Factors affecting planned return to work after trauma: A prospective descriptive qualitative and quantitative study.

The use of patient reported outcome measures (PROMs) in trauma is limited. The aim of this pilot study is to evaluate qualitative responses and factors affecting planned return to work following significant trauma, for which there is currently a poor evidence base. National ethical approval was obtained for routine prospective PROMs data collection, including EQ-5D, between Sept 2013 and March 2015 for trauma patients admitted to the Sussex Major Trauma Centre (n=92). 84 trauma patients disclosed their intended return to work at discharge. Additional open questions asked 'things done well' and 'things to be improved'. EQ-5D responses were valued using the time trade-off method. Statistical analysis between multiple variables was completed by ANOVA, and with categorical categories by Chi squared analysis. Only 18/68 of patients working at admission anticipated returning to work within 14days post-discharge. The injury severity scores (ISS) of those predicting return to work within two weeks and those predicting return to work longer than two weeks were 14.17 and 13.59, respectively. Increased physicality of work showed a trend towards poorer return to work outcomes, although non-significant in Chi-squared test in groups predicting return in less than or greater than two weeks (4.621, p=0.2017ns). No significant difference was demonstrated in the comparative incomes of patients with different estimated return to work outcomes (ANOVA r2=0.001, P=0.9590ns). EQ-5D scores were higher in those predicting return to work within two weeks when compared to greater than two weeks. Qualitative thematic content analysis of open responses was possible for 66/92 of respondents. Prominent positive themes were: care, staff, professionalism, and communication. Prominent negative themes were: food, ward response time, and communication. This pilot study highlights the importance of qualitative PROMs analysis in leading patient-driven improvements in trauma care. We provide standard deviations for ISS scores and EQ-5D scores in our general trauma cohort, for use in sample size calculations for further studies analysing factors affecting return to work after trauma.

A comparative analysis of the patient characteristics and cost of managing intravenous drug users (IVDU) with soft tissue abscesses with non-IVDU.

BACKGROUND: Intravenous drug users (IVDU) often present to hospitals with complex co-morbidities, associated with prolonged in-patient admissions. The aim of this study was to compare a cohort of IVDU patients with soft tissue abscesses with non-IVDUs. We analysed the demographics, comorbidities, location of abscesses, multidisciplinary input and financial costs of managing both groups. METHODS: A retrospective cohort study was conducted between January 2010 and September 2013. Two age and sex matched cohorts were compared: IVDU and non-IVDU. RESULTS: We identified 44 IVDU patients and 54 non-IVDU patients. The IVDU had higher rates of smoking (89% p < 0.001) and unemployment (73% p < 0.05). The most common comorbidities in the IVDU cohort were hepatitis C (17%) and HIV (14%), whereas diabetes mellitus (15%) and hypertension (11%) were the most common in the non-IVDUs (p < 0.01). The most common location for an abscess in non-IVDU patients was the hand, whereas IVDU patients had abscesses in their groin. Groin injecting led to a referral to multiple specialties. The median length of stay for the IVDU patients was 4 days and for non-IVDU patients 1 day (p < 0.01). The average cost of managing IVDU patients in our unit was £1280: for non- IVDU the cost was £530 (p < 0.001). CONCLUSIONS: IVDU patients with soft tissue abscesses have higher rates of smoking, unemployment, infection with hepatitis C and HIV compared to a control group. We have suggested several recommendations to optimise the management of these patients including the implementation of an additional code to compensate for the complexity of their management.

Renal replacement therapy: implications for the surgeon.

Renal replacement therapy comprises peritoneal dialysis, haemodialysis and renal transplantation. Patients undergoing renal replacement therapy often require surgery for a number of different reasons. This review summarizes likely surgical procedures for these patients and some of the common complications.

Increasing compliance with the World Health Organisation's Surgical Safety Checklist.

The World Health Organisation Surgical Safety Checklist (WHO SSC) is a validated tool for reducing in-patient surgical morbidity and mortality. It is not performed universally with full compliance. Two audit cycles were completed at two different trauma and orthopaedic units and compliance was measured. Site 1 was found to have a significantly lower compliance with the team-brief (p<0.001). Following a change in practice the compliance significantly increased (p>0.00001) at Site 1. The team de-brief was found to be consistently poorly complied with. We recommend regular audit of compliance and change in practice for all surgical units, and suggest national monitoring to ensure the benefits of the WHO checklist are applied to all in-patient surgery.

The surgical management of patients who deliberately self-harm.

INTRODUCTION: Deliberate self-harm is a common problem that often requires orthopaedic treatment. Patients with injuries due to deliberate self-harm are often referred to our unit. This study assessed the type of treatment required and the cost of treatment. PATIENTS AND METHODS: We undertook a retrospective survey of deliberate self-harm patients with known ICD-10 psychiatric disorders admitted for orthopaedic care from a medium-secure, female-only, psychiatric unit. Data were collected on admission rate, duration of stay, surgical interventions and complications. RESULTS: Over a 36-month period there were 73 admissions for 15 patients (mean age, 25.1 years) requiring 65 operative interventions, a mean of 4.3 (range, 0-9) per patient. Over 50% of patients were admitted more than 3 times, totalling 416 hospital bed-days and 80% had methicillin-resistant Staphylococcus aureus (MRSA) isolated. The orthopaedic treatment costs for these patients was 453,000 pounds during the period studied. DISCUSSION: The significant resources required to manage this patient cohort demonstrates the need for a co-ordinated management policy. We recommend day-case surgery for infected wounds only. Postoperatively, wounds should be protected with plaster of Paris. All patients with deliberate self-harm should be regarded as being infected with MRSA.

Plaster cast burns: the reality.

An in vivo experimental study was performed of the temperatures produced by a setting plaster cast using hot and cold water. The results confirmed a statistical difference in the temperatures reached using hot and cold water. Forearm and below knee plasters did not represent a burn risk. Lower limb cylinder casts reached sufficient temperatures to cause burns with hot water but did not remain at these temperatures long enough to pose a clinical risk.

The misuse of 'no significant difference' in British orthopaedic literature.

INTRODUCTION: Many studies published in medical journals do not consider the statistical power required to detect a meaningful difference between study groups. As a result, these studies are often underpowered: the sample size may not be large enough to pick up a statistically significant difference (or other effect of interest) of a given size between the study groups. Therefore, the conclusion that there is no statistically significant difference between groups cannot be made unless a study has been shown to have sufficient power. The aim of this study was to establish the prevalence of negative studies with inadequate statistical power in British journals to which orthopaedic surgeons regularly submit. MATERIALS AND METHODS: We assessed all papers in the last consecutive six issues prior to the start of the study (April 2005) in The Journal of Bone and Joint Surgery (British), Injury, and Annals of the Royal College of Surgeons of England. We sought published evidence that a power analysis had been performed in association with the main hypothesis of the paper. RESULTS: There were a total of 170 papers in which a statistical comparison of two or more groups was undertaken. Of these 170 papers, 49 (28.8%) stated as their primary conclusion that there was no statistically significant difference between the groups studied. Of these 49 papers, only 3 (6.1%) had performed a power analysis demonstrating adequate sample size. CONCLUSIONS: These results demonstrate that the majority of negative studies in the British orthopaedic literature that we have looked at have not performed the statistical analysis necessary to reach their stated conclusions. In order to remedy this, we recommend that the journals sampled include the following guidance in their instructions to authors: the statement 'no statistically significant difference was found between study groups' should be accompanied by the results of a power analysis.

How accurate and reliable are doctors in estimating fracture angulation?

This study assessed the accuracy of doctors in estimating fracture angulation. Radiographs of fractured wrist and forearm of varying angulations were shown to all grades of doctors in the speciality of trauma and orthopaedics. They were asked to estimate the angulation at the fracture site without using a goniometer. The estimates were analysed for accuracy and variability. This study showed that doctors have a mean error of 8-9 degrees and had poor agreement with themselves and others. We recommend the use of a goniometer to assess fracture angulation.

The extended scope physiotherapist in orthopaedic out-patients - an audit.

INTRODUCTION: We undertook an audit of the activity of the extended scope physiotherapists (ESPs) in our unit. We assessed their activity against three benchmark data: (i) independent assessment and management by the ESP of 85% of patients seen by them; (ii) no patient to be re-referred to a surgeon with the same problem; and (iii) patient satisfaction rate of 89%. PATIENTS AND METHODS: All new referrals seen by the ESPs over the 6-month period between July 2002 and December 2002 were included in the audit. Patient medical records were reviewed retrospectively. Patients were contacted by telephone 12 months after their initial clinic appointment to obtain patient satisfaction scores. RESULTS: In the 6-month period, 150 patients (75 male, 75 female) were seen. Their median age was 43.5 years (range, 17-85 years). Their main complaints related to the spine (42%), knee (33%), shoulder (18%), or other site (7%). The ESPs saw and managed 82/150 patients (55%) independently. Consultant review was required for 81% of shoulder cases, 34% of knee cases and 11% of back cases. GPs re-referred 4/150 patients (3%). We successfully contacted 126 patients by telephone: 97 (77%) were satisfied with their management by ESPs. Of patients who were dissatisfied, 76% did not see a consultant at any stage in their management. CONCLUSIONS: ESPs fulfilled a useful role in our orthopaedic out-patient clinic particularly in the back clinic. The percentage of independently managed patients was much lower than the figure quoted in the literature. We suspect that the published literature does not reflect modern referral patterns and recommend that time for review of new patients seen by ESPs should be factored into consultant's clinic time. Patients' expectations may be a barrier to achieving greater levels of patient satisfaction.

From presentation to publication: the natural history of orthopaedic abstracts in the United Kingdom.

BACKGROUND: Up to 63% of the chapters in major orthopaedic textbooks use the results from abstracts that have been presented at international orthopaedic meetings. METHODS: Orthopaedic abstracts were reviewed that were presented at the 1997 and 1998 meetings of the British Orthopaedic Association and other specialist orthopaedic meetings. The number of abstracts that had gone on to a full text publication was assessed and changes in study design or outcome were determined. RESULTS: Of the 415 abstracts 137 (33.0%) went on to full text publication. Abstracts presented at the British Orthopaedic Association were significantly more likely to go on to full text publication than abstracts from the other meetings studied. The mean time to publication was 15.6 months. Sample sizes in unpublished studies were smaller (mean 129.8 subjects compared with a mean of 191.4 subjects for published studies). Of full text papers, 19.0% differed regarding study design from the abstract presented at the initial meeting and 10.9% had published different results. Randomised controlled trials had the highest rate of later full text publication (53.6%) followed by observational studies (32.8%), basic science studies (31.4%), and case reports (6.7%). CONCLUSIONS: In comparison with a study from North America, similar numbers of abstracts presented at meetings finally became published as full text articles, the abstracts had fewer authors, more often included randomised controlled trials and follow up data, and had fewer changes to the results. It is questionable whether the inclusion of such results from abstracts presented at international meetings by major orthopaedic textbooks should be undertaken before full text publication.

The distribution of cement penetration into bovine acetabular bone utilising various pressurisation techniques.

Most mechanical failures of acetabular fixation within ten years of primary cemented hip replacement are attributable to a failure to achieve good initial fixation of bone and cement. Several studies have suggested that to achieve good fixation between bone and cement between 3 mm and 5 mm of cement penetration into bone is desirable. Whilst several acetabular cement pressurisation systems exist, little is known about the effects of cement pressurisation on the pattern of penetration of cement into cancellous bone within the pelvis. The current paper assesses the penetration of bone cement into bovine acetabular bone by various pressurisation techniques. We found that pressurisation with the use of a swab in glove or the DePuy pressuriser led to improvement in cement penetration both in terms of maximum depth and also percentage cover of the cup by cement (p<0.05). There was no significant difference in mean maximal penetration between the use of the pressuriser and the swab in a glove technique (p=0.3). If only a plain cup was used as a pressuriser, the penetration achieved was significantly lower in comparison to use of a pressuriser (p<0.02). When compared to previously documented acrylic models, the pattern of intrusion noted in the bovine model was different: penetration was lower at the equatorial and base regions of the acetabulum.

Balancing priorities in the management of hip fractures: guidelines versus resources.

BACKGROUND: About 60,000 patients are treated for hip fractures each year in the UK and the incidence is increasing. The majority of these patients are elderly and sick, and delay to operation may be fatal. The National Confidential Enquiry into Peri-Operative Deaths (NCEPOD) guidelines aim to improve quality of care for such patients. However, we present an audit highlighting the importance of balancing the implementation of such guidelines with available local resources to ensure that established priorities in the care of these patients remain paramount. METHODS: The 2001 NCEPOD report recommends that pre-operative transthoracic echocardiography be performed in patients who have evidence of aortic stenosis in order to identify those requiring invasive monitoring and high dependency unit care postoperatively. RESULTS: We have assessed the impact of the implementation of these guidelines on surgery for fractured neck of femur at our hospital, auditing both delay to surgery and the effect of the investigation on subsequent management. In the period studied prior to the introduction of the NCEPOD guidelines, no patients underwent pre-operative echocardiography. Subsequent to their introduction, 10% of patients underwent the investigation, which in the current study did not alter management but did delay surgery by 4-8 days in all cases. CONCLUSIONS: For such guidelines to be implemented, adequate resources should first be provided. In the absence of these resources, clinicians must balance the need for adequate pre-operative assessment with the need for urgent surgery.

The femoral cement mantle in three total hip replacements.

We measured the size and volume of the femoral broaches and stems supplied with three commercial total hip replacement (THR) systems (JRI Furlong, Biomet Stanmore, and Howmedica Exeter). Using an in vitro method, we created cement mantles that could be directly measured. The broaches supplied with the Biomet Stanmore and the Howmedica Exeter systems allowed the creation of significantly thicker cement mantles than the JRI broaches and stems (Stanmore mean thickness = 1.7 mm, defects at 3% of measurement sites; Exeter mean thickness = 2.0 mm, no defects; JRI mantles mean thickness = 0.9 mm, cement defects at 29% of measurement sites). We conclude that, in vivo, the broaches supplied with the Stanmore and Exeter systems are significantly larger than the corresponding stems, and will excavate a cavity large enough to accommodate the appropriate femoral stem surrounded by an intact cement mantle.