblique distal distal third third extraextraneurovascular articular articular displaced displaced femoral femoral fracture. fracture.

The The patient patient was was admitted admitted and and underwent underwent an an open open reduction reduction and and internal internal fixation fixation the the following day. day. Anatomical Anatomical reduction reduction was was achieved achieved using using a a pre-contoured pre-contoured distal distal femoral femoral following locking plate plate and and screw screw construct construct through through a a direct direct lateral lateral vastus vastus sparing sparing approach. approach. locking

Poster Poster 14 14

LER IN IN DIAGNOSING DIAGNOSING ACUTE ACUTE PROSTHETIC PROSTHETIC JOINT JOINT INFECTION INFECTION LER

CO CO AUTHORS AUTHORS

We report report a a case case of of a a distal distal femoral femoral fracture fracture in in a a twenty-three twenty-three year year old old male male army army We recruit who who presented presented to to the the Accident Accident and and Emergency Emergency department department following following a a twisting twisting recruit injury injury during during a a routine routine marching marching exercise exercise METHODS METHODS

th Poster Poster Presentations Presentations –– Wednesday Wednesday 4 4th November November

BTS - 25th Annual Scientific Meeting

97

Poster Presentations – Wednesday 4th November Poster Presentations – Wednesday 4th November

Poster 15 Poster 15

AUTOLOGOUS CHONDROCYTE IMPLANTATION WITH BONE CYLINDER AUTOLOGOUS CHONDROCYTE IMPLANTATION WITH GRAFT IN OSTEOCHONDRAL DEFECTS IN BONE KNEE CYLINDER GRAFT IN OSTEOCHONDRAL DEFECTS IN KNEE MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

Atanu Bhattacharjee Atanu Bhattacharjee The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust HS McCarthy, B Tins, JH Kuiper, S Roberts, JB Richarson HS McCarthy, B Tins, JH Kuiper, S Roberts, JB Richarson Atanu Bhattacharjee Atanu Bhattacharjee To assess the structural and functional outcome of bone graft with first or second To assess the structuralchondrocyte and functional outcome of bone with first ordefects secondof the generation autologous implantation (ACI) in graft osteochondral generation autologous chondrocyte implantation (ACI) in osteochondral defects of the knee knee Seventeen patients (mean age of 27±7 years, range 17-40), twelve with osteochondritis Seventeen patients (mean age3 of 27±7 years, 17-40), traumatic twelve with osteochondritis dissecans (OD) (ICRS Grade and 4) and fiverange with isolated osteochondral dissecans (OD) (ICRS Grade and treated 4) and five isolated traumatic osteochondral defect (OCD) (ICRS Grade 4) 3were withwith a combined implantation of a defect (OCD) (ICRS Grade were treated withOsplug a combined implantation of a outcome unicortical autologous bone 4) graft with ACI (the technique).

Functional unicortical autologous with scores.

ACI (theThe Osplug Functional outcome was assessed clinicallybone with graft Lysholm repairtechnique). site was evaluated with the was assessed clinicallyScore with Lysholm scores. The repair site was evaluated with score. the Oswestry Arthroscopy (OAS), MOCART MRI score and ICRS II histology Oswestry Score (OAS), MRI score ICRSgrafts II histology score.

FormationArthroscopy of subchondral lamina andMOCART lateral integration of and the bone were also Formation of subchondral evaluated with MRI scans.lamina and lateral integration of the bone grafts were also evaluated with MRI scans.

RESULTS RESULTS

The mean defect size was 4.5±2.6SD cm² (range 1-9) and depth was 11.3±5SD mm The mean defect was 4.5±2.6SD cm²score (range 1-9) andfrom depth (range 5-18).

Thesize pre-operative Lysholm improved 45 was (IQR11.3±5SD 24, rangemm 16-79) (range 5-18). pre-operative score improved from (IQR range 16-79) to 77 (IQR 28,The range 41-100) at Lysholm 1 year (p-value 0.001) and 70 45 (IQR 35,24, range 33-91) at to 77 (IQR 28, range 41-100) at 1 year 0.001)site and 70 6.2 (IQR 35, range 33-91) at 5 years (p-value 0.009).

The mean OAS(p-value of the repair was (range 0-9) at a 5 yearsof(p-value 0.009).

The mean OAS score of the of repair site was 0-9)was at a61 ± mean 1.3 years.

The mean MOCART the repair site6.2 on(range MRI scan mean (range of 1.3 years. mean MOCART score of thedemonstrated repair site on MRI scan good was 61 ± 22SD 20-85)The at 2.6 ± 1.8SD years.

Histology generally 22SD (range at 2.6 ± 1.8SD years.

Histology demonstrated generally good of integration of 20-85) the repair cartilage with the underlying bone. Poor lateral integration integration of the cartilage witha the Poor lateral integration the bone graft on repair the MRI scan and low underlying OAS were bone. significantly associated with aofpoor the bone score graft on the MRI scan and a low OAS were significantly associated with a poor Lysholm and failure.

Lysholm score and failure.

CONCLUSIONS CONCLUSIONS

Osplug technique shows significant improvement of mid-term functional outcome for up Osplug technique shows improvement of mid-term outcome for up to 5 years in patients withsignificant a high grade OD or OCD. This is thefunctional first report describing to 5 years inofpatients withintegration a high grade or OCD.outcome This is the firstsuch report describing It association bone graft withOD functional after a procedure. association of bonehistological graft integration with of functional outcome after such a procedure. also demonstrates evidence integration of the repair cartilage with the It also demonstrates histological evidence of integration of the repair cartilage with the underlying bone graft. underlying bone graft.

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BTS - 25th Annual Scientific Meeting

th Poster November Poster Presentations Presentations –– Wednesday Wednesday 4 4th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

Poster Poster 16 16

FEMORAL FEMORAL HEAD HEAD HISTOLOGY HISTOLOGY IN IN HIP HIP FRACTURE FRACTURE SURGERY: SURGERY: TO TO SEND SEND OR OR NOT NOT TO TO SEND? SEND?

Sebastien Sebastien Crosswell Crosswell Royal Royal Shrewsbury Shrewsbury Hospital Hospital

O O Salar, Salar, CER CER Meyer, Meyer, SM SM Hay, Hay, DJ DJ Ford Ford The Royal The Royal Shrewsbury Shrewsbury Hospital, Hospital, Shrewsbury, Shrewsbury, England England Sebastien Sebastien Crosswell Crosswell

OBJECTIVES OBJECTIVES

Assess Assess our our adherence adherence to to the the Royal Royal College College of of Pathologists Pathologists 2011 2011 recommendations recommendations regarding regarding intra-articular intra-articular tissue tissue specimen specimen sampling sampling and and hip hip fracture fracture surgery. surgery. Assess Assess and and report the outcomes of histological analysis of these intra-operative report the outcomes of histological analysis of these intra-operative femoral femoral head head samples.

Aim to report trends in 1-year survival on the basis of histological diagnosis samples. Aim to report trends in 1-year survival on the basis of histological diagnosis of of these femoral femoral heads. heads. these

METHODS METHODS

A A retrospective retrospective review review of of all all patients patients undergoing undergoing arthroplasty arthroplasty surgery surgery for for hip hip fractures fractures between between January January 2012 2012 and and March March 2014 2014 was was undertaken. undertaken. Patients Patients who who had had their their femoral head sent for analysis were identified and their outcomes collated. femoral head sent for analysis were identified and their outcomes collated. For For all all patients, baseline patient demographics, type of operation and past history patients, baseline patient demographics, type of operation and past history of of malignancy were were also also recorded. recorded. A A consultant consultant radiologist radiologist reported reported all malignancy all pre-operative pre-operative imaging imaging and and any any patients patients with with suspicious suspicious findings findings on on imaging imaging were were identified identified for for subsequent subsequent sub-group sub-group analysis. analysis. Mortality Mortality at at 1 1 year year was was verified verified via via our our weekly weekly updated updated clinical coding administered hospital database linked to primary care services. clinical coding administered hospital database linked to primary care services.

RESULTS RESULTS

360 360 patients patients were were identified identified of of which which 267 267 (74%) (74%) were were female female and and 93 93 (26%) (26%) male. male. 329 329 (91%) received (91%) received a a hemiarthroplasty hemiarthroplasty and and 33 33 (9%) (9%) a a total total hip hip replacement. replacement. 57 57 (16%) (16%) had had a a history history of of malignancy malignancy with with colon, colon, breast breast and and prostate prostate being being the the commonest. commonest. 221 221 (61%) (61%) had had their their femoral femoral heads heads sent sent for for histological histological analysis. analysis. 96 96 (43%) (43%) were were reported reported as as osteoporotic, osteoporotic, 74 74 (35%) (35%) normal normal and and 40 40 (18%) (18%) osteoarthritic. osteoarthritic. One One (0.5%) (0.5%) pathological pathological fracture was found in a patient known to have active haematological malignancy.

16 fracture was found in a patient known to have active haematological malignancy. 16 (4%) (4%) suspicious suspicious x-rays x-rays were were identified identified pre-operatively pre-operatively of of which which 14 14 (88%) (88%) had had histological analysis analysis with with none none (0%) (0%) identifying identifying a a malignancy. malignancy. Overall Overall mortality mortality was was histological 17% 17% at at 6-months 6-months and and 21% 21% at at 12-months.

12-months. Osteoporosis Osteoporosis diagnosed diagnosed on on histology histology conferred conferred a a mortality mortality of of 6% 6% at at 6-months 6-months and and 7% 7% at at 12-months 12-months compared compared with with 3% 3% at at 66months and 4% at 12-months for specimens from patients with a past history months and 4% at 12-months for specimens from patients with a past history of of malignancy. malignancy.

CONCLUSIONS CONCLUSIONS

The The Royal Royal College College of of Pathologists Pathologists recommend recommend that that all all articular articular specimens specimens be be sent sent for for histological histological analysis. analysis. This This audit audit demonstrated demonstrated only only 61% 61% compliance compliance with with this. this. The The incidence incidence of of pathological pathological fracture fracture was was 0.5%, 0.5%, which which nationally nationally may may represent represent a a significant significant number number requiring requiring onward onward assessment assessment and and treatment. treatment. We We would would encourage encourage all trauma surgeons to adhere to Royal College guidelines for articular specimens all trauma surgeons to adhere to Royal College guidelines for articular specimens ifif only only to to confirm confirm or or refute refute the the presence presence of of an an insufficiency insufficiency fracture fracture as as well well as as to to maintain maintain throughput of of specimens specimens through through your your local local pathology pathology service. service. The The latter latter being being throughput recommended recommended by by the the Royal Royal College College of of Pathologists Pathologists as as an an invaluable invaluable tool tool for for training training the the next next generation generation of of pathologists pathologists and and increasing increasing accuracy accuracy of of specimen specimen analysis. analysis.

BTS - 25th Annual Scientific Meeting

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Poster Presentations – Wednesday 4th November Poster Presentations – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

100

Poster 17 Poster 17

Poster Presentations – Wednesday 4th November Poster Presentations – Wednesday 4th November

SHOULD WE REMOVE BULLETS FROM THE SPINAL CORD? SHOULD WE REMOVE BULLETS FROM THE SPINAL CORD?

ATTENDANCE AT FRACTURE CLINICS ATTENDANCE AT FRACTURE CLINICS

Lisa Grandidge Lisa Grandidge Northern General Hospital, Sheffield, UK

MAIN AUTHOR MAIN AUTHOR

Lisa Grandidge. Northern General Hospital, Sheffield.

CO AUTHORS CO AUTHORS

Northern General Hospital, Sheffield, UK Antony Rex Michael.

Northern General Hospital, Sheffield.

Antony Rex Michael.

Northern General Hospital, Sheffield.

Lisa Grandidge. Northern General Hospital, Sheffield.

To discuss a case and review evidence for and against intra-dural bullet removal.

To discuss a case and review evidence and against bullet removal. below A 45 year-old gentleman presented withfor gunshot wound,intra-dural with a loss of sensation

A 45 year-old gentleman presented withlimbs. gunshot with athere loss of sensation his chest and loss of power in his lower Onwound, examination was a single below his chest and loss entry of power in his limbs. On examination there was a single 1cmx0.5cm bullet wound on lower the anterolateral aspect of the left shoulder, with a T3 1cmx0.5cm bullet entry on the anterolateral the left shoulder, with a T3 motor and sensory level.wound PR revealed reduced toneaspect and noofsqueeze. motor and sensory level. PR revealed reduced tone and no squeeze.

A full body CT showed a bullet within the spinal canal adjacent to the T3 vertebral body.

A fullspinal body injuries CT showed bullet within thecomplete spinal canal adjacent to the T3 vertebral body.

The teamadiagnosed a T3 ASIA A paraplegia.

The spinal injuries team diagnosed a T3 complete ASIA A paraplegia.

He underwent a posterior decompression of T3 and intra-dural bullet removal with dura He underwent a posterior decompression T3 and intra-dural bullet removal repair on the same day. Surgery revealed of a dural tear and an intra-dural bulletwith withdura repair oncord the same day.This Surgery revealed with a dural tear andforceps an intra-dural bullet to with obvious damage. was removed rubberised and handed police obvious cord He damage.

This flucloxacillin was removed with rubberised andinjuries handed to for police for ballistics. was given and transferred toforceps the spinal unit for ballistics. He given flucloxacillin recovery and transferred the spinal injuries unit for rehabilitation.

Hewas made no neurological but didto not develop any further rehabilitation. He made no neurological recovery but did not develop any further complications. complications.

A thorough literature search revealed the role of surgery in gaining lost neurological A thorough literature search revealed thefor rolebullet of surgery in include gaining acute lost neurological function remains ambiguous.

Indications removal neurological function remains for bullet removal include acute neurological deterioration and ambiguous.

CSF fistulas.Indications Epidural haematoma/abscesses, radiological deterioration and fistulas. spine Epidural radiological compression or a CSF destabilised are haematoma/abscesses, also considerations. compression or a destabilised spine are also considerations.

Removals of bullets below T12 have had an effect on motor recovery. However similar Removals of recoveries bullets below T12 have had an in effect motor and recovery.

However similar neurological have been reported bothon surgical conservative neurological recoveries havedeficits. been reported in deficits both surgical and conservative management of incomplete Compete are unlikely to improve management of incomplete deficits are unlikely improve neurologically regardless of deficits. surgical Compete intervention, however cervicaltoinjuries with early neurologically regardless of surgical should intervention, however cervical injuries withare early detection of compressive pathology be considered.

Complication rates detectiontoofbe compressive pathology should be considered. Complication rates are reported higher if operated. reported to be higher if operated.

Prophylactic antibiotics should be started immediately on admission. Surgery does not Prophylactic antibiotics be started immediately on admission. Surgery does not reduce the incidence of should infection. reduce the incidence of infection.

Pain may be intensified when caused by a gunshot injury, but there is no evidence of Pain may be intensified caused by a gunshot injury, but there is no evidence of improvement with bullet when removal. improvement removal.

One indicationwith for bullet surgery in this case was to prevent post traumatic syringomyelia One indication for surgery in this case was to prevent post traumatic syringomyelia (PTS).

The incidence is 0.3-3.2%, however radiological/autopsy studies suggest up to (PTS). The has incidence is 0.3-3.2%, however radiological/autopsy studies suggest up to 22%.There been one prior reported case where a patient developed symptoms 14 22%.There has been prior reported case where symptoms months following initialone gunshot injury. However due a topatient lack of developed data it is uncertain if 14 months following initial gunshot injury.

However due lack syrinxes. of data it is uncertain if initial surgical management reduces development of to future initial surgical management reduces development of future syrinxes.

This appears to be the first reported case of an intra-dural bullet in the UK. Treatment This appears to be on theensuring first reported of anenhancing intra-duralpotential bullet in for theneurological UK. Treatment should be focused spinecase stability, should beand focused on ensuring spine stability, enhancing potential for neurological recovery preventing complications.

The role of surgery vs. non-surgical treatment is recovery and preventing complications. The role of surgery vs. non-surgical treatment is still debated. still debated.

BTS - 25th Annual Scientific Meeting

Poster 18 Poster 18

PRESENTER PRESENTER

Pratima Khincha Pratima Khincha Royal Albert Edward Infirmary, Wigan, Wrightington and Leigh NHS Foundation Trust, Royal Edward Infirmary, Wigan, Wrightington and Leigh NHS Foundation Trust, Wigan,Albert United Kingdom Wigan, United Kingdom Neelam Patel, Ravi Badge, Lindy Fairhurst, Puneet Monga – Kohila Vani Sigamoney, Kohila Vani Sigamoney, NeelamWigan, Patel, Wrightington Ravi Badge, and LindyLeigh Fairhurst, Puneet Monga – Royal Albert Edward Infirmary, NHS Foundation Trust, Royal Edward Infirmary, Wigan, Wrightington and Leigh NHS Foundation Trust, Wigan,Albert United Kingdom Wigan, NeelamUnited Patel Kingdom Neelam Patel

OBJECTIVES OBJECTIVES

BOAST (British Orthopaedic Association Standard for Trauma) 7 guidelines state that BOAST Orthopaedic Association Standard forshould Trauma) guidelines state that following(British acute traumatic orthopaedic injury, patients be 7seen in a new fracture following acute traumatic orthopaedic injury, patientsreferrals should be seen in a new fracture clinic within 72 hours of presentation.

This includes from emergency clinic within 72 hours of presentation.

This includes referrals emergency department (ED), minor injury units and general practice.

Sofrom far we have a very good department (ED), minor injuryour units and general practice. far we have a very good triage system which ensures patients are seen by theSo appropriate specialist (upper triage whichinensures patients arealso seen byas thea appropriate (upper limb orsystem lower limb) a timelyour manner.

This acts safety net tospecialist reduce missed limb or lower limb) in a timely manner.

This also as a safety net to reduce missed injuries, but the question is, are we meeting this acts guideline? injuries, but the question is, are we meeting this guideline?

METHODS METHODS

In the initial audit, all patients referred for a fracture clinic appointment in July 2014 In the included. initial audit, patients for aPatient fracture clinic appointment in July 2014 were Weallused EPRreferred (Electronic Record) as our data source.

We were included.

Wedemographics, used EPR (Electronic Patient ourattended data source.

We seen collected data on diagnosis, date Record) of injury,as date ED, date collected data on demographics, diagnosis,follow date up. of injury, date attended ED, date in clinic and complications on subsequent The prospective re-audit we seen in clinic andincomplications on subsequent follow up. The prospective re-audit we conducted May 2015 closed the audit cycle. conducted in May 2015 closed the audit cycle.

RESULTS RESULTS

There were 363 patients seen in fracture clinic in July 2014. 222 were upper limb There seen in fracture in July 222tissue were upper injurieswere and 363 141 patients lower limb patients; 257 clinic fractures and2014.

106 soft injurieslimb were injuries and(74.1%) 141 lower limb patients; 257more fractures 106post softinitial tissuereview injuries noted. 269 patients were seen than and 3 days in were ED; noted.

269 (74.1%) dayspatients post initial review average was 6 dayspatients (Rangewere 1-32 seen days).more Onlythan 2 of 3these were seeninbyED; average was doctors 6 days (Range 1-32 days).

Only 2 of these patients were by clinic Orthopaedic in ED. Hence, 73.6% of patients were not seen in seen fracture Orthopaedic doctors in ED. Hence, of patients were not seen clinic within 72 hours of presentation with73.6% no convincing complications dueintofracture delay (26.4% within 72 hours of presentation with no convincing complications due to delay compliance).Findings were highlighted and awareness of the guidelines were (26.4% raised compliance).Findings were staff. highlighted andtoawareness of the guidelines wereclinics raisedand amongst the fracture clinic Plan was triage to appropriate specialist amongst the fracture staff. Plan was2015 to triage appropriate specialist andto re-audit. Re-audit wasclinic conducted in May withto emphasis on the reasonclinics for delay re-audit.

Re-audit was conducted in May 2015met with emphasis the reasonDelays for delay to fracture clinic.

Amongst 423 patients, 81.1% the BOAST 7onguidelines. were fracture clinic.

Amongst 423 patients, 81.1% the BOAST 7 guidelines.

Delays were mainly due to appointments sent via post as met patients could not be contacted mainly due to appointments sent via post as patients could not be contacted telephonically. telephonically.

CONCLUSIONS CONCLUSIONS

The “72 hour to fracture clinic” guideline was not met in a large proportion according to The “72 hour to fracture clinic”increased guidelinefrom was 26.4% not mettoin81.1% a large proportion according to the initial audit.

Compliance following implementation the initial audit. Compliance from 26.4% to 81.1% implementation of recommendations.

Virtual increased clinics to improve services in thefollowing future could be of recommendations.

Virtual clinics to improve in thenetwork future could be considered.

With a good triage system in place,services and a good of orthopaedic considered.

With a good triage system in place, and a good network of orthopaedic doctors, nursing staff, physiotherapists and plaster technicians, we are able to provide doctors, nursing staff, physiotherapists and plaster technicians, are demonstrate able to provide an optimal service to our patients. Re-audits at regular intervalswe would an optimal adherence service to our patients.guidelines.

Re-audits at regular intervals would demonstrate continued to BOAST continued adherence to BOAST guidelines.

BTS - 25th Annual Scientific Meeting

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Poster Presentations – Wednesday 4th November

MAIN AUTHOR

Poster 19

RESULTS FOLLOWING REVISION OF THE FEMORAL PROSTHESIS FOR PERIPROSTHETIC HIP FRACTURES, USING A MODULAR, HYDROXYAPATITE COATED, INTERLOCKED FEMORAL STEM

Henry Wynn-Jones

Wrightington, Wigan and Leigh NHS Foundation Trust CO AUTHORS PRESENTER

Robert Hewitt (Manchester University), Nikhil Shah, Timothy Board, Martyn Porter (Wrightington, Wigan and Leigh NHS Foundation Trust) Henry Wynn Jones

Poster Presentations – Wednesday 4th November Poster Presentations – Wednesday 4th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

OBJECTIVES

To assess the outcome following femoral revision for periprosthetic fractures, using a modular, hydroxyapatite coated, interlocked femoral stem.

METHODS

We performed a retrospective study of 50 consecutive patients who underwent femoral revision for a periprosthetic fracture using a modular, hydroxyapatite coated, interlocked femoral stem at our hospital. Patients were identified using a data search from the National Joint Registry, our hospital implant database, and surgeons own log books.

Patient demographic, previous implants, time from fracture to revision, and implant details were recorded. Fractures were classified using the Vancouver classification system. Outcome measures that were recorded included mortality, fracture union, stem survival, stem loosening, major local complications, major medical complications and re-operations.

RESULTS

The mean patient age at surgery was 73.4 years with a range of 32-97. Mean follow up was 33.3 months. There were 32 women and 28 men. 6 cases were revisions for a non-union of a previous fixation of a periprosthetic fracture. There were no deaths within 90 days. One patient aged 91 died within 1 year. Three patients required a rerevision of the stem: One was for a stem fracture 3 years after surgery due to fatigue secondary to non-union, and two re-revisions were for subsidence (one with locking bolt fracture and one with bolts missing the prosthesis). All the stem re-revisions were in cases where the smallest stem diameter (10mm) was used, and 50% of the 10mm stems required revision. 5 patients (14.7%) had a dislocation. 17.6% of patients underwent acetabular revision or augmentation.

CONCLUSIONS

Revision using modular, hydroxyapatite coated, interlocked femoral prosthesis achieves reliable femoral reconstruction in patients with periprosthetic femoral fractures that are not suitable for fixation, or have previous failed fixation. The mortality rate was low. The dislocation rate is high, and we recommend that augmention or revision of the acetabular component to a more stable design be considered. 10mm diameter stems should be used with caution because of the fracture and subsidence risk.

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METHODS METHODS RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Poster 20 Poster 20

AN AUDIT OF PRIMARY TRAUMATIC HIP DISLOCATIONS ACCORDING AN AUDIT OF PRIMARYTO TRAUMATIC HIP DISLOCATIONS ACCORDING BOAST3 GUIDELINES Muhammad Adeel Akhtar TO BOAST3 GUIDELINES Muhammad Adeel Akhtar Royal Victoria Infirmary, Newcastle, United Kingdom.

Royal Victoria Infirmary, Newcastle, United Kingdom.

Lysander Gourbault, Amir Mukhtar, Andrew Colin Gray Lysander Gourbault, Amir Mukhtar, Andrew Colin Gray Royal Victoria Infirmary, Newcastle, United Kingdom.

Royal Victoria Infirmary, Newcastle, United Kingdom.

Amir Mukhtar Amir Mukhtar

Our aim was to study the epidemiology, associated fractures and outcomes following Our aim traumatic was to study the epidemiology, associated fractures and outcomes followingour primary hip dislocations presented at a major trauma centre and compare primary traumatic hipBOAST3 dislocations presented at a major trauma centre and compare our practice against the standards for audit. practice againstcase the BOAST3 standards for audit.

A retrospective notes review of patients admitted with primary traumatic Hip A retrospective caseVictoria notes review of patients admitted with primary traumatic Hip dislocation at Royal infirmary during the last 3 years was performed. dislocation at Royal infirmary the last 3 years was performed.

The mean age of 21Victoria patients(17 male during and 4 female)was 42 years(14-91).The The mean age of 21 was patients(17 and 4 female)was 42inyears(14-91).The mechanism of injury RTA in male 12 patients,Fall >2 meter 4,Fall <2 meter in mechanism injury was in RTA in 12 patients,Fall >2 meter in 4,Fall <2 meter in 3,assault in 1ofand sports 1 patient.15 patients had posterior dislocations,2 had 3,assault in 1 and sportshad in 1superior patient.15 had posterior dislocations,2 anterior,2 had central,1 andpatients 1 had inferior dislocation.6 patients had had no anterior,2 had central,1had hadcomplex superiorfractures,3 and 1 had had inferior dislocation.6 patients had no associated fractures,7 posterior column,2 had posterior associated fractures,7 wall and 1 had anteriorhad wallcomplex fracture.fractures,3 had posterior column,2 had posterior wall and 1 had anterior wall fracture.

1- 19 patients had closed reduction,1 had failed closed reduction and 1 patient was 1- 19 reduction,1Allhad failed closed 1 patient was toopatients unstablehad for closed any intervention. reductions were reduction performedand within 24 hours toopresentation.4 unstable for any intervention. reductions were performed within 24 hours of patients had no All documentation of hip stability following of presentation.4 patients had no documentation of hip stability following reduction. reduction.

2- The neurovascular status was recorded for 16 patients before reduction and for 2- The neurovascular status was recorded for 16 patients before reduction and for 18 patients after reduction. patients reduction.

3- 18 Traction wasafter applied in 13 patients;9 had skeletal traction and 4 had skin 3- Traction traction. was applied in 13 patients;9 had skeletal traction and 4 had skin traction. reduction hip was unstable in 4 patients and urgent advice was taken 4- Following 4- for Following in 4nopatients and urgent was taken 3 of thereduction unstable hip hipswas andunstable there was documentation for advice 1 patient. for patients 3 of the unstable hipsfollowing and thereHip was no documentation 1 patient.

5- 19 had imaging relocation;14 had CTfor scans and 5 had x5- 19 patients had imaging following Hippatients relocation;14 CT scans 5 had xrays.CT scan was performed in 9/14 within had 24 hours after and reduction. scan was performed in 9/14 patients within 24mean hourstime afterfor reduction.

6- rays.CT 10 patients had ORIF for the acetabular fractures.The ORIF was 6- 10 patients ORIF for the acetabular time 3 days (1-7).had 9/10 patients had definitive fractures.The surgery withinmean 5 days andfor1 ORIF withinwas 10 3 days (1-7). 9/10 patients had definitive surgery within 5 days and 1 within 10 days. days.

9 patients had FU arranged,9 patients had their care transferred,1 patient died and no 9 patients had FU for arranged,9 patients hadFU their patient and no FU was arranged 1 patient.The mean wascare 5.5 transferred,1 months(3-12).At the died last FU,3 FU was arranged for and 1 patient.The mean FU patients was 5.5 returned months(3-12).At the last FU,3 patients had no pain 5 had some pain.4 to full function.2 patients patients had no pain and 5 had some pain.4 patients returned to full function.2 patients returned to work. returned to work.

1- All hip dislocations were reduced within 24h after presentation.

1dislocations were within 24h afterpatients presentation.

2- All Thehip neurovascular statusreduced was recorded for 76% before reduction and 2- The neurovascular status was recorded for 76% patients before reduction and for 85% patients after reduction. for 85% patients after reduction.

3- Skeletal Traction was applied in 43% cases following reduction.

3was applied 43% cases reduction.

4- Skeletal CT scan Traction was performed withinin24 hours afterfollowing reduction in 43% patients.

4- 90% CT scan was performed within 24 hours reduction in 43% patients.

5patients had definitive surgery withinafter 5 days.

90% definitiveour surgery within 5 days. the junior and senior This5-audit willpatients help ushad to improve practice by educating This audit will help us to improve our practice by educating the junior and senior doctors. doctors.

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Poster Presentations – Wednesday 4th November

MAIN AUTHOR

Poster 21

THE EFFECT OF MAJOR TRAUMA CENTRE (MTC) STATUS ON THE ADMISSIONS AND OUTCOMES WITH PELVIC FRACTURES IN A TEACHING HOSPITAL

Muhammad Adeel Akhtar

James Cook University Hospital, Middlesbrough, United Kingdom.

CO AUTHORS PRESENTER OBJECTIVES

METHODS

RESULTS

Oladiran Olatunbode, Jim McVie James Cook University Hospital, Middlesbrough, United Kingdom.

Oladiran Olatunbode

Major trauma centres provide specialised trauma care. James Cook University Hospital (JCUH) was designated as a major trauma centre in April 2012.Our aim was to compare the effect of MTC status on demographics and patient outcomes admitted with pelvic fractures.

We studied demographic details, mechanism of injuries, hospital stay, severity of injuries and outcomes for 202 patients admitted with pelvic fractures; 101 before April 2012 (Group A) and 101 after April 2012 (Group B).

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Mr Jonathan Yates Aintree University Hospital

CO CO AUTHORS AUTHORS

Mr James Fountain – Aintree University Hospital Jonathan Yates

PRESENTER PRESENTER

The number of patients admitted with pelvic fractures increased following the MTC status. More patients were transferred into JCUH before the MTC status 11 vs 6 and more patients were transferred out following MTC status 13 vs 4.The length of stay in the critical care increased after the MTC status 3.9 vs 2.5 days. This data can help the NHS trusts with major trauma centres to plan for the financial impact of their MTC status.

BTS - 25th Annual Scientific Meeting

Poster 22

TOTAL HIP ARTHROPLASTY PERIPROSTHETIC FRACTURES: A SEVEN YEAR, SINGLE CENTRE EXPERIENCE

MAIN MAIN AUTHOR AUTHOR

OBJECTIVES OBJECTIVES

Total hip arthroplasty (THA) periprosthetic fracture management presents a difficult challenge to the hip surgeon. The literature has indicated that the overall incidence is rising. We present our experience of managing these complex injuries across five hip surgeons in one unit over the past seven years.

METHODS METHODS

All THA periprosthetic fractures which presented to the orthopaedic on call team between August 2008 to August 2015 where identified using electronic handover sheets. A retrospective case note analysis was performed and pre and post-operative radiographs were analysed to classify fractures using the validated Vancouver classification system.

RESULTS RESULTS

A total of 28 patients were identified with THA periprosthetic fractures. This cohort was 46% male with an overall average age of 79 years (59-97). There was no observed increasing incidence over this time period. Five patients were managed none operatively. Of the 23 operatively managed fractures, 12 were B2 type, six B3 type and five were C type fractures. 13 of these patients were American Society of Anaesthesiologist (ASA) grade III-IV. Two B type fractures were managed definitively with a girdlestones procedure due to patient factors. All five C type fractures where treated with open reduction and internal fixation. The remaining B type fractures where mostly treated by revision of the femoral stem, which by 2013 involved using a modular cementless stem in all cases. The average length of time from injury to operation was 5 days (1-16) and total length of stay was 39 days (9-105). We also noted an average post-operative Hb count drop of 2.7g/dL with 57% of patients requiring a blood transfusion. All patients were discharged from hospital with ongoing rehabilitation.

Three patients (13%) required revision of the stem within the first year, two due to infection and one due to re-fracture. Two patients had conservatively managed infected wounds and one patient had an isolated dislocation managed with reduction in theatre with no ongoing issues. There was an overall one year mortality rate of 21%.

CONCLUSIONS CONCLUSIONS

This review did not observe an increasing incidence of THA periprosthetic fractures. It has highlighted the potential issues faced by surgeons when managing these patients including a prolonged hospital stay, increased risk of complications and need for transfusion which we will use to improve the service. This work also has also highlighted our change in management with respect to utilising newer modular cementless stems and therefore the need to monitor this change in practise more closely.

Group A patients were admitted between September 2008 and March 2012 (42 months). 58 were male and 43 female. 53 were involved in road traffic accidents (RTA), 34 had a fall from less than 2 meter height and 10 had a fall from more than 2 meter height. 11 patients were transferred into JCUH and 4 were transferred out. The mean age was 48 years. The mean Glasgow Coma Scale (GCS) score was 14. The average length of hospital stay was 21 days (range 1-152) and critical care stay was 2.5 days (range 0-32). The mean injury severity score (ISS) was 17 (4-75) and Physical score (PS) was 93 (12.7-99.8). The recent follow up showed that 90 patients were alive, 6 were dead and 5 were transferred out.

Group B patients were admitted between April 2012 and December 2013 (20 months).

55 were male and 46 female. 50 were involved in RTA, 34 had a fall from less than 2 meter height and 15 had a fall more than 2 meters height. 6 were transferred into JCUH and 13 were transferred out. The mean age was 52 years. The mean GCS was 14. The average length of hospital stay was 22 days (range1-171) and critical care stay was 3.9 days (range 0-84).The mean ISS was 19 (4-57) and PS was 91.4 (20.3-99.8). The recent follow up showed that 80 patients were alive, 6 were dead and 15 were transferred out.

CONCLUSIONS

th November Poster Presentations – Wednesday 4th

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Poster Presentations – Wednesday 4th November Poster Presentations – Wednesday 4th November

Poster 23 Poster 23

ARE STAINLESS STEEL ELASTIC NAILS THE SOLUTION TO HEAVIER ARE STAINLESS STEEL ELASTIC NAILS THE SOLUTION TO HEAVIER CHILDREN WITH FEMORAL SHAFT FRACTURES? CHILDREN WITH FEMORAL SHAFT FRACTURES? MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

Mr Richard Hutchinson Mr Richard Hutchinson Cardiff University Cardiff University Prof Sam Evans – Cardiff University Prof Sam Evans – Cardiff University Mr Richard Hutchinson Mr Richard Hutchinson

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

OBJECTIVES OBJECTIVES

The use of titanium elastic intramedullary nails for the treatment of femoral shaft The use in of children titaniumweighing elastic intramedullary nailsquestioned for the treatment femoral rates shaft fractures, ≥ 45 kg, has been due to theofincreased fractures, in children ≥ 45if kg, been questioned due the increased rates of malunion.

Our aimweighing was to see the has mechanical properties of to stainless steel elastic of malunion. aim was to see if thetomechanical of stainless nails providedOur enough fracture stability justify theirproperties use in heavier children.steel elastic nails provided enough fracture stability to justify their use in heavier children.

METHODS METHODS

20 synthetic paediatric-sized femoral Sawbones®, with mid-shaft fractures, fixed with 20 synthetic paediatric-sized femoral Sawbones®, with mid-shaft with either titanium or stainless steel elastic nails, were tested using a fractures, four-point fixed bending either or stainless steel elastic nails, were tested a four-point bending set-up.titanium The bending stiffness and bending moments of theusing constructs were calculated set-up.

The bending stiffness of the constructs calculatedof at increasing loads, along withand thebending angle ofmoments fracture deformation.

Fromwere this estimates at increasing loads, along with theforangle fracture deformation.

From this estimates of maximum permitted body weight eachofnail type could be extrapolated. maximum permitted body weight for each nail type could be extrapolated.

RESULTS RESULTS

Stainless steel nails created significantly stiffer constructs than titanium in both the Stainless steel nails planes created(psignificantly constructs than titanium in both the coronal and sagittal < 0.0001). stiffer Steel nails required much bigger bending coronal and sagittal < 0.0001).

Steel nails required much bigger bending moments (19.1 Nm) planes before (p loosing acceptable alignment, than titanium (14.2 Nm), in moments Nm) loosing acceptable alignment, titanium (14.2 Nm), in in the sagittal(19.1 plane (p <before 0.0001).

However, despite steel justthan out performing titanium the < 0.0001).

However, steelsignificant. just out performing titanium in the sagittal coronal plane plane,(pthis difference was not despite statistically The estimated body the coronal plane, thisindifference was not were statistically significant.

The estimated weights extrapolated the sagittal plane 45 kg and 61 kg, in titanium and body steel weights extrapolated in theInsagittal planeplane were they 45 kgwere and42 61kg kg,and in titanium steel respectively (p < 0.0001). the coronal 44 kg, inand titanium respectively (p < 0.0001).

In the coronal plane they were 42 kg and 44 kg, in titanium and steel respectively (p = 0.457). and steel respectively (p = 0.457).

CONCLUSIONS CONCLUSIONS

As stainless steel has nearly twice the Young’s modulus of titanium, it seems logical As the Young’s modulus it seems logical it is thatstainless fracturessteel fixedhas withnearly steel twice nails would be stiffer and failofattitanium, higher loads.

However that fractures fixeddid with would be stiffer and fail at plane. higher Aloads.

However it is unclear why steel notsteel out nails perform titanium in the coronal theory was unclear why steel did not perform titanium in the coronal A theory was proposed that unequal nailout slip from the insertion sites might plane. be a contributing factor to proposed that unequal nail slip from the insertion sites might be a contributing factor to these findings. these findings.

Current evidence suggests neither stainless steel nor titanium elastic nails are suitable Current evidence suggests neither stainless steel norkg, titanium are suitable for stabilizing femoral shaft fractures in children ≥ 45 due toelastic risk ofnails malunion. for stabilizing femoral shaft fractures in children ≥ 45 kg, due to risk of malunion.

Further research into the use of end caps is needed to see if they provide the added Further the use of end caps is needed to see if they provide the added stability research needed ininto heavier children. stability needed in heavier children.

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November Poster Presentations – Wednesday 4th Poster Presentations – Wednesday 4th November

BTS - 25th Annual Scientific Meeting

Poster 24 Poster 24

LOCKING VERSUS NON-LOCKING PLATES FOR DISTAL FIBULA LOCKING VERSUS NON-LOCKING PLATES FOR DISTAL FIBULA FRACTURES FRACTURES

Shirley A Lyle Shirley A Lyle University College London Hospitals NHS Foundation Trust University College London Hospitals NHS Foundation Trust Catherine Malik, University College London Hospitals NHS Foundation Trust Catherine Malik, University College London Hospitals NHS Foundation Trust Michael J Oddy, University College London Hospitals NHS Foundation Trust Michael J Oddy, University College London Hospitals NHS Foundation Trust Shirley A Lyle Shirley A Lyle

OBJECTIVES OBJECTIVES

Locking plates offer a biomechanical fixation advantage for distal fibula fractures with Locking plates offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011 our unit introduced a bone-specific comminution or osteoporotic bone. In January 2011 our unit introduced a bone-specific locking plate for the distal fibula with a cluster of 2.4/2.7mm distal screws and 3.5mm locking plate for the distal fibula with a cluster of 2.4/2.7mm distal screws and 3.5mm proximal screws. The aim of this study is to review the implant selection for lateral proximal screws. The aim of this study is to review the implant selection for lateral malleolar fixation and to assess the cost and incidence of complications of bonemalleolar fixation and to assess the cost and incidence of complications of bonespecific locking versus more conventional plating systems. specific locking versus more conventional plating systems.

METHODS METHODS

We retrospectively reviewed a consecutive cohort of patients with closed malleolar We retrospectively reviewed a consecutive cohort of patients with closed malleolar fractures of the ankle admitted for fixation in our unit between January 2011 and fractures of the ankle admitted for fixation in our unit between January 2011 and December 2012. Clinical and radiographic outcomes were compared between December 2012. Clinical and radiographic outcomes were compared between conventional plating using either a 1/3 semi-tubular plate (STP), a 3.5mm limited conventional plating using either a 1/3 semi-tubular plate (STP), a 3.5mm limited contact dynamic compression plate (LC-DCP) or a 2.7mm / 3.5mm LCP distal fibula contact dynamic compression plate (LC-DCP) or a 2.7mm / 3.5mm LCP distal fibula plate (LCP-F). Complications, including re-operations and subsequent removal of plate (LCP-F). Complications, including re-operations and subsequent removal of metal, were recorded from clinic data over the following two years to December 2014. metal, were recorded from clinic data over the following two years to December 2014.

Data were collected on risk factors for osteoporosis according to the FRAX assessment Data were collected on risk factors for osteoporosis according to the FRAX assessment tool. The costs of the implants were calculated at 2015 prices for the plates and screws tool. The costs of the implants were calculated at 2015 prices for the plates and screws procured at our institution. procured at our institution.

RESULTS RESULTS

145 patients underwent fixation with 87 STP, 22 LC-DCP and 36 LCP-F with mean 145 patients underwent fixation with 87 STP, 22 LC-DCP and 36 LCP-F with mean patient ages of 39, 38 and 56 respectively. Patient characteristics demonstrated a patient ages of 39, 38 and 56 respectively. Patient characteristics demonstrated a higher proportion with established osteoporosis or osteoporosis risk factors the LCP-F higher proportion with established osteoporosis or osteoporosis risk factors the LCP-F group (41.7%) compared to 3% and 0% in the STP and LC-DCP groups respectively. group (41.7%) compared to 3% and 0% in the STP and LC-DCP groups respectively.

The total re-operation rates were 24.1%, 22.7% and 16.7% for the STP, LC-DCP and The total re-operation rates were 24.1%, 22.7% and 16.7% for the STP, LC-DCP and LCP-F groups respectively with most re-operations being for uncomplicated LCP-F groups respectively with most re-operations being for uncomplicated symptomatic hardware. There were no significant differences in the rate of infection or symptomatic hardware. There were no significant differences in the rate of infection or other complications from surgery including failure of fixation. The mean hardware costs other complications from surgery including failure of fixation. The mean hardware costs were £104.82 STP and £142.47 LC-DCP compared with £673.83 for the LCP-F group. were £104.82 STP and £142.47 LC-DCP compared with £673.83 for the LCP-F group.

CONCLUSIONS CONCLUSIONS

Bone-specific LCP fibula locking plates add to the portfolio of implants available Bone-specific LCP fibula locking plates add to the portfolio of implants available particularly for unstable fractures with poor bone quality. The implant has a substantial particularly for unstable fractures with poor bone quality. The implant has a substantial increased financial burden costing six times that of a standard fibula fixation construct. increased financial burden costing six times that of a standard fibula fixation construct.

This retrospective analysis indicates that the introduction and use of the implant in our This retrospective analysis indicates that the introduction and use of the implant in our unit appears to be appropriate and rationalised for patient characteristics. unit appears to be appropriate and rationalised for patient characteristics.

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www.bts-org.co.uk

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th Poster November Poster Presentations Presentations –– Thursday Thursday 5 5th November

MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Poster Poster 1 1

OUTCOME OUTCOME OF OF PLATE PLATE FIXATION FIXATION OF OF COMPLEX COMPLEX OLECRANON OLECRANON FRACTURES. FRACTURES. A A RETROSPECTIVE RETROSPECTIVE STUDY. STUDY.

Mohammed Mohammed Ali Ali Royal Derby Derby Hospital Hospital Royal

Dimitrios Dimitrios Aspros, Aspros, David David Clark, Clark, Amol Amol Tambe Tambe Mohammed Ali Ali Mohammed

OBJECTIVES OBJECTIVES

To To evaluate evaluate the the functional functional outcome outcome of of plate plate fixation fixation for for comminuted comminuted olecranon olecranon fractures. fractures.

METHODS METHODS

A A retrospective retrospective study study of of patients patients operated operated in in the the Shoulder Shoulder unit unit of of a a District District General General Hospital Hospital in in England England over over a a period period of of three three year. year. We We included included only only patients patients with with isolated isolated comminuted comminuted olecranon olecranon fractures. fractures. Average Average follow-up follow-up was was eighteen eighteen months. months. Outcome Outcome measures measures included included radiographic radiographic healing, healing, post-operative post-operative range range of of motion, motion, complications, complications, outcome outcome score score and and patient patient satisfaction. satisfaction.

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

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We We identified identified twenty-three twenty-three patients patients that that underwent underwent plate plate fixation fixation of of displaced displaced and and comminuted comminuted olecranon olecranon fractures; fractures; all all fractures fractures were were classified classified as as Mayo Mayo types types IIB IIB and and IIIB. IIIB. All All the the operations operations were were performed performed within within three three days days from from injury. injury. All All the the patients patients were were referred referred to to physiotherapy physiotherapy post-operatively. post-operatively. Fifteen Fifteen patients patients had had no no complications complications post-operatively post-operatively with with good good outcome. outcome. Two Two patient patient developed developed neuropraxia neuropraxia which which had had improved with physiotherapy. improved with physiotherapy.

Five Five patients patients had had range range of of motions motions between between 20 20 to to 90 90 degrees. degrees. One One of of those those five five patients patients needed needed metal metal work work removal removal and and physiotherapy physiotherapy while while the the others others were were just just managed managed by by physiotherapy. physiotherapy. One One patient patient developed developed heterotopic heterotopic ossifications ossifications and and needed needed metal metal work work removal removal and and long long term term physiotherapy physiotherapy with with unsatisfactory unsatisfactory outcome. outcome.

November Poster Presentations – Thursday 5th Poster Presentations – Thursday 5th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS

PRESENTER PRESENTER

A CASE OF UNPROVOKED SHOULDER HAEMARTHROSIS ASSOCIATED A CASE OF UNPROVOKED SHOULDER HAEMARTHROSIS ASSOCIATED WITH RIVAROXABAN THERAPY WITH RIVAROXABAN THERAPY Ahmed Ezzat Ahmed Ezzat Orthopaedics Trauma Unit, Aberdeen Royal Infirmary, Aberdeen, Scotland Orthopaedics Trauma Unit, Aberdeen Royal Infirmary, Aberdeen, Scotland Daragh Chakravarty Daragh Chakravarty (Orthopaedics Trauma Unit, Aberdeen Royal Infirmary. Aberdeen University); (Orthopaedics David Cairns Trauma Unit, Aberdeen Royal Infirmary. Aberdeen University); David Cairns (Orthopaedics Trauma Unit, Aberdeen Royal Infirmary. Aberdeen University); (Orthopaedics Trauma Unit, Aberdeen Royal Infirmary. Aberdeen University); Niall Craig Niall Craig (Orthopaedics Trauma Unit, Aberdeen Royal Infirmary. Aberdeen University) (Orthopaedics Trauma Unit, Aberdeen Royal Infirmary. Aberdeen University) Ahmed Ezzat Ahmed Ezzat

OBJECTIVES OBJECTIVES

Newer irreversible oral anticoagulants such as rivaroxaban, a direct factor 10a inhibitor, Newer irreversible oral anticoagulants such as rivaroxaban, direct 10a inhibitor, are increasingly employed to prevent thromboembolic eventsa in atrialfactor fibrillation (AF) are increasingly employed to prevent thromboembolic events in atrial fibrillation patients, and to manage venous thromboembolism (VTE).

Unlike warfarin, these(AF) agents patients, to manage (VTE). Unlike these require noand monitoring andvenous involvethromboembolism infrequent dose adjustment.

Wewarfarin, report the caseagents of a require no monitoring and involve dose adjustment. report the case of a patient treated with rivaroxaban forinfrequent AF. Patient presented with We unprovoked sudden patient treated with rivaroxaban for AF. Patient presented with unprovoked sudden onset right shoulder pain which clinically resembled shoulder haemarthrosis. onset right shoulder pain which clinically resembled shoulder haemarthrosis.

METHODS METHODS

A single case was anonymised and retrospectively reviewed through examination of A singleand case was anonymised clinical radiographic data. and retrospectively reviewed through examination of clinical and radiographic data.

RESULTS RESULTS

A 70 year old female with known AF presented to Accident and Emergency with sudden A 70 year old shoulder female with known AF presented to Accident and Emergency with sudden onset of right pain and limited movement, which developed over one hour. onset of right and limited which developed hour.

The pain was shoulder constant,pain localised to the movement, shoulder and without trauma.over Pastone medical The pain was constant, localised to the shoulder and without trauma.

Pastaneurysm, medical history included severe aortic regurgitation and associated thoracic aortic historyfailure, included severe aorticand regurgitation and associated thoracic aortic aneurysm, heart atrial fibrillation hypertension.

Observations were normal upon heart failure, atrial fibrillation and hypertension. were normal uponshoulder admission with no haemodynamic compromise Observations or pyrexia. Examining the right admission withdistension no haemodynamic compromise or pyrexia.

Examining the rightrange shoulder demonstrated of shoulder joint capsule, tenderness and a reduced of demonstrated distension of shoulder joint capsule, and were a reduced range of movement. Temperature and neurovascular status tenderness in the right arm normal. movement.

Temperature and neurovascular status in the right arm were normal.

Investigations upon admission included an INR of 1.2. An anteroposterior right shoulder Investigations upon no admission an INR of 1.2.

Anmanaged anteroposterior right shoulder radiograph showed evidenceincluded of fracture.

Patient was conservatively with radiograph no Importantly, evidence of rivaroxaban fracture. Patient managed conservatively with simple oral showed analgesia. was was withheld for 5 days and symptoms simple oral analgesia.

Importantly, rivaroxabancommenced was withheld for 5 days and symptoms resolved.

Warfarin therapy was subsequently instead as treatment for AF. resolved.

Warfarin therapy subsequently commenced instead aspost-discharge. treatment for AF. Patient was discharged onewas week later and seen in clinic two weeks A Patient was discharged onewith week later andof seen in clinic in two post-discharge. A full recovery occurred and a full range movement theweeks right shoulder. full recovery occurred and with a full range of movement in the right shoulder.

CONCLUSIONS CONCLUSIONS

In the UK, current National Institute for Health and Care Excellence (NICE) guidelines In the UK, current National Institute for Health Care Excellence guidelines recommend the use of factor 10a inhibitors, forand prevention of stroke (NICE) in AF patients, and recommend the use of hip factor inhibitors, for prevention ofto stroke in AF patients, following elective total and10a knee replacement operations prevent VTE. In turn,and following elective total hip and knee replacement to prevent VTE. In turn, rivaroxaban is increasingly prescribed as first lineoperations therapy. Whereas warfarin has a rivaroxaban increasingly prescribed as first there line therapy.

Whereas warfarin has a documentedisassociation with haemarthrosis, is no primary literature evaluating documented association with haemarthrosis, there is no primary literature evaluating the incidence of factor 10a therapy associated haemarthrosis. In our case, the the incidenceshoulder of factorhaemarthrosis 10a therapy associated haemarthrosis.

In ourcessation. case, the In unprovoked resolved following rivaroxaban unprovoked with shoulder haemarthrosis resolved following rivaroxaban cessation.

In comparison warfarin, rivaroxaban is irreversible.

With warfarin and a high INR, comparison with rivaroxaban is irreversible. With warfarin and a highforINR, vitamin K can be warfarin, used to reverse the anticoagulation.

There is no equivalent vitamin K canWe be suggest used to reverse the anticoagulation. is no equivalent for rivaroxaban. further studies into incidenceThere of haemarthrosis associated rivaroxaban.

We suggest furtherbestudies into incidence of haemarthrosis with oral anticoagulant therapy undertaken, and treating physicians beassociated aware of with anticoagulant therapy be undertaken, and treating physicians be aware of suchoral complication. such complication.

Plate Plate fixation fixation of of complex complex olecranon olecranon fracture fracture is is an an effective, effective, reliable reliable way way of of treatment treatment with with low low risk risk of of non-union. non-union. Stiffness Stiffness can can complicate complicate the the post-operative post-operative period period but but most most of of the the patients patients respond respond well well to to physiotherapy. physiotherapy.

BTS - 25th Annual Scientific Meeting

Poster 2 Poster 2

BTS - 25th Annual Scientific Meeting

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Poster Presentations – Thursday 5th November

MAIN AUTHOR

Poster 3

th Poster November Poster Presentations Presentations –– Thursday Thursday 5 5th November

OUTCOME OUTCOME OF OF THE THE UNAFFECTED UNAFFECTED CONTRALATERAL CONTRALATERAL HIP HIP IN IN UNILATERAL UNILATERAL SLIPPED CAPITAL FEMORAL EPIPHYSIS: COMPARISON SLIPPED CAPITAL FEMORAL EPIPHYSIS: COMPARISON OF OF

THE COMPLIANCE TO NICE GUIDELINES AND ITS IMPACT ON CARE OF PATIENTS WITH NECK OF FEMUR FRACTURE A COMPLETED AUDIT LOOP.

Sudhir.Kannan

MAIN AUTHOR MAIN AUTHOR

University Hospitals of Leicester

Poster Poster 4 4

PROPHYLACTIC PROPHYLACTIC FIXATION FIXATION WITH WITH OBSERVATION OBSERVATION

Atanu Atanu Bhattacharjee Bhattacharjee The The Robert Robert Jones Jones and and Agnes Agnes Hunt Hunt Orthopaedic Orthopaedic Hospital Hospital NHS NHS Foundation Foundation Trust Trust

CO AUTHORS

Arijit Ghosh, Alwyn Abraham, Nicky Morgan

PRESENTER

Sudhir.Kannan

CO AUTHORS CO AUTHORS PRESENTER PRESENTER

OBJECTIVES

The NICE Guidelines provide best practise advice on care of hip fracture patients. Nice has provided guidelines for the managements of patients with hip fracture starting from arrival to emergency department to discharge. We chose to audit our trust’s compliance with the targets mentioned below 1. Perform surgery on same day or day after .2.Identify and treat comorbidities (Volume depletion, cardiac arrhythmias) 3.Assesment of pain.6.Offer immediate and regular analgesia.7. NSAIDS are not recommended

OBJECTIVES OBJECTIVES

To To assess assess the the outcome outcome of of unaffected unaffected hip hip managed managed with with prophylactic prophylactic fixation fixation or or observation observation in in patients patients presenting presenting with with primary primary unilateral unilateral Slipped Slipped Capital Capital Femoral Femoral Epiphysis (SCFE).

Epiphysis (SCFE).

METHODS METHODS

A A retrospective retrospective review review of of 80 80 patients patients with with unilateral unilateral slipped slipped capital capital femoral femoral epiphysis epiphysis from from 1998-2012 1998-2012 was was undertaken undertaken to to determine determine the the outcome outcome of of the the unaffected unaffected hip. hip. All All patients were treated with either prophylactic single Richards screw fixation patients were treated with either prophylactic single Richards screw fixation or or observation of the uninvolved hip and were followed up for at least 12 months.

The observation of the uninvolved hip and were followed up for at least 12 months. The primary primary outcome outcome is is to to evaluate evaluate the the incidence incidence of of sequential sequential slip slip of of the the initially initially unaffected unaffected hips in these patients.

The secondary outcome is to ascertain the incidence hips in these patients. The secondary outcome is to ascertain the incidence of of avascular avascular necrosis, necrosis, chondrolysis, chondrolysis, infection infection and and metal-work metal-work related related problem problem in in the the contralateral contralateral unaffected unaffected hips. hips.

RESULTS RESULTS

The The unaffected unaffected hip hip of of 44 44 patients patients (mean (mean age age 12.6 12.6 years, years, range range 9-17) 9-17) had had simultaneous simultaneous prophylactic fixation prophylactic fixation and and 36 36 patients patients (mean (mean age age 13.4 13.4 years, years, range range 9-17.4) 9-17.4) were were managed managed with with observation. observation. Sequential Sequential slip slip of of the the unaffected unaffected hip hip was was noted noted in in 10 10 patients patients (28 (28 per per cent) cent) in in the the observation observation group group and and only only in in 1 1 patient patient (2 (2 per per cent) cent) in in the the group managed with prophylactic fixation.

A Fisher’s exact test showed significantly group managed with prophylactic fixation. A Fisher’s exact test showed significantly high incidence of sequential slip in unaffected hips when managed with regular high incidence of sequential slip in unaffected hips when managed with regular observation observation (p-value (p-value 0.002).

0.002). Only Only 3 3 cases cases had had symptomatic symptomatic hardware hardware on on the the unaffected unaffected side side after after prophylactic prophylactic fixation fixation with with one one requiring requiring revision revision of of the the metal metal work; work; one one had had superficial superficial wound wound infection infection treated treated with with antibiotics. antibiotics. No No cases cases had had AVN AVN or or chondrolysis. chondrolysis.

CONCLUSIONS CONCLUSIONS

Simultaneous Simultaneous prophylactic prophylactic fixation fixation of of the the unaffected unaffected hip hip significantly significantly reduces reduces the the incidence incidence of of sequential sequential slip slip in in unilateral unilateral SCFE SCFE with with minimal minimal complications. complications.

METHODS

A retrospective audit of existing practice was conducted at authors affiliated university hospital. All patients with neck of femur fracture admitted between October and to June 2012 were included in the study. The results of the audit were analysed and we identified areas where NICE guidelines was not being followed, a simple logistic change in form a checklist was introduced. A prospective re-audit was performed between Feb 2015 – April 2015 and results were compared with previous audit using appropriate statistics (Continuous variable expressed as mean, average, and range).

RESULTS

A total of 100 patients were included in initial audit in 2012, about 32 patients were included in 2015. The changes implemented following initial audit improved the assessment and review of pain form 8%-4% to 78%-75% respectively. Regular analgesia prescription improved from 80%-100%, ECG and EWS recording increased from 85% and 60% respectively to 100%, intravenous fluid prescription in 100% patients (which was 83% in previous audit) and none of the patients had volume depletion. Mental score testing improved to 100% from 74%,about 75% of patients had surgery within 36 hours.

CONCLUSIONS

Focussing of NICE guidelines which were not being followed of had low compliance rate can produce a significant improvement in achieving full compliance to these guidelines and in turn improve the care for patients admitted with neck of femur fracture

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Robert Robert Freeman, Freeman, Andrew Andrew P P Roberts, Roberts, Nigel Nigel T T Kiely Kiely Atanu Bhattacharjee Atanu Bhattacharjee

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Poster Poster 5 5

Poster Presentations – Thursday 5th November Poster Presentations – Thursday 5th November

DISLOCATION DISLOCATION RATES RATES OF OF HIP HIP HEMIARTHROPLASTY HEMIARTHROPLASTY MAIN MAIN AUTHOR AUTHOR CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Peter Peter Craig Craig Royal Royal Stoke Stoke University University Hospital, Hospital, Stoke-on-Trent, Stoke-on-Trent, UK UK

Ross Ross Fawdington, Fawdington, Philip Philip Roberts Roberts (Royal (Royal Stoke Stoke University University Hospital) Hospital) Ross Fawdington Ross Fawdington

OBJECTIVES OBJECTIVES

Following Following a a recent recent increase increase in in hip hip hemiarthroplasty hemiarthroplasty dislocations, dislocations, we we set set out out to to ascertain ascertain our our departmental departmental rate rate of of dislocation dislocation and and to to identify identify any any association association following following a a change change in in practice practice from from the the traditional traditional uncemented uncemented Thompson Thompson hemiarthroplasty hemiarthroplasty (UCTH) (UCTH) and and Austin-Moore Austin-Moore (AM) (AM) to to C-Stem C-Stem with with bipolar bipolar heads heads (CSBP) (CSBP) or or the the Exeter Exeter trauma trauma stem stem (ETS).

(ETS).

METHODS METHODS

Patients Patients admitted admitted with with a a hemiarthroplasty hemiarthroplasty dislocation dislocation between between January January 2010 2010 and and December December 2014 2014 were were included. included. Patients Patients that that had had primary primary surgery surgery at at other other institutions institutions were were excluded. excluded. Patient Patient demographics, demographics, comorbidities, comorbidities, primary primary surgeon surgeon grade, grade, implanted implanted prosthesis, prosthesis, time time from from surgery surgery to to dislocation, dislocation, mechanism mechanism of of dislocation, dislocation, treatment treatment required required and and any any positive positive microbiology microbiology suggesting suggesting infection infection were were recorded. recorded. Abnormal Abnormal pre-operative hip morphology (coxa valga / vara) was assessed by neck-shaft pre-operative hip morphology (coxa valga / vara) was assessed by neck-shaft angle angle measurement measurement on on the the AP AP Pelvis Pelvis radiograph. radiograph.

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

114

Between Between 2010 2010 and and 2014, 2014, an an average average of of 255 255 hip hip hemiarthroplasties hemiarthroplasties were were performed performed per per year. year. Following Following exclusions, exclusions, 22 22 dislocations dislocations were were identified identified (6 (6 males, males, 16 16 females females – – mean mean age age 85 85 years). years). A A registrar/middle registrar/middle grade grade primary primary surgeon surgeon performed performed 21/22 21/22 cases. cases. Three Three dislocations dislocations occurred occurred in in 2010 2010 and and 2011, 2011, 2 2 were were UCTH UCTH and and 1 1 was was AM AM with with a a bipolar bipolar head. head. In In 2013 2013 there there were were 8; 8; 2 2 UCTH, UCTH, 5 5 CSBP CSBP and and 1 1 Exeter Exeter universal universal stem stem with with a a bipolar bipolar head. head. In In 2014, 2014, 11 11 dislocations dislocations occurred; occurred; 2 2 UCTH, UCTH, 2 2 CSBP, CSBP, 7 7 ETS. ETS. Two Two patients patients had had coxa coxa valga valga (2011 (2011 -- AM; AM; 2014 2014 -- ETS) ETS) and and two two patients patients had had coxa coxa vara vara (2014 (2014 -CSBP).

CSBP). Time Time to to dislocation dislocation was was 32 32 days days (10-70).

(10-70). Fourteen Fourteen patients patients had had a a confirmed confirmed history history of of a a fall, fall, 6 6 had had no no history history of of trauma trauma preceding preceding the the dislocation. dislocation. Stem Stem positioning positioning was was satisfactory satisfactory in in terms terms of of length length in in 4/6 4/6 UCTH UCTH whilst whilst 2 2 were were proud proud due due to to an an incorrect incorrect neck cut.

Of the cemented stems, 6 were too long with the shoulder of the prosthesis neck cut. Of the cemented stems, 6 were too long with the shoulder of the prosthesis at at or or above above the the level level of of the the greater greater trochanter. trochanter. Whilst Whilst assessment assessment of of stem stem version version was was not not formally formally measured measured on on the the AP AP radiograph, radiograph, 2 2 ETS ETS were were excessively excessively anteverted. anteverted. Eleven Eleven patients patients underwent underwent at at least least one one closed closed reduction reduction under under anaesthesia, anaesthesia, 6 6 required required excision excision arthroplasty, arthroplasty, 2 2 patients patients required required open open reduction reduction and and abductor abductor repair, repair, 2 2 were were revised revised to to a a total total hip hip replacement replacement and and 1 1 was was too too sick sick to to operate. operate.

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS CONCLUSIONS CONCLUSIONS

Poster 6 Poster 6

SPORTS INJURIES: THE RADIAL NIGHTSTICK FRACTURE AND ITS SPORTS INJURIES: THE RADIAL NIGHTSTICK FRACTURE AND ITS TREATMENT TREATMENT Alistair Jones Alistair Jones Worcestershire Royal Hospital Worcestershire Royal Hospital Andrew Pearse Andrew Pearse Alistair Jones Alistair Jones

As orthopaedic surgeons we often see nightstick type fractures to the ulna, that is As orthopaedic surgeons often seeThese nightstick type fractures to thewith ulna, is fractures sustained from a we direct blow. tend to occur in isolation, nothat radial fractures sustained from can a direct blow. Theseastend occur in isolation, radial fracture. Their treatment be complicated the to radius splints the ulnawith in ano position fracture. treatment be complicated as the radius splints the aulna in anightstick position where theTheir two ends of thecan fracture are not opposed.

Here we present radial where theIt two ends of the fracture nothistory opposed.

Here we is present a radial fracture. is very uncommon and ifare a full of the injury not taken can nightstick easily be fracture. is very uncommon if aprognosis. full history By of the injury is not missed, It which can lead to aand poor presenting thistaken casecan we easily hope be to missed, which canonlead a poor prognosis.

By presenting this case we hope to educate delegates this to uncommon fracture pattern educate delegates on this uncommon fracture pattern Our patient is a young man who sustained the injury playing rugby. There is a typical Our patient is a young mantowho sustained the injury playing is afootball typical history of swinging the arm tackle an opponent in games likerugby. rugby, There american history of swinging the arm to tackle opponent in games like and rugby, football or martial arts. Contact is made withanthe border of the radius anamerican isolated fracture or martial Contact is madewith withathe borderfragment. of the radius isolated occurs.

It arts. is often comminuted butterfly The and ulna,anDRUJ andfracture elbow occurs. oftenand comminuted withtoadelayed butterflyunion fragment. ulna, DRUJ andfracture elbow joint are Itallisintact this can lead as theyThe naturally splint the joint are allWe intact and this canoflead delayed asstages they naturally the fracture site open. present XRays the to initial injuryunion and at through splint treatment. site open. We present XRays of the initial injury and at stages through treatment.

Prolonged casting is often required and if delayed union develops we can consider Prolonged casting is often and if delayed union develops we can consider ulnar osteotomy or ORIF withrequired bone graft ulnar osteotomy or ORIF with bone graft Radial fracture sustained from a fall on an outstretched hand or forearm torsion typically Radial fracture sustained from a and fall on an the outstretched or forearm torsion typically break two structures; the radius ulna, radius andhand DRUJ or the radius with elbow break two structures; radiuspatterns and ulna, the radius DRUJ or the radius elbow disruption.

All of thesethe fracture eliminate theand tensile forse present in with the radial/ disruption.

All of these fracture patterns eliminate the tensile forse present and in the radial/ ulnar ring and allow bone healing.

The radial nightstick fracture is atypical must be ulnar ring and allow healing.

The that radialin nightstick fracture atypicaltensile and must be diagnosed early.

Webone should be aware this isolated radialisfracture forces diagnosed early. should be aware in this isolated radial still act within theWe bony structures of that the forearm and hold thefracture fracturetensile apart,forces often still act delayed within the bony structures of the forearm and hold the fracture apart, often causing union with simple non-operative management. causing delayed union with simple non-operative management.

The The recommendation recommendation from from NICE NICE to to change change practice practice from from using using a a Thompson Thompson or or AustinAustinMoore Moore hemiarthroplasty hemiarthroplasty to to a a proven proven femoral femoral stem stem design design has has led led to to an an increase increase in in our our rate rate of of hemiarthroplasty hemiarthroplasty dislocation. dislocation. This This could could be be due due to to poorly poorly implanted implanted prostheses prostheses or it could be that cemented stems are less forgiving, as 16/22 dislocations were or it could be that cemented stems are less forgiving, as 16/22 dislocations were cemented. cemented.

BTS - 25th Annual Scientific Meeting

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Poster Poster 7 7

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ETS VERSUS VERSUS THOMPSON THOMPSON HEMIARTHROPLASTY. HEMIARTHROPLASTY. HOW HOW NICE NICE ARE ARE THE THE ETS NICE NICE GUIDELINES? GUIDELINES? MAIN AUTHOR MAIN AUTHOR

Mr Mr Saif Saif UL UL Islam Islam University University Hospital Hospital Aintree, Aintree, Liverpool, Liverpool, Merseyside Merseyside

CO AUTHORS CO AUTHORS

Names: Dr Dr Sadaf Sadaf Afzaal, Afzaal, Mr Mr James James Fountain, Fountain, Mr Mr Paul Paul Carter.

Carter.

Names:

PRESENTER PRESENTER

Dr Dr Sadaf Sadaf Afzaal Afzaal

OBJECTIVES OBJECTIVES

Implant Implant choice choice was was changed changed from from cemented cemented Thompson Thompson to to Exeter Exeter Trauma Trauma Stem Stem (ETS) (ETS) for treatment of displaced intra-capsular neck of femur fractures in University for treatment of displaced intra-capsular neck of femur fractures in University Hospital Hospital Aintree, Aintree, following following the the NICE NICE guidelines guidelines that that advised advised about about the the use use of of a a proven proven femoral femoral stem stem design design rather rather than than Austin Austin Moore Moore or or Thompson Thompson stems stems for for arthroplasties. arthroplasties. ETS ETS is is mentioned as an example of such implant design. mentioned as an example of such implant design.

The aim of our study was to compare the results of Thompson versus ETS The aim of our study was to compare the results of Thompson versus ETS hemiarthroplasty hemiarthroplasty in in Aintree.

Aintree.

METHODS METHODS

We We compared compared 100 100 Thompson Thompson hemiarthroplasties hemiarthroplasties that that were were performed performed before before the the start start of of ETS ETS use, use, with with 100 100 ETS ETS hemiarthroplasties. hemiarthroplasties.

RESULTS RESULTS

There There was was no no statistically statistically significant significant difference difference between between the the two two groups groups in in terms terms of of patients’ demographics demographics (age, (age, sex sex and and ASA ASA grade), grade), intra-operative intra-operative patients’ difficulties/complications, difficulties/complications, post post op op medical medical complications, complications, blood blood transfusion, transfusion, in-patient in-patient stay stay and and dislocations. dislocations.

The operative time was statistically significantly longer in the ETS group The operative time was statistically significantly longer in the ETS group (p= (p= .0067). .0067).

Worryingly, Worryingly, the the 30 30 days days mortality mortality in in ETS ETS group group was was more more than than three three times times higher higher in in ETS group (5 in Thompson group versus 16 in ETS group.

P= .011).

ETS group (5 in Thompson group versus 16 in ETS group. P= .011).

CONCLUSIONS CONCLUSIONS

This This we we feel feel may may be be due due to to longer longer and and more more surgically surgically demanding demanding operative operative technique technique including including pressurised pressurised cementation cementation in in some some patients patients with with significant significant medical medical comorbidities.

Due to our surprising results we are reviewing a further cohort comorbidities. Due to our surprising results we are reviewing a further cohort of of ETS ETS patients. patients.

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Poster 8

RECOVERY OF RADIAL NERVE PALSY AFTER LOCKING PLACE FIXATION OF DIAPHYSEAL HUMERUS FRACTURES: A SEVEN YEAR SERIES

MAIN MAIN AUTHOR AUTHOR

Alexander Duguid Royal Derby Hospital, UK

CO CO AUTHORS AUTHORS

Robert Burton, Conal Keene, Marius Espag, Tim Cresswell, David Clark, Amol Tambe.

Royal Derby Hospital, UK Alexander Duguid

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Little has been written regarding locking plate fixation of humeral shaft fractures and associated radial nerve injuries; our aim was to describe outcomes and complications following fixation, including the incidence and recovery of radial nerve palsy, whether caused by the initial injury or during surgery.

METHODS METHODS

We conducted a retrospective cohort study reviewing all diaphyseal humerus fractures treated with a locking plate over 7 years at our unit. Fractures treated with a single plate or distal bicolumn plates were included.

RESULTS RESULTS

74 internal fixations of diaphyseal humerus fractures were performed. Mean patient age was 50.1. Single plating was used in 60 cases, bicolumn plating in 14. Internal fixation was primary treatment for 63 cases (85%); otherwise fixation was after failed conservative treatment.

13 patients (17.6%) had radial nerve palsy before surgery. This resolved for 12 patients (mean time 6.8 months). In one case weakness has not resolved (13 months postinjury).

4 patients (5.4%) developed post-operative radial nerve palsy. In all cases this resolved by 6 months post-procedure (mean 3.1 months) without further surgery.

66 patients (89.2%) completed follow up. 3 required revision surgery for non-union.

One bicolumn plating was revised after further trauma caused failure. Mean union time for single plate fixation was 17.6 weeks, for double plating 13 weeks.

Other surgical complications were superficial infection (1), adhesive capsulitis (3) and pectoralis major tendon rupture (1).

CONCLUSIONS CONCLUSIONS

We found good rates of union and low complication rates following internal locking plate fixation of diaphyseal humerus fractures using single and bicolumn plating techniques.

In this series, patients were more likely to develop radial nerve palsy at the time of injury than due to surgery. In both cases the prognosis was good, with full recovery occurring in 94% of cases overall. The rate of iatrogenic radial nerve injury was 5.4% with complete resolution in all cases, without further surgery.

Our study supports the use primary or secondary locked plate fixation in diaphyseal humerus fractures when indicated; iatrogenic radial nerve injury can be avoided by adequate protection of the nerve during surgery.

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MAIN AUTHOR AUTHOR MAIN CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Poster Poster 9 9

REVIEW OF OF PATIENT PATIENT TRANSFERS TRANSFERS FROM FROM SPINAL SPINAL SURGERY SURGERY TO TO THE THE REVIEW SPINAL INJURIES INJURIES UNIT UNIT SPINAL

Lisa Lisa Grandidge Grandidge Northern Northern General General Hospital, Hospital, Sheffield, Sheffield, UK UK

Lisa Lisa Grandidge, Grandidge, Michael Michael Athanassacopoulos, Athanassacopoulos, Lee Lee Breakwell, Breakwell, Neil Neil Chiverton, Chiverton, Ashley Ashley Cole, Cole, Marcel Marcel Ivanov, Ivanov, Antony Antony Michael.

Michael. Sheffield Sheffield Teaching Teaching Hospitals.

Hospitals.

Lisa Grandidge.

Grandidge. Northern Northern General General Hospital, Hospital, Sheffield.

Sheffield.

Lisa

OBJECTIVES OBJECTIVES

To To review review the the length length of of time time patients patients are are awaiting awaiting spinal spinal injury injury reviews reviews on on the the spinal spinal surgery surgery ward ward and and awaiting awaiting beds beds on on the the spinal spinal injuries injuries unit. unit.

METHODS METHODS

A A list list of of all all spinal spinal surgery surgery patients patients with with a a spinal spinal injuries injuries episode episode within within the the same same spell spell during during the the period period 01/04/12 01/04/12 to to 26/11/14 26/11/14 were were gained gained by by coding coding (n=37). (n=37). Three Three patients patients were excluded excluded from from the the data data (one (one under under neurosurgery, neurosurgery, two two were were transferred transferred from from the the were spinal injuries injuries unit unit (SIU) (SIU) and and were were both both discharged discharged from from the the spinal spinal surgery surgery ward) ward) spinal (n=34). Data Data was was obtained obtained via via a a case case note note review. review. (n=34).

RESULTS RESULTS

The The mean mean number number of of days days patients patients were were awaiting awaiting a a SIU SIU bed bed (calculated (calculated from from spinal spinal injuries injuries review review to to transfer) transfer) was was 19 19 (+/-14). (+/-14). The The maximum maximum time time waiting waiting on on the the spinal spinal surgery ward ward was was 39 39 days, days, and and one one patient patient waited waited 48 48 days days for for a a ventilator ventilator bed. bed. surgery

Poster Presentations – Thursday 5th November Poster Presentations – Thursday 5th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

The most most frequent frequent type type of of injury injury which which resulted resulted in in patients patients requiring requiring transfer transfer for for The rehabilitation was was fracture fracture (44%), (44%), followed followed by by infection infection (29%).

(29%). 47% 47% of of injuries injuries were were in in rehabilitation the the thoracic thoracic spine. spine. 71% 71% recieved recieved surgery surgery during during their their admission. admission.

CONCLUSIONS CONCLUSIONS

This This review review shows shows patients patients are are waiting waiting considerable considerable amounts amounts of of time time awaiting awaiting SIU SIU beds beds and the the delays delays are are increasing increasing each each year. year. Delays Delays cause cause significant significant implications implications for for and patients such such as as psychological psychological issues issues and and risk risk of of complications complications including including pressure pressure patients sores, contractures contractures and and infections, infections, all all of of which which can can impact impact on on functional functional outcomes. outcomes. sores, Delays Delays are are a a high high cost cost to to the the NHS NHS (the (the cost cost of of a a critical critical care care bed bed is is over over £800 £800 more more than than a a ventilated ventilated SIU SIU bed). bed).

CLOSING THE LOOP ON LOWER LIMB OPEN FACTURE MANAGEMENT: CLOSING THE LOOP ON LOWER LIMB OPEN FACTURE MANAGEMENT: A MAJOR TRAUMA CENTRE AUDIT OF BOAST 4 GUIDANCE A MAJOR TRAUMA CENTRE AUDIT OF BOAST 4 GUIDANCE

Aranghan Lingham Aranghan Lingham Royal Stoke University Hospital Royal Stoke University Hospital Amy Laurent, Royal Stoke University Hospital; Yashashwi Sinha, Keele University Amy Laurent, Royal Stoke University Hospital; Yashashwi Sinha, Keele University Medical School; John Blackwell, Royal Stoke University Hospital, Justin Lim Royal Medical School; John Blackwell, Royal Stoke University Hospital, Justin Lim Royal Stoke University Hospital Stoke University Hospital Aranghan Lingham Aranghan Lingham The British Orthopaedic Association Standards for Trauma issued a 15 point guideline The British Orthopaedic Association Standards for Trauma issued a 15 point guideline in 2009 for the management of severe lower limb open fractures. Management of these in 2009 for the management of severe lower limb open fractures. Management of these types of injuries requires excellent multidisciplinary teamwork including Orthopaedic types of injuries requires excellent multidisciplinary teamwork including Orthopaedic Surgery, Emergency Medicine and Plastic Surgery.

Surgery, Emergency Medicine and Plastic Surgery.

We sought to close the loop of our audit cycle assessing adherence to BOAST 4 We sought to close the loop of our audit cycle assessing adherence to BOAST 4 guidelines and to assess the impact the University Hospital of North Midlands becoming guidelines and to assess the impact the University Hospital of North Midlands becoming a Level 1 Major Trauma Centre (MTC) March 2012. a Level 1 Major Trauma Centre (MTC) March 2012.

METHODS METHODS

Data was collected retrospectively using the hospital electronic system and patients Data was collected retrospectively using the hospital electronic system and patients notes on all patients who sustained a high energy open lower limb fracture at the notes on all patients who sustained a high energy open lower limb fracture at the University Hospital of North Midlands between 1st September 2013 to 1st September University Hospital of North Midlands between 1st September 2013 to 1st September 2014. Data was then compared to a previous audit from September 2010 to September 2014. Data was then compared to a previous audit from September 2010 to September 2011 prior to the University Hospital of North Midlands becoming a Level 1 Adult Major 2011 prior to the University Hospital of North Midlands becoming a Level 1 Adult Major Trauma Centre (MTC).

Trauma Centre (MTC).

RESULTS RESULTS

35 patients were identified meeting inclusion criteria, of which notes were available for 35 patients were identified meeting inclusion criteria, of which notes were available for 30. The mean time from injury to antibiotics was 2.38 ± 1:18 hours (h). Neurovascular 30. The mean time from injury to antibiotics was 2.38 ± 1:18 hours (h). Neurovascular status was documented before and after surgery in 29/30 as opposed to 0/13 status was documented before and after surgery in 29/30 as opposed to 0/13 documented post procedure in our previous audit. Plastics was involved in documented post procedure in our previous audit. Plastics was involved in management in 21/30 patients compared to 4/13. Photographs were held in 4/30, and management in 21/30 patients compared to 4/13. Photographs were held in 4/30, and 1/13 in our previous audit. 14/30 were documented to have splinting versus 10/13 1/13 in our previous audit. 14/30 were documented to have splinting versus 10/13 previously. previously.

CONCLUSIONS CONCLUSIONS

Our transformation into a level 1 Major Trauma Centre has seen substantial progress in Our transformation into a level 1 Major Trauma Centre has seen substantial progress in high quality evidence based multidisciplinary management of severe lower limb open high quality evidence based multidisciplinary management of severe lower limb open fractures in adherence with BOAST 4 guidelines. There is however room to improve fractures in adherence with BOAST 4 guidelines. There is however room to improve with regards to joint care from orthopaedics and plastics, clinical photography, and with regards to joint care from orthopaedics and plastics, clinical photography, and documentation. documentation.

The later later the the admission admission the the longer longer patients patients were were waiting, waiting, with with a a positive positive correlation correlation but but The this this was was not not significant significant (r=0.28, (r=0.28, p=0.18). p=0.18). The The mean mean waiting waiting time time was was 9 9 days days in in 2012, 2012, 17 17 days days in in 2013 2013 and and 24 24 days days in in 2014.

2014. There There was was a a positive positive correlation correlation between between the the length length of time patients were awaiting a SIU bed and their length of spinal injuries stay of time patients were awaiting a SIU bed and their length of spinal injuries stay (r=0.105, P=0.39).

P=0.39). (r=0.105, The mean mean time time awaiting awaiting a a spinal spinal injuries injuries review review was was 5.9 5.9 days. days. However However often often there there was was The limited limited documentation documentation regarding regarding how how patients patients were were referred referred and and so so was was not not clear clear when when referrals referrals were were received received by by the the spinal spinal injuries injuries team. team. Two Two patients patients had had no no documented documented review review before before transfer transfer ..

Poster 10 Poster 10

Further work work can can be be carried carried out out reviewing reviewing reasons reasons for for delays delays and and to to look look at at delays delays in in Further SIU discharges. discharges. Patients Patients could could benefit benefit from from an an increase increase in in spinal spinal injury injury reviews reviews whilst whilst SIU beds are are awaited. awaited. An An audit audit on on the the management management of of SCI SCI patients patients whilst whilst they they are are on on an an beds orthopaedic orthopaedic ward ward could could ensure ensure care care meets meets current current recommendations. recommendations.

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Poster Poster 11 11

th Poster Poster Presentations Presentations –– Thursday Thursday 5 5th November November

PREDICTING PREDICTING BLOOD BLOOD TRANSFUSION TRANSFUSION IN IN HIP HIP FRACTURE FRACTURE PATIENTS PATIENTS MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Calum Calum Thomson Thomson Countess Countess of of Chester Chester NHS NHS Trust Trust

CO CO AUTHORS AUTHORS PRESENTER PRESENTER

Major Major blood blood loss loss is is a a recognised recognised complication complication of of hip hip fracture fracture surgery. surgery. Currently, Currently, transfusion transfusion delays delays exist exist postoperatively postoperatively due due to to slow slow recognition recognition of of post post operative operative anaemia, anaemia, and and delays delays in in the the administration administration of of transfusion transfusion where where required. required. Although Although transfusion thresholds remain controversial, maintaining Hb levels >10g/dL transfusion thresholds remain controversial, maintaining Hb levels >10g/dL is is thought thought to to reduce post operative risk in elderly trauma patients, particularly those with reduce post operative risk in elderly trauma patients, particularly those with cardiovascular disease, and this forms the basis for our local transfusion guideline with cardiovascular disease, and this forms the basis for our local transfusion guideline with 10g/dL being being the the post post operative operative Hb Hb target target in in those those patients patients with with cardiovascular cardiovascular disease, disease, 10g/dL and and 9g/dL 9g/dL for for those those without. without. We We hypothesised hypothesised that that post post operative operative transfusion transfusion requirements requirements could could be be accurately accurately predicted predicted pre pre operatively operatively based based on on pre pre operative operative Hb Hb levels, levels, providing providing the the opportunity opportunity for for timely timely intraoperative, intraoperative, or or pre pre operative operative blood blood transfusion, and avoiding or minimizing postoperative anaemia. transfusion, and avoiding or minimizing postoperative anaemia.

METHODS METHODS

By By using using our our local local trauma trauma database, database, we we identified identified all all patients patients undergoing undergoing dynamic dynamic hip hip screw screw (DHS) (DHS) or or hemi-arthroplasty hemi-arthroplasty surgery surgery (ETS) (ETS) for for fractured fractured neck neck of of femur femur between between 4/4/12 and 18/09/13.

We then examined the medical records of these patients to 4/4/12 and 18/09/13. We then examined the medical records of these patients to ascertain ascertain baseline baseline pre pre operative operative Hb, Hb, and and all all recorded recorded post post operative operative Hb Hb levels levels for for the the first first 7 7 post post operative operative days. days. We We also also collected collected information information on on the the incidence incidence of of transfusion within 7 days of surgery. transfusion within 7 days of surgery.

RESULTS RESULTS

Between Between 4/4/124/4/12- 18/09/13, 18/09/13, a a total total of of 365 365 patients patients underwent underwent neck neck of of femur femur fracture fracture surgery. surgery. 171 171 patients patients underwent underwent DHS, DHS, and and 194 194 underwent underwent ETS. ETS. Average Average drop drop in in Hb Hb (pre op Hb – lowest post op Hb) was 2.3g/dL in the DHS group, and 2.4g/dL in the (pre op Hb – lowest post op Hb) was 2.3g/dL in the DHS group, and 2.4g/dL in the ETS ETS group.

In total 301/365 patients (82%) underwent a drop of >1g/dL. The vast majority group. In total 301/365 patients (82%) underwent a drop of >1g/dL. The vast majority of of transfusions transfusions 123/148 123/148 (83%) (83%) were were given given post post operatively, operatively, with with only only 25/365 25/365 (16%) (16%) patients patients receiving receiving pre pre op op transfusion. transfusion. Of Of those those patients patients who who did did not not receive receive pre pre operative operative transfusion, transfusion, 85% 85% of of patients patients in in the the ETS ETS group group and and 79% 79% of of patients patients in in the the DHS DHS group with a pre op Hb between 9-10 went on to receive post operative transfusion. group with a pre op Hb between 9-10 went on to receive post operative transfusion.

CONCLUSIONS CONCLUSIONS

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THE TRAUMATIC TRAUMATIC ABDOMEN: ABDOMEN: HOW HOW EXPOSED EXPOSED ARE ARE TRAINEES? TRAINEES? THE MAIN MAIN AUTHOR AUTHOR

Helen Helen Owen, Owen, Phillip Phillip Holland Holland Calum Thomson Thomson Calum

Poster Poster 12 12

Sarah Sarah Barkley Barkley Chesterfield Chesterfield Royal Royal Hospital Hospital

Hayley Hayley Hutchings, Hutchings, Swansea Swansea University University Sarah Barkley Sarah Barkley

OBJECTIVES OBJECTIVES

Trauma Trauma patients patients requiring requiring urgent urgent surgical surgical intervention intervention are are relatively relatively uncommon uncommon in in the the UK. UK. The The Major Major Trauma Trauma Network Network facilitates facilitates the the management management of of these these patients patients in in a a few few major hospitals hospitals around around the the country, country, so so all all treatment treatment can can be be in-house. in-house. major Surgical trainees trainees are are expected expected (according (according to to the the curriculum) curriculum) to to have have knowledge knowledge and and Surgical experience of of various various trauma trauma operations, operations, including including exploratory exploratory laparotomy laparotomy and and liver liver experience packing. packing.

METHODS METHODS

An An online online survey survey was was devised devised to to collect collect data data regarding regarding volumes volumes of of surgery surgery and and opinions opinions on trauma trauma training. training. on All deaneries deaneries were were contacted contacted and and asked asked to to disseminate disseminate this this to to higher higher surgical surgical trainees. trainees.

All

RESULTS RESULTS

Over Over half half of of trainees trainees had had rotated rotated through through a a Major Major Trauma Trauma Centre Centre during during training, training, although although only only 33% 33% in in the the preceding preceding year. year.

Seventy percent percent of of trainees trainees had had performed performed 10 10 or or fewer fewer exploratory exploratory laparotomies laparotomies for for Seventy trauma and and 96% 96% had had packed packed 10 10 or or fewer fewer livers. livers. trauma One third third felt felt their their trauma trauma exposure exposure was was adequate adequate to to achieve achieve the the requirements requirements for for One completion completion of of training. training.

The The majority majority of of trainees trainees thought thought lack lack of of trauma trauma experience experience was was due due to to trauma trauma being being relatively relatively uncommon, uncommon, the the increasing increasing use use of of nonoperative nonoperative management, management, and and the the European Working Time Directive.

European Working Time Directive.

CONCLUSIONS CONCLUSIONS

Surgical trainees trainees do do not not feel feel they they are are exposed exposed to to enough enough trauma trauma to to gain gain the the necessary necessary Surgical experience experience for for completion completion of of training. training. Despite Despite the the curriculum curriculum highlighting highlighting several several trauma-related trauma-related operations operations they they should should be be competent competent in in performing, performing, many many trainees trainees have have done very few. done very few.

The reason reason for for this this appears appears multifactorial, multifactorial, but but should should be be explored explored to to improve improve training. training.

The

Our Our data data suggests suggests that that there there is is likely likely to to be be a a significant significant drop drop in in Hb Hb in in patients patients undergoing fractured neck of femur surgery, with a large majority of undergoing fractured neck of femur surgery, with a large majority of patients patients loosing loosing at at least least 1g/dL. 1g/dL. Where Where pre pre op op Hb Hb levels levels are are below below 10g/dL, 10g/dL, but but above above our our transfusion transfusion target target of 9.0g/dL, the probability of requiring transfusion is high, and these patients should be of 9.0g/dL, the probability of requiring transfusion is high, and these patients should be evaluated evaluated early early with with a a view view to to pre pre operative operative or or intra intra operative operative blood blood transfusion. transfusion.

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November Poster Presentations – Thursday 5th Poster Presentations – Thursday 5th November

Poster 13 Poster 13

STEMMING THE TIDE? CAN AN EXTRA, WEEEKLY, CONSULTANTSTEMMING THE TIDE? CAN AN EXTRA, WEEEKLY, CONSULTANTDELIVERED OPERATING SESSION OF 3 NECK OF FEMUR FRACTURES DELIVERED OPERATING SESSION OF 3 NECK OF FEMUR FRACTURES REALLY MAKE A DIFFERENCE TO A TRAUMA SERVICE? REALLY MAKE A DIFFERENCE TO A TRAUMA SERVICE? MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER

Gavin McLean Gavin McLean Royal Victoria Hospital, Belfast Royal Victoria Hospital, Belfast Ryan Moffatt, Sinead McDonald, David Kealey. Royal Victoria Hospital, Belfast Ryan Moffatt, Sinead McDonald, David Kealey. Royal Victoria Hospital, Belfast Gavin McLean Gavin McLean

OBJECTIVES OBJECTIVES

Does the addition of an extra neck of femur list (3 cases) result in a decrease in time to Does the addition of an extra neck of femur list (3 cases) result in a decrease in time to surgery, mortality and length of hospital stay? surgery, mortality and length of hospital stay?

METHODS METHODS

Data was collected prospectively by FORD and reviewed retrospectively by the authors.

Data was collected prospectively by FORD and reviewed retrospectively by the authors.

2 time periods were analysed: 1st December 2013 to 31st May 2014 and1st December 2 time periods were analysed: 1st December 2013 to 31st May 2014 and1st December 2014 to 31st May 2015.

2014 to 31st May 2015.

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

A similar number of patients were analysed in each group (488 v 484 patients). When A similar number of patients were analysed in each group (488 v 484 patients). When comparing demographics of each group it was noted that in the second time period comparing demographics of each group it was noted that in the second time period (after implementation of the list) that there was an increase in average age of patients (after implementation of the list) that there was an increase in average age of patients (37.9% v 40.5% of cohort >85 years) and higher ASA scores (ASA 3 - 283 v 276 and (37.9% v 40.5% of cohort >85 years) and higher ASA scores (ASA 3 - 283 v 276 and ASA 4 - 106 v 100) than that of the initial cohort .Average time from admission to ASA 4 - 106 v 100) than that of the initial cohort .Average time from admission to surgery has decreased from 62 hours to 50 hours and 100 day mortality has decreased surgery has decreased from 62 hours to 50 hours and 100 day mortality has decreased from 7% to 3.9%. from 7% to 3.9%.

th Poster Poster Presentations Presentations –– Thursday Thursday 5 5th November November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

This audit has shown that, despite a more aged population with increased ASA grades, This audit has shown that, despite a more aged population with increased ASA grades, there has been an overall decrease in mortality rates, time from admission to surgery there has been an overall decrease in mortality rates, time from admission to surgery and length of hospital stay in neck of femur fractures following implementation of an and length of hospital stay in neck of femur fractures following implementation of an additional operating session. additional operating session.

Poster Poster 14 14

HIP HIP FRACTURE FRACTURE SURGERY SURGERY AND AND NEWER NEWER ANTICOAGULANTS: ANTICOAGULANTS: A A MATTER MATTER OF OF DEBATE? DEBATE?

Muhammad Muhammad Adeel Adeel Akhtar Akhtar Royal Victoria Royal Victoria Infirmary, Infirmary, Newcastle, Newcastle, United United Kingdom.

Kingdom.

Amir Amir Mukhtar, Mukhtar, Lysander Lysander Gourbault, Gourbault, Andrew Andrew Colin Colin Gray Gray Royal Victoria Infirmary, Newcastle, United Kingdom.

Royal Victoria Infirmary, Newcastle, United Kingdom.

Amir Amir Mukhtar Mukhtar Many Many elderly elderly patients patients and and their their relatives relatives request request newer newer anticoagulants anticoagulants for for different different heart condition heart condition from from their their GP's GP's due due to to lower lower risk risk of of bleeding bleeding complications complications and and easy easy monitoring. monitoring. Our Our aim aim was was to to study study the the current current practice practice for for the the management management of of the the newer newer anticoagulants anticoagulants in in the the perioperative perioperative period period in in patients patients undergoing undergoing hip hip fracture fracture surgery. surgery.

We We identified identified 11 11 patients patients who who were were on on newer newer anticoagulants anticoagulants when when they they presented presented with with neck neck of of femur femur fracture fracture during during the the last last 3 3 years. years. 2 2 patients patients had had undisplaced undisplaced fracture fracture which which was treated treated non-operatively non-operatively and and the the rest rest required required operative operative intervention. intervention. was The The mean mean age age was was 83 83 years years (range (range 77-91) 77-91) for for 4 4 female female and and 5 5 male male patients. patients. 5 5 patients patients had had intracapsular intracapsular fracture fracture and and 4 4 patients patients had had extracapsular extracapsular fracture. fracture. All All patients patients who who required surgery were on Rivaroxiban.

The dose range was from 15-20 mg with required surgery were on Rivaroxiban. The dose range was from 15-20 mg with 7 7 patients on 20mg and 2 patients on 15 mg.

Most common indication was Atrial patients on 20mg and 2 patients on 15 mg. Most common indication was Atrial Fibrillation Fibrillation (AF) (AF) in in 7 7 patients patients followed followed by by spontaneous spontaneous PE PE and and DVT DVT in in 1 1 patient patient each. each.

Haematology Haematology advice advice was was sought sought for for 4 4 cases; cases; 2 2 requiring requiring Hemiarthroplasty Hemiarthroplasty and and 1 1 each each requiring requiring DHS DHS and and IM IM nail. nail. The The advice advice given given was; was; wait wait until until itit flushed flushed out out of of system system in in 2 2 cases, wait for 48 hours in one case and repeat clotting in 24 hours in 1 case. cases, wait for 48 hours in one case and repeat clotting in 24 hours in 1 case.

On On anaesthetic anaesthetic review, review, no no concern concern was was raised raised for for 6 6 patients patients and and 1 1 patient patient was was discussed with discussed with haematology haematology again again after after waiting waiting for for 72 72 hours hours with with deranged deranged clotting clotting who who advised advised to to proceed proceed with with the the surgery. surgery.

The The mean mean pre-op pre-op Hb Hb was was 122 122 (101-157) (101-157) and and post post op op was was 104 104 (89-154).

(89-154). 4 4 patients patients had had abnormal abnormal PT PT and and 2 2 patients patients had had abnormal abnormal APTT APTT on on admission. admission. 1 1 patient patient was was given given perioperative Tranexamic acid.

1 patient required blood transfusion and FFP during perioperative Tranexamic acid. 1 patient required blood transfusion and FFP during the the surgery. This This patient patient had had poor poor renal renal function function and and deranged deranged clotting clotting preoperatively. preoperatively. surgery.

The The mean mean length length of of operation operation was was 100 100 min min (45-120).

(45-120). All All patients patients had had general general anaesthesia. anaesthesia. One One patient patient had had post post op op superficial superficial wound wound dehiscence. dehiscence. 6 6 patients patients were were restarted on anticoagulants on discharge. restarted on anticoagulants on discharge.

CONCLUSIONS CONCLUSIONS

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Haematology Haematology advice advice was was taken taken for for 4/9 4/9 patients patients in in this this study. study. The The mean mean delay delay after after haematology haematology advice advice was was 2 2 days. days. Most Most common common indication indication for for newer newer anticoagulants anticoagulants was was AF AF and and all all patients patients were were on on Rivaroxiban.

Rivaroxiban. 1/9 1/9 patient patient required required blood blood products. products. We We are are conducting conducting a a regional regional audit audit to to study study the the current current practice practice and and develop develop guidelines guidelines for for patients patients who who are are on on newer newer anticoagulants anticoagulants and and require require surgery surgery for for neck neck of of femur femur fracture. fracture.

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Poster 15

THE EPIDEMIOLOGY AND OUTCOMES OF PELVIC FRACTURES IN THE SOUTH TEES DURING THE LAST 6 YEARS. MAIN MAIN AUTHOR AUTHOR

Muhammad Adeel Akhtar James Cook University Hospital, Middlesbrough, United Kingdom.

CO CO AUTHORS AUTHORS

Oladiran Olatunbode, Jim McVie James Cook University Hospital, Middlesbrough, United Kingdom.

Oladiran Olatunbode

PRESENTER PRESENTER OBJECTIVES OBJECTIVES

METHODS METHODS

RESULTS RESULTS

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES

Pelvic Fractures are significant orthopaedics injuries which can result in significant morbidity and mortality. The management of these Injuries has changed due to improvement in resuscitation techniques and organization of major trauma networks.

Our aim was to study the epidemiology of pelvic fractures in South Tees.

Patients admitted in James Cook University Hospital (JCUH) with pelvic fractures between January 2008 and December 2013 were identified from trauma database.

Demographic details, type of injuries, mechanism of injuries, hospital stay, severity of injuries and outcomes were studied.

METHODS METHODS

Total number of patients were 232 patients. 37 were admitted in 2008, 17 in 2009, 36 in 2010, 36 in 2011, 45 in 2012 and 61 in 2013. The type of injury was blunt trauma in 231 and penetrating in 1 patient. The mechanism of injury was road traffic accidents in 123 patients, fall less than 2 meter height in 73 patients and fall more than 2 meter in 30 patients.

191 patients attended local emergency department, 19 patients were transferred in, 18 patients were transferred out and 4 patients were transferred in and then out. The mean age was 50 years (range10-98). The mean Glasgow Coma Scale (GCS) score was 13.

The mean length of stay in hospital was 22.5 days (range1-171). The mean length of stay in the critical care was 3.3 days (range 0-84 days). There were 130 male and 102 female patients.

The mean Injury severity score (ISS) was 18.3 (range 4-75). The mean Physical score (PS) was 90 (range 7.6-99.8). The outcome of these patients; 193 were alive at last FU, 22 were transferred out and 17 had died.

CONCLUSIONS CONCLUSIONS

Poster Presentations – Thursday 5th November Poster Presentations – Thursday 5th November

RESULTS RESULTS

The number of patients admitted with pelvic fractures in JCUH has increased from 37 in 2008 to 61 in 2013. The most common mechanism of injury was road traffic accidents in 53%. 9% patients were transferred in while 7.7% were transferred out. This data can help the NHS trust in planning the future services for trauma care.

CONCLUSIONS CONCLUSIONS

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Poster 16 Poster 16

CEMENTED VS UNCEMENTED TOTAL HIP REPLACEMENT FOR NECK OF FEMUR FRACTURES CEMENTED VS UNCEMENTED TOTAL HIP REPLACEMENT FOR NECK OF Atif Mahmood FEMUR FRACTURES Atif Mahmood Royal Liverpool University Hospital Royal Liverpool HospitalUniversity Hospital Ansar MahmoodUniversity - Royal Liverpool Ansar Mahmood Mahmood - Royal Liverpool University Hospital Ansar Ansar Mahmood

A number of studies done in the last decade have shown better results for replacement over internal fixation done for displaced intracapsular neck of femur studies A number of studies in the last decade have shown betterfractures. results forMany replacement have shown Total HipforReplacement (THR) leadsneck to a ofbetter in the over internal fixation displaced intracapsular femurfunctional fractures.outcome Many studies active elderly population with these a prospective have shown Total Hip Replacement (THR)fractures. leads to a We betterconducted functional outcome in the nonrandomised of 2 with groupsthese of patients undergoing cemented or active elderly analysis population fractures.

We a conducted a uncemented prospective THR for neck of femur fracture. nonrandomised analysis of 2 groups of patients undergoing a cemented or uncemented Our was fracture. to see the outcome of cemented versus uncemented total hip THR primary for neckaim of femur replacements forwas displaced neck of femur fractures versus and record complications.

Our primary aim to see the outcome of cemented uncemented total hip Secondary outcome measures neck were subjective done

by Oxford hip scores replacements for displaced of femur assessments fractures and record complications. and SF12 validated Secondary outcomescores. measures were subjective assessments done by Oxford hip scores and SF12 validated scores.

Between November 2009 and August 2011, 35 patients underwent an uncemented total hip replacement for neck femur fractures and 35 patients underwent a cemented Between November 2009 andof August 2011, 35 patients underwent an uncemented total hip replacement replacement.for Average of fractures the patient was years.underwent Demographic data of total hip neck ofage femur and 35 68 patients a cemented both are shown:Average (Table 1) total groups hip replacement. age of the patient was 68 years. Demographic data of Uncemented THR Cemented THR P value both groups are shown: (Table 1) (n=35) (n=35) Uncemented THR Cemented THR P value Age 68 +/- 4.6 68 +/- 5.4 0.68 (n=35) (n=35) M:F 16:19 17:18 0.54 Age 68 +/- 4.6 68 +/- 5.4 0.68 ASA I16:19 – 19, II -16 I17:18 – 20, II – 15 0.71 M:F grade 0.54 Haemoglobin 11.5 +/-II 1.8 10.9 +/-II 1.6 0.59 ASA grade I – 19, -16 I – 20, – 15 0.71 Haemoglobin 11.5 +/- 1.8 10.9 +/- 1.6 0.59 All patients had a mini-mental test (MMT) score of 10/10. Mean follow-up was 18.6 months (range – 48months).

Patients follow-up one year had a All patients had12 a mini-mental test (MMT)available score of for 10/10.

Mean at follow-up was 18.6 clinical subjectivePatients assessments were with oxford scores monthsevaluation (range 12 and – 48months). available fordone follow-up at one hip year had aand SF12 clinicalscores. evaluation and subjective assessments were done with oxford hip scores and SF12 scores.

Mean surgical time, hospital stay, blood loss and postop transfusion rate was higher in the cemented (Table 2)stay, blood loss and postop transfusion rate was higher in Mean surgical group time, hospital Uncemented THR Cemented THR P value the cemented group (Table 2) (n=35) (n=35) Uncemented THR Cemented THR P value Surgical time 70.9 +/- 1.6 80.4 +/- 2.3 0.03 (n=35) (n=35) Blood loss 410 480 0.04 Surgical time 70.9+/+/-15.6 1.6 80.4+/+/-20.4 2.3 0.03 Transfusion 40 60 0.03 Blood loss (%) 410 +/- 15.6 480 +/- 20.4 0.04 Mean hospital stay 11.2 +/1.2 15.3 +/2.4 0.04 Transfusion (%) 40 60 0.03 Oxford hip score 30.5 30.8 0.77 Mean hospital stay 11.2 +/- 1.2 15.3 +/- 2.4 0.04 SF12 physical 31.3 30.3 0.33 Oxfordscore hip score 30.5 30.8 0.77 SF12 47.9 0.35 SF12 Mental score physical 48.7 31.3 30.3 0.33 SF12 Mental 48.7 47.9 0.35 There were no incidences of intraoperative fractures, 2 patients in each group had a superficial infection treated successfully with oral antibiotics.

In the uncemented 2 There were no incidences of intraoperative fractures, 2 patients in each groupgroup had a patients had traumatic periprosthetic fractures requiring revision surgery. superficial infection treated successfully with oral antibiotics.

In the uncemented group 2 Most of the reported being back to pre-injury functional patients hadpatients traumatic periprosthetic fractures requiring revision status. surgery.

Most of the patients reported being back to pre-injury functional status.

Our results show a satisfactory outcome with either technique. Cemented THR had a higher incidence systemic complications.

Our results show of a satisfactory outcome with either technique. Cemented THR had a higher incidence of systemic complications.

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Poster 17

Poster Presentations – Thursday 5th November

POSTOPERATIVE NAUSEA AND VOMITING AND DELAYED DISCHARGE IN ELECTIVE ORTHOPAEDIC SURGERY MAIN AUTHOR

Ahmed Fadulelmola

MAIN AUTHOR

Wrightington Wigan and Leigh NHS trust

Poster 18

MANAGEMENT OF SUSPECTED CLINICAL SCAPHOID FRACTURE IN WIGAN, WRIGHTINGTON AND LEIGH (Re-audit)

Kohila Sigamoney

Wigan, Wrightington and Leigh

CO AUTHORS

T Kwaees, A. Turaev, J Davenport, N Shah, M Walt

CO AUTHORS

Abdullah Gabr, Hugo Lewkowicz; Ceyon Jeyarajah, Adam Watts

PRESENTER

Ahmed Fadulelmola

PRESENTER

Kohila Sigamoney

OBJECTIVES

To assess whether or not Postoperative Nausea and Vomiting (PONV0 was delaying discharge following elective orthopaedic procedures and to assess the financial burden of this delays (average cost of the bed in the trust per day is 430₤)

OBJECTIVES

To check our compliance to the new protocol and to evaluate if the protocol is to continue or changed and to share our treatment method.

METHODS

We prospectively collected data from Case notes and Electronic patient records.

Case Identification; we had done daily ward review (February, March and April 2015, in Wrightington Hospital). Exclusion criteria: delayed discharge for any other cause other than PONV and children. We have analysed the data using software package for statistical analysis (SPSS).

METHODS

All patients with a suspected scaphoid fracture from August 2013 to March 2014 were reviewed retrospectively.

RESULTS

There were 55 patients. Age range was 12 to 79 (average 34) years old. 34 were seen within a week in fracture clinic from being seen in A&E (61.8%). The average time seen from A&E to clinic was 8.7 days. All were seen by a Consultant, fellow or SPR. 9 patients were seen initially in clinic and discharged to hand physiotherapy as they had improved/ no suspected scaphoid fractures. 46 patients had MRIs (83.6%) and 35 within 1 week (76.1%). 38 had only one XR prior to MRI (82.6%). After being seen in clinic, 2 patients were seen back later than 1 week (95.7%). A total of 9 patients had pathways longer than 2 weeks mainly due to initial presentation (83.6%). However, the average total pathway was 1.9 weeks. 6 had scaphoid fractures (10.9%) and there was no reported missed scaphoid fractures. 2 patients (No MRI initially) had persistent symptoms and had repeat MRI scans showing no fractures. Total compliance to the whole pathway was 60% as compared to 20% in the previous audit. There was also a significant reduction in cost compared to that seen in the previous audit.

CONCLUSIONS

Suspected scaphoid fractures are defined as the presence of clinical signs of scaphoid fracture with a normal plain radiograph. In the suspected fractures, studies reported 510 % prevalence of scaphoid fracture. We had a protocol to manage these suspected scaphoid fractures within the trust started in 2009. This was audited and our compliance was low. Equally the whole pathway took an average of 4 weeks before patients are cleared of any fractures and they also had multiple hospital visits.

RESULTS

We had 25 patients. The mean age was 68.24 years (range 33-100). 22 (88%) were females and 3(12%) were males. 5 (20%) had primary total hip arthoplasty (THA), 6 (24%) primary total knee arthoplasty (TKA), 4 (16%) revision THAs, 4 (16%) revision TKAs, 2 (8%) shoulder replacements and 4 miscellaneous. Mean days of delay is 2.37.

15 (60%) had spinal anaesthesia and 10 (40%) had general anaesthesia. 24 (96%) were non-smoker and 1 (4%) was a smoker. 24 (96%) had no past medical history (PMH) of post-operative nausea and vomiting and 1 (4%) had positive PMH. 20 (80%) had intra-operative morphine. The entire patients had post-operative morphine; 76% as patient controlled analgesia (PCA), 20% as regular and 4% as when needed (PRN). All the patients (100%) had Cyclizine as the first line of management.

CONCLUSIONS

The author concluded that all patients should be assessed prior to surgery and categorized as Low/High risk for Post-operative nausea and vomiting. All patients should be reviewed immediately post-op and managed appropriately. This can be done through; Clerking Proforma, Local agreed guidelines and Use of anti-emetics protocol after day 1 post-operative.

The entire patients (100%) had received morphine and this must be minimized in both Intra-operative and post-operative use. alternative pain management pathways such as intra-venous Paracetamol and /or Nefopam has been suggested.

In May 2013, a new protocol was introduced. All patients are seen in A & E with combined clinical tests & scaphoid series X-rays. If a scaphoid fracture is suspected, the patient is referred to hand clinic within 1 week. At that point if a fracture is still suspected, the patient is referred for limited sequence scaphoid MRI scan. This is then treated accordingly.

There was a significant reduction in treatment time for patients with no fractures as compared to the previous audit in 2010. We recommend this protocol for the management of suspected scaphoid fractures. It is beneficial to the patient, clinician and also cost effective.

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MAIN AUTHOR

Poster 19

IMPLEMENTATION OF FORMAL DOCUMENTATION OF TERTIARY TRAUMA SURVEY FOR TRANSFERRED POLYTRAUMA PATIENTS (TERTIARY PELVIC REFERRAL)

Kohila Sigamoney

Wigan, Wrightington and Leigh CO AUTHORS

Abdullah Gabr, Pratima Khincha, Nikhil Shah

PRESENTER

Kohila Sigamoney

OBJECTIVES

To look at our compliance of completing the proformas for tertiary trauma surveys.

METHODS

In RAEI, we implemented the formal documentation of all pelvic trauma patients that have been referred. A modified tertiary survey profoma is filled on admission. This allows us to keep track of all injuries and procedures done as well as follow-up appointments. This proforma is filled out again prior to discharge.We prospectively audited this.

RESULTS

15 pelvic referrals over a period of 3 months (Jan 2015 – Mar 2015). From the referring hospital 100% had primary surveys, 80% had secondary surveys and 0% had tertiary surveys despite being admitted for more than 36 hours. 86.7% had the proformas filled on admission to RAEI and 80% had repeat proformas filled prior to discharge.

Fortunately in this cohort of patients, there were no missed injuries.

CONCLUSIONS

ATLS and Major Trauma Network protocols state that patients should have primary survey on admission, secondary survey as soon as the patient is stabilised and tertiary survey within 36 hours of admission. Royal Albert Edward Infirmary (RAEI) is a tertiary centre for pelvic trauma and receives such patients. Although these patients have been admitted in the referring hospital for a few days, it appeared that most of the time, tertiary surveys were not carried out and some patients had missed injuries.

Very low completion rate of tertiary surveys from regional hospitals. Our compliance to performing tertiary surveys for these patients are quite high and can be improved. Even though there is was no missed injury here, this can always happen and therefore we should always perform a complete tertiary survey on polytrauma patients.

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Poster Presentations – Thursday 5th November Poster Presentations – Thursday 5th November

MAIN AUTHOR MAIN AUTHOR CO AUTHORS CO AUTHORS PRESENTER PRESENTER OBJECTIVES OBJECTIVES METHODS METHODS

RESULTS RESULTS

CONCLUSIONS CONCLUSIONS

Poster 20 Poster 20

ARE POST- ANKLE FIXATION REPEAT RADIOGRAPHS IN FRACTURE ARE POST- ANKLE FIXATION REPEAT RADIOGRAPHS IN FRACTURE CLINICS NECESSARY? CLINICS NECESSARY?

Angus Fong Angus Fong Doncaster Royal Infirmary Doncaster Royal Infirmary Samuel Osieku, Doncaster Royal Infirmary Samuel Osieku, Doncaster Royal Infirmary Paul Haslam, Doncaster Royal Infirmary Paul Haslam, Angus Fong Doncaster Royal Infirmary Angus Fong

To audit the current practice of re-imaging post-operative ankle fixations in fracture To audit currentrelevance. practice of re-imaging post-operative ankle fixations in fracture clinic and the its clinical clinic and its clinical relevance.

A retrospective audit of all patients who had open reduction internal fixation for A retrospective audita of all patients had 1/8/14 open reduction fixation for fractured ankle within 6 months periodwho between to 31/1/15.internal Data was collected fractured ankle theatre within amanagement 6 months period between 1/8/14 to 31/1/15.

Datatowas collected from Bluespier system, synapse PACS and access clinic letters from Bluespier theatresystem. management PACS andtoaccess topractice clinic letters through the Medisec These system, are thensynapse cross-referenced identify and through the Medisec There system.

These are then cross-referenced to identify practice and clinical significance. is an exclusion criteria for children aged under 16. clinical significance. There is an exclusion criteria for children aged under 16.

A total of 51 patients were identified with 1 child excluded. Out of the 50 patients, there A of 51 patients were identified 1 child excluded.

Out of the 50 there is total no significance difference betweenwith male/female or left/right ankle.

41patients, had a repeat is no significance difference between male/femaleOf or the left/right ankle. 22 41 of had a repeat radiograph during their fracture clinic appointment.

41 patients, them had a radiograph during their fracture Of the of them had a check radiograph around the 2clinic weekappointment. post-op period and41 19patients, of them22 were performed check around theIn2 total week9post-op 19 ofindication them were aroundradiograph the 6-8 week mark. patientsperiod had aand clinical for performed repeating around the 6-8 week mark.

In totalunions 9 patients clinicalnon-operatively. indication for repeating radiographs.

There were 2 delayed whichhad werea treated None of radiographs.

There were surgical 2 delayed unions which treated None of the patients had further intervention as awere result of thenon-operatively. follow up radiographs. the surgical intervention as a result screws of the follow up 5radiographs.

We patients also notehad thatfurther 24 of the 50 patients had syndesmotic inserted. of these 24 We also required note that further 24 of the 50 patients hadinitiation syndesmotic screws inserted. these 24 patients radiographs after of weight bearing after5 6ofweeks.

In patients furtherwere radiographs afterfor initiation of weight bearingthese after patients 6 weeks.fell In addition, required DEXA scans performed 5 patients.

However, addition, scans were performed for 5 for patients.

However,forthese patients fell outside ofDEXA the NICE recommended age range DEXA referrals fragility fractures. outside of thethe NICE recommended range for fragility fractures.

Interestingly, 11 patients that fallsage within thefor ageDEXA rangereferrals did not have a DEXA scan.

Interestingly, the 11 patients that falls within the age range did not have a DEXA scan.

We feel that there is a trend of requesting repeat radiographs in fracture clinic without We feel that there is a trendWhen of requesting repeat radiographs in reason fracturefor clinic without concrete clinical indication. it was recorded, the common re-imaging concrete clinical indication. it was recorded, the common for re-imaging was mostly because of painWhen on examination.

However, none of reason the patients who had was mostly becauserequired of pain on examination.

However, none thethem patients had post-op re-imaging further surgery even though twoof of had who delayed post-op re-imaging further surgerynot even though two of post-ORIF them had ankles delayed union. We therefore required propose that we should routinely re-image in union. therefore propose shouldclinical not routinely re-image in fractureWe clinic unless there that werewestrong indications, for post-ORIF example, ankles complex fracture unless theresub-optimal were strong clinical indications, forimages, example, complex fixations, clinic tenuous fixation, fixation in intra-operative post-fixation fixations, tenuousdeterioration fixation, sub-optimal fixationThis in intra-operative images, post-fixation trauma, sudden of symptoms. should be applied to syndesmotic trauma, sudden as deterioration symptoms. should will be applied syndesmotic screws fixation well. Theofreduction of This re-imaging ensure to radioprotection screws fixation as improve well. The reduction of re-imaging willcost ensure radioprotection standards are met, efficiency and potentially reduce in fracture clinic. We standards met, improve efficiency potentially reduce in guidance. fracture clinic. We should alsoare endeavour to refer patientsand for DEXA scans as percost NICE should also endeavour to refer patients for DEXA scans as per NICE guidance.

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th Poster Presentations â&#x20AC;&#x201C; Thursday 5th November

Poster 21

Notes

THE MANAGEMENT OF HIP FRACTURE IN ADULTS: IMAGING OPTIONS IN OCCULT HIP FRACTURE IMPLEMENTING NICE GUIDANCE MAIN AUTHOR AUTHOR MAIN

Akmal Turaev Wrightington, Wigan and Leigh NHS Foundation Trust

CO AUTHORS AUTHORS CO

Ahmed Fadulelmola, S. Ramachandran, Nikhil Shah, R Smith, J Davenport Akmal Turaev

PRESENTER PRESENTER

OBJECTIVES OBJECTIVES

To analyse the time taken for inpatient MRI to be fracture, identify the reasons for delay and produce times in future.

To encourage requesting of MRI for patients in suspected.

performed for occult femoral neck an action plan for reducing waiting which hip fractures are strongly

METHODS METHODS

Retrospective audit with closing the loop conducted in Wrightington, Wigan and Leigh NHS Foundation Trust (2014-2015).

RESULTS RESULTS

The sample for initial audit included 130 patients. 78(60%) female and 52(40%) male.

Age range: 48 to 96. Average age: 72.27 (66.80 male and 75.92 female). Average wait between X-ray and MRI scan was 3.01 days. Average wait between X-ray and CT scan was 2.74 days.

Delayed MRIs was 35 (48hrs-17 days). Delayed CT: 20 (48hrs-14 days). There were 83 MRI requested from 83 patients, six of them cancelled due to following reasons: One scan was cancelled as the patient did not tolerate it. Another scan was refused as the patient was unable to answer safety questions. Two were refused due to patients cardiac co-morbidities (pace-maker) and two were cancelled due to agitation. There were 51 CT scans requests with 15scans confirming the diagnosis and 35 being negative. One CT was cancelled as patient was uncooperative.

In cycle two, MRI performed for 42(58.33%) patients within 24 hours and 17(40.47%) were positive for fracture and 25(59.52%) were negative. CT performed for 30(60%) patients within 24 hours. From these 30 (60%) patients 10(33.33%) had positive finding in CT and 20(66.66%) negative. 35(49.29%) had MRI hip scan >48 hours. From this 35(49.29%) patients 8(22.85%) were positive and 27(77.14%) were negative. CT performed for 20(40%) patients >48 hours and 5(25%) was positive for fracture. Only 15(75%) patients CT were negative. There were 6 MRI cancellations and 1 CT cancellations as the patients were uncooperative. Standard achieved for MRI scan: 58%. Standard achieved for CT scan: 60%.

CONCLUSIONS CONCLUSIONS

Our conclusion is that MRI is more sensitive than CT in diagnosing occult hip fractures.

MRI is a useful and sensitive tool to investigate occult femoral neck fracture. Inpatient MRI waiting times can significantly be reduced by a targeted approach which embodies improved team working and awareness which can significantly impact on costs but more importantly on overall patient outcome. Early diagnosis of occult hip fractures should shorten hospitalisation by expediting definitive treatment, leading to reduced costs and improvements in both morbidity and mortality.

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Notes

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We are a leading, professionally recognised event management company. With over 30 years experience of organising and managing events, from conception right through to completion, on all scales from an executive board meeting to large annual conferences.

Let us help you create a memorable event that reflects and exceeds your targets and expectations. We can research, plan, deliver and evaluate every element from travel to destination, hotel and entertainment to technical production and booking management.

For a no obligation chat and to help you develop your ideas further, contact our friendly team on 01608 659900 or email Managing Director Julie Archer at Julie@archer-yates.co.uk

“Today’s Solution to Tomorrow’s Event” MarquardtUK UK Ltd. Ltd. Marquardt MarquardtUK UKLtd. Ltd. Marquardt Marquardt Marquardt UK UK Ltd. Ltd. DevonshireHouse House Devonshire Devonshire House Devonshire House Devonshire House 582Honeypot Honeypot Lane Devonshire House 582 Lane 582 Honeypot Lane 582 Honeypot Lane Stanmore, Middx, HA7 1JS 1JS 582 Honeypot Lane 582 Honeypot LaneHA7 Stanmore, Middx, HA7 Stanmore, Middx, HA7 1JS 1JS Stanmore, Middx, Stanmore, Stanmore, Middx, Middx, HA7 HA7 1JS 1JS

Phone: 0208 732 5579 Phone: 0208 732 5579 Phone: 0208 732 5579 Phone: 0208 732 5579 Phone: 0208 732 5579 Fax: 732 5584 Phone: 0208 0208 732 5579 Fax: 0208 732 5584 Fax: 0208 732 5584 Fax: 0208 Fax: 0208732 7325584 5584

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Archer Yates Associates Ltd

» Tel: +44 (0)1608 659900 » www.archer-yates.co.uk

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Event Managed by Archer Yates Associates Ltd 7 Threshers Yard, West Street, Kingham, Oxfordshire. OX7 6YF enquiries@archer‐yates.co.uk