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Background The COVID-19 pandemic induced unprecedented changes in medical practices, prompting a reassessment of their impact on adult foot and ankle fractures within the National Health Service (NHS). This study employs a retrospective observational approach, leveraging the Pathpoint™ eTrauma platform for a comprehensive analysis of prospectively collected data. Methods Data encompassing weekly fracture incidence, weekly surgical procedures, patient demographics, and mean wait time from injury presentation to surgery were systematically evaluated. The study population included all adults (18+) admitted during five distinct periods: pre-pandemic, national lockdown 1, post-lockdown, national lockdown 2, and national lockdown 3. Results An analysis of 434 foot and ankle fractures revealed that national lockdown 1 exhibited the lowest fracture incidence (4.97 per week) and surgeries performed (4.77 per week), reflecting a notable reduction in trauma cases and elective procedures. Conversely, post-lockdown displayed the highest fracture incidence (7.46 per week) and surgeries performed (6.31 per week), suggesting a resurgence in both trauma and elective surgical activities. The pre-pandemic cohort, characterized by the highest mean age (51.98 years) and mean wait time (8.74 days), served as a temporal baseline. Conclusion While the incidence of fractures decreased during all three national lockdowns compared to pre-pandemic or post-lockdown periods, a gradual increase was observed in subsequent lockdowns. Notably, mean wait times showed a significant reduction, reaching the lowest point (5.79 days) during national lockdown 3. These findings underscore the complex interplay between pandemic-related disruptions, evolving guidelines, and adaptive measures within the healthcare system, influencing the dynamics of foot and ankle fracture management.
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Introduction Cauda equina syndrome (CES) is a very rare but devastating surgical emergency that can lead to permanent bowel, bladder or sexual dysfunction and lower limb paralysis. Although it is a clinical syndrome, an MRI scan is a critical diagnostic investigation for these patients and should be done as soon as possible. Our hospital is a district general hospital with no spinal services on site. There is a protocol in place for the management of these patients locally with MRI scanning during daytime hours. However, if the patient presents after 8 pm, they are discussed with the tertiary spinal centre, which then advises if the patient requires transfer overnight for urgent scanning. Considering an MRI scan is a critical diagnostic step for these patients, we introduced a role for an orthopaedic doctor in the Emergency Department (ED) to assess all of these patients before collecting data for the second cycle. The aim of this audit was to see the effect of having an orthopaedic doctor in the ED for the assessment of these patients and its impact on waiting times and admission rates. Methods A closed-loop audit cycle was done looking into all referrals to trauma and orthopaedics with acute back pain and suspected CES in a district general hospital with no spinal services on site. The first cycle was between September 30, 2020, and May 31, 2021, and included 93 patients in total. Following this, a role for an orthopaedic doctor in ED was introduced from December 1, 2021, to January 31, 2022, for assessment of these patients. Data was then collected retrospectively for all patients referred during this period (n=36). Data was extracted from all relevant clinical systems including electronic patient record (EPR), Patient Pass (Patient Pass Ltd, Greater Manchester, England), which is the system used to digitally communicate with regional spinal services, and PACS (picture archiving and communication systems). The data was collated on a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, Washinton, United States) and analysed. Results Data were collected for a total of 36 patients in the second cycle following the introduction of an orthopaedic doctor in the ED. The age of patients referred was 30-89 years with a mean age of 51; 44.4% were male (n=16) and 55.5% female (n=20). All the patients who were referred received their MRI scan and report within 24 hours of presentation to the ED. In the first cycle of the audit, the mean waiting time for an MRI scan had been 12.5 hours, which was reduced to eight hours following the introduction of an orthopaedic doctor in the ED during daytime hours. This was stratified further according to the time patients presented to the hospital. From 8 am to 4 pm, the mean waiting time for an MRI scan was 9.5 hours pre-intervention and 5.5 hours after. From 4 pm to 12 am, the mean waiting time was 18 hours before and 13 hours after, and from 12 am to 8 am, the waiting time for scans improved from 8.5 hours to 6.5 hours. The number of patients discharged on the same day greatly improved from 29% (n=27) in the initial study to 58% (n=21). This decreased unnecessary inpatient stays from 71% (n=66) to 42% (n=15). Conclusion This study showed that an orthopaedic doctor in the ED for the acute assessment of patients referred with possible CES is an effective way of improving their management. This decreases waiting times for MRI scans and therefore allows the patient to be managed more efficiently.
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Introduction The emergence of the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in late 2019 ushered in a global crisis that profoundly impacted healthcare systems worldwide. In the United Kingdom, COVID-19 resulted in a significant toll on public health and the National Health Service (NHS). As the virus surged, the NHS faced unprecedented challenges, including surges in COVID-19 cases, a dire need for medical equipment, and a strain on intensive care units. Simultaneously, stringent nationwide lockdowns were imposed to curb the virus's spread, disrupting daily life and healthcare access. Amid this crisis, the interactions between COVID-19 and other prevalent health conditions came to the forefront of medical research, sparking interest in understanding their connections. This study delves into the intriguing interplay between COVID-19 and neck of femur (NoF) fractures, exploring shared risk factors, resource implications, and potential alterations in patient pathways. Given the severity of both conditions and their impact on the vulnerable elderly population, elucidating these connections is crucial for comprehensive patient care and resource allocation within the healthcare system. Methods This study used data from the National Hip Fracture Audit (NHFA) database, focusing on NoF fracture patients at Wythenshawe Hospital. We examined two cohorts: pre-pandemic (from March 2019 to March 2020) and pandemic (from March 2020 to March 2021). We compared key parameters and incorporated COVID-19 data. Graphs showed trends and cohort similarities. We also analyzed demographic data (age, gender, fracture type, times, COVID-19 status, and mortality), removing outliers for accuracy. Results The data revealed that while certain factors such as patient age and mobilization remained largely unaffected, there was a modest association between COVID-19 incidence and NoF fracture patients. Notably, regional lockdown measures had a substantial impact on patient care. The initial lockdown effectively reduced COVID-19-positive cases upon admission but led to prolonged intervals and surgical delays. However, the second lockdown showed improvements, attributed to lessons learned, increased resource allocation, and better familiarity with hospital-specific lockdown measures. This research sheds light on the intricate relationship between a global pandemic and orthopedic patient care, highlighting the importance of adapting healthcare systems to evolving challenges. Conclusion This study explores the impact of COVID-19 on neck of femur (NoF) fracture patients, highlighting key findings from Wythenshawe Hospital. It uncovers a dynamic relationship between the pandemic and patient care, with increased COVID-19 cases coinciding with reduced NoF fracture rates. Lockdowns influenced outcomes, with the first causing delays and higher post-discharge mortality, while the second improved efficiency and safety. These insights extend beyond Wythenshawe Hospital, offering implications for healthcare practices in the United Kingdom and beyond, especially in countries with limited vaccination resources. This research underscores the need for tailored strategies to optimize NoF fracture patient outcomes during pandemics and lockdowns.
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Introduction There is clear guidance for the follow-up of acute orthopaedic trauma patients within 72 hours of presentation as per British Orthopaedic Association (BOA) guidelines. The virtual fracture clinic (VFC) model has been adopted nationwide to increase compliance with these guidelines. Traditionally our VFC was paper-based, but recently it has been made completely electronic with the introduction of Hive which is a comprehensive electronic patient record (EPR). The aim of this audit was to assess the effectiveness of the Hive VFC and to see the impact it has on improving the patient experience. Methods Data was collected retrospectively by looking at referrals to the Hive VFC across a seven-month period from its date of introduction. No patients were excluded and data was collected for 2,158 patients. Patient demographics, referral details, and outcomes were recorded on a Microsoft Excel version 16.0 for Windows spreadsheet (Microsoft Corporation, Washington, United States). Data was analysed using Microsoft Excel. Results Data was collected for 2,158 patients between September 9, 2022, and March 31, 2023, in the Hive VFC. The largest proportion of injuries was found in the foot and ankle region with 32% of referrals (n=688), followed by hand and wrist with 30% (n=651), upper limb with 28% (n=595), and lower limb with 7% (n=142). There was a 50.4% (n=125) increase in the number of patients seen in the VFC across the study period with 248 patients being seen in September 2022, increasing to 373 in March 2023. The number of patients with acute traumatic orthopaedic injuries that were assessed within 72 hours on average was 94.5% per month. There was an increase of 7.3% during the study period from September 2022 to March 2023, 89.9% to 96.5%, respectively. Conclusion We believe that Hive VFC is a clinically sound and effective way of assessing acute traumatic orthopaedic patients and increasing compliance with BOA and NICE guidelines. The number of patients needing acute orthopaedic assessment is rising steadily, and this should alert us to find more convenient, time and cost-saving methods of delivering safe and effective patient care.
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STUDY DESIGN: Systematic review. BACKGROUND: Although degenerative cervical myelopathy (DCM) is the most prevalent spinal cord condition worldwide, the pathophysiology remains poorly understood. Our objective was to evaluate existing histological findings of DCM on cadaveric human spinal cord tissue and explore their consistency with animal models. METHODS: MEDLINE and Embase were systematically searched (CRD42021281462) for primary research reporting on histological findings of DCM in human cadaveric spinal cord tissue. Data was extracted using a piloted proforma. Risk of bias was assessed using Joanna Briggs Institute critical appraisal tools. Findings were compared to a systematic review of animal models (Ahkter et al. 2020 Front Neurosci 14). RESULTS: The search yielded 4127 unique records. After abstract and full-text screening, 19 were included in the final analysis, reporting on 150 autopsies (71% male) with an average age at death of 67.3 years. All findings were based on haematoxylin and eosin (H&E) staining. The most commonly reported grey matter findings included neuronal loss and cavity formation. The most commonly reported white matter finding was demyelination. Axon loss, gliosis, necrosis and Schwann cell proliferation were also reported. Findings were consistent amongst cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. Cavitation was notably more prevalent in human autopsies compared to animal models. CONCLUSION: Few human spinal cord tissue studies have been performed. Neuronal loss, demyelination and cavitation were common findings. Investigating the biological basis of DCM is a critical research priority. Human spinal cord specimen may be an underutilised but complimentary approach.
