Postoperative mobilization after terrible triad injury: systematic review and single-arm meta-analysis.

BACKGROUND: Terrible triad injury is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar collateral ligament, and fracture of the coronoid. These injuries are commonly managed surgically with fixation or replacement of the radial head and repair of the collateral ligaments with or without fixation of the coronoid. Postoperative mobilization is a significant factor that may affect patient outcomes; however, the optimal postoperative mobilization protocol is unclear. This study aimed to systematically review the available literature regarding postoperative rehabilitation of terrible triad injuries to aid clinical decision making. METHODS: We systematically reviewed the PubMed, Embase, Cochrane, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were studies with populations aged ≥16 years with terrible triad injury in which operative treatment was performed, a clear postoperative mobilization protocol was defined, and the Mayo Elbow Performance Score (MEPS) was reported. Secondary outcomes were pain, instability, and range of motion (ROM). Postoperative mobilization was classified as either "early," defined as active ROM commencement before or up to 14 days, or "late," defined as active ROM commencement after 14 days. RESULTS: A total of 119 articles were identified from the initial search, of which 11 (301 patients) were included in the final review. The most common protocols (6 studies) favored early mobilization, whereas 5 studies undertook late mobilization. Meta-regression analysis including mobilization as a covariate showed an estimated mean difference in the pooled mean MEPS between early and late mobilization of 6.1 (95% confidence interval, 0.2-12) with a higher pooled mean MEPS for early mobilization (MEPS, 91.2) than for late mobilization (MEPS, 85; P = .041). Rates of instability reported ranged from 4.5% to 19% (8%-11.5% for early mobilization and 4.5%-19% for late mobilization). CONCLUSION: Our findings suggest that early postoperative mobilization may confer a benefit in terms of functional outcomes following surgical management of terrible triad injuries without appearing to confer an increased instability risk. Further research in the form of randomized controlled trials between early and late mobilization is advised to provide a higher level of evidence.

Informed consent for surgery on neck of femur fractures: A multi-loop clinical audit.

BACKGROUND: The Montgomery case in 2015 resulted in a pivotal change in practice, leading to a patient-centric approach for informed consent. Neck of femur (NOF) fractures are associated with a high rates perioperative morbidity and mortality. Using guidelines highlighted by the British Orthopaedic Association we performed a multi-loop audit within our department to assess the adequacy of informed consent for NOF fractures. METHODS: Two prior cycles had been performed utilising a similar framework. Prior interventions included ward posters, verbal dissemination of information at Junior Doctor's (JD) induction and amendments to the JD handbook. For the latest audit loop, a retrospective analysis of 100 patients was performed. Risk were classified as common, less common, rare and 'other' non-classifiable risks. The adequacy of informed consent was evaluated by assessing the quality and accuracy of documentation in the signed Consent Form-1s for compos mentis patients. RESULTS: Infection, bleeding risks, clots and anaesthetic risks were documented in all patients (100%). Areas of improvement included documentation of neurovascular injuries (98%), pain (75%) and altered wound healing (69%). There was no significant change in the documentation of failure of surgery (83%) and neurovascular injuries (98%). Poorly documented risk factors included mortality (21%), prosthetic dislocation (14%) and limb length discrepancy (6%). CONCLUSION: Following the latest cycle, the trust has now approved the use of 2 consent-specific stickers (for arthroplasty or fixation), amendable on a patient-to-patient basis. As part of the multi-loop process, the cycle will be repeated every year, in line with Junior Doctor rotations. Medical professionals have an ethical, moral and legal obligation to ensure they provide all information regarding surgical interventions to aid patients in making an informed decision.