Arthroscopic double bone block augmentation is a salvage procedure for anterior and posterior shoulder instability secondary to glenoid bone loss.

PURPOSE: The aim of this study was to describe a one-step arthroscopic anterior and posterior bone block augmentation technique for bidirectional shoulder instability and to present preliminary results. METHODS: Seven consecutive patients who underwent a concomitant anterior and posterior bone block procedure between 2007 and 2015 were retrospectively reviewed. Clinical scores, return to sport rate, and complications were assessed. Radiological outcome, with CT scan at 6 months and plain radiographs at final follow-up were reviewed. Patient reported functional outcomes were also assessed via phone or email interview. RESULTS: Seven consecutive patients were included in the study with a median age at surgery of 27 years. Median clinical and radiological follow-up was 7 months (4-72 months). Walch-Duplay score and Rowe scores were improved. Four patients were able to return to sport. One patient experienced recurrent dislocation, and one subjective instability/subluxation without confirmed recurrence. CT scan showed union in all cases, with one case of anterior bone block osteolysis and one case of partial posterior bone block osteolysis. Radiographs showed no detectable progression of osteoarthritis using the Samilson and Prieto classification. At final follow-up the median WOSI score was 187 (100-1140). CONCLUSIONS: An all-arthroscopic technique for the treatment of combined anterior and posterior glenoid bone loss as a cause of shoulder instability can provide fair to good clinical outcomes, with a low incidence of intra-operative complications. The rate of failure in our series remains higher than that seen in primary stabilization procedures. As such we consider this largely as a salvage procedure for cases in which alternative treatments have failed or are unlikely to succeed. LEVEL OF EVIDENCE: IV.

Improving value-add work and satisfaction in medical residents training: a resident-led quality improvement project employing the lean method to improve hospital supply usage.

PURPOSE: Our hospital has a Housestaff Quality Council that fosters education and mentorship of medical residents for quality improvement methodologies. Medical residents on our council identified non-standardised storage rooms as a source of medical resident inefficiency and dissatisfaction. To improve value-add work, medical residents implemented and evaluated a quality improvement project of storage room supplies using the lean method. METHODS: Using 5S principle and lean methodology, we designed and implemented a standardised supply cart with physician specific supplies. Between April 2014 and April 2015, 40 random observations (20 residents and 20 nurses) both before and after the standardised supply cart implementation were made. The duration time to locate an item was measured in seconds. The paths taken to locate items were drawn as spaghetti diagrams. Nurses served as our control group given that their supplies were not moved in the implementation. Fifty residents were surveyed to assess their satisfaction. RESULTS: Implementation of the standardised supply cart reduced the time for residents to locate an item per visit from 50.8 to 30.2 s in one unit (p<0.05) and 127 to 28.3 s in the second unit (p<0.05). Mean time savings per day per resident were 5 min. The spaghetti diagrams indicated that finding supplies became more efficient after the intervention for residents. After the intervention, 92% of residents reported finding supplies more rapidly and 86% reported less frustration with finding supplies. CONCLUSIONS: Residents applied the 5S principles and lean methodology to identify and solve a problem that created inefficiency and dissatisfaction.

First UK patient cohort treated with stereotactic ablative radiotherapy for primary kidney cancer.

Aims: Stereotactic ablative radiotherapy (SABR) for primary renal cell carcinoma (RCC) is a promising non-invasive ablative treatment option. A prospective interventional clinical trial published showed that treatment was feasible and well tolerated. We present the first single-institution UK cohort of patients with primary RCC receiving protocol-based SABR with prospective follow-up. We also present a protocol that could be used to facilitate more widespread use of the treatment. Materials and methods: Nineteen biopsy-proven primary RCC patients were treated with either 42 Gy in three fractions on alternate days or 26 Gy in a single fraction based on predefined eligibility criteria using either Linear Accelerator or CyberKnife platform. Prospective toxicity data using CTCAE V4.0 and outcome data such as estimated glomerular filtration rate (eGFR) and tumour response using CT thorax, abdomen and pelvis (CT-TAP) were collected at 6 weeks, 3, 6, 12, 18 and 24 months post treatment. Results: The 19 patients had a median age of 76 years (interquartile range [IQR] 64-82 years) and 47.4% were males, and they had a median tumour size of 4.5 cm (IQR 3.8-5.2 cm). Single and fractionated treatment was well tolerated and there were no significant acute side effects. The mean drop from baseline in eGFR at 6 months was 5.4 ml/min and that at 12 months was 8.7 ml/min. The overall local control rate at both 6 and 12 months was 94.4%. Overall survival at 6 and 12 months was 94.7% and 78.3%, respectively. After a median follow-up of 17 months, three patients experienced a Grade 3 toxicity, which was resolved with conservative management. Conclusion: SABR for primary RCC is a safe and feasible treatment for medically unfit patients, which can be delivered in most UK cancer centres using standard Linear Accelerator as well as CyberKnife platforms.

Acute lower limb ischemia associated with use of an immersion suit.

External compression is a rare cause of acute lower limb ischemia. Workers required to wear immersion suits during helicopter simulation training are exposed to external compressive forces which can alter the hemodynamics in arterial bypass conduits. Herein a case of arterial thromboembolization to the lower limb following the wearing of an immersion suit, in a patient who had undergone arterial bypass surgery 13 yr previously is presented. The potential for this episode of acute leg ischemia being a direct result of the compressive forces exerted by the immersion suit and the possible implications for wearers of immersion suits following arterial graft surgery is discussed.

Compression garments: no enhancement of high-intensity exercise in hot radiant conditions.

PURPOSE: To establish the thermal and performance effects of wearing a lower-body graduated compression garment (GCG) in a hot environment (35.2°C ± 0.1°C) with a representative radiant heat load (~800 W/m²) in contrast to a control (running shorts) and sham condition (a compression garment 1 size larger than that recommended by the manufacturer), with the latter included to establish any placebo effect. METHOD: Eight participants (mean ± SD; age 21 ± 2 y, height 1.77 ± 0.06 m, mass 72.8 ± 7.1 kg, surface area, 1.89 ± 0.10 m²) completed 3 treadmill tests at a fixed speed for 15 min followed by a self-paced 5-km time trial. Performance (completion time) and pacing (split time), thermal responses (aural, skin, and mean body temperature, cardiac frequency), and perceptual responses (rating of perceived exertion [RPE], thermal sensation, thermal comfort) were measured. RESULTS: Performance in the compression group was not different than in either sham or control at any stage (P > .05); completion time 26.08 ± 4.08, 26.05 ± 3.27, and 25.18 ± 3.15 min, respectively. At the end of the 5-km time trial, RPE was not different; it was 19 ± 1 across conditions. In general, thermal and perceptual responses were not different, although the radiant heat load increased site-specific skin temperature (quadriceps) in the garment conditions. CONCLUSION: GCG did not enhance performance in a hot environment with a representative radiant heat load. The sham treatment did not benefit perception. GCG provided no evidence of performance enhancement.

The use of a spirit-level to improve radiograph quality in ring fixators.

The use of ring fixators in lower limb reconstruction and deformity correction both for trauma and elective procedures is now widespread. The long course of treatment requires regular outpatient review with frequent radiological imaging to assess the progression of treatment and plan correctional adjustment. Following publication of a technique using a frame mounted spirit-level to aid radiographers in accurately aligning the limb for optimal imaging we implemented a similar technique in our department and carried out a two part prospective comparative study to assess the impact on radiograph quality. Comparison was made of radiograph quality, X-rays taken, patient trips to the radiology department and X-ray exposure before and after implementation of the spirit-level guide technique in patients attending an out-patient clinic for routine follow up following ring fixator application. 26 patients were included in the control arm and 33 in the intervention group. On review, 42.3% of patients in the control group were deemed to have had suboptimal imaging compared with only 9.1% of those imaged using the spirit-level guide, a statistically significant improvement. When comparing total numbers of images taken for each group to achieve the requested number of adequate views there was less statistical significance, nor was there a statistically significant difference in radiation dose between the groups. A significant reduction in the number of inadequate images being taken, with a subsequent reduction in patients requiring return to the radiology department for re-imaging and then re-review in clinic, has clear implications for patients, clinicians and hospital efficiency. The patient journey time is reduced, less time and fewer resources are used in the radiology department and patients in clinic are seen more efficiently and with less wasted time. We conclude that the implementation of a simple frame mounted spirit-level as a guide for radiographers in the outpatient clinic significantly reduces the number of suboptimal and wasted images taken in the assessment of patients being treated by ring fixator.