Disclosure and reporting of surgical complications: a double-edged sword?

Challenges in providing surgical procedures during the COVID-19 pandemic: Qualitative study among Operating Department Practitioners in Pakistan

The surgical theatre is associated with the highest mortality rates since the onslaught of the COVID-19 pandemic. However, Operating Department Practitioners (ODPs) are neglected human resources for health in regards to both professional development and research for patient safety; even though they are key practitioners with respect to infection control during surgeries. Therefore, this study aims to describe challenges faced by ODPs during the pandemic. The secondary aim is to use empirical evidence to inform the public health sector management about both ODP professional development and improvement in surgical procedures, with a specific focus on pandemics. A qualitative study has been conducted. Data collection was based on an interview guide with open-ended questions. Interviews with 39 ODPs in public sector teaching hospitals of Pakistan who have been working during the COVID-19 pandemic were part of the analysis. Content analysis was used to generate themes. Ten themes related to challenges faced by ODPs in delivering services during the pandemic for securing patient safety were identified: (i) Disparity in training for prevention of COVID-19; (ii) Shortcomings in COVID-19 testing; (iii) Supply shortages of personal protective equipment; (iv) Challenges in maintaining physical distance and prevention protocols; (v) Human resource shortages and role burden; (vi) Problems with hospital administration; (vii) Exclusion and hierarchy; (viii) Teamwork limitations and other communication issues; (ix) Error Management; and (x) Anxiety and fear. The public health sector, in Pakistan and other developing regions, needs to invest in the professional development of ODPs and improve resources and structures for surgical procedures, during pandemics and otherwise.

Early Definitive Fracture Fixation is Safely Performed in the Presence of an Open Abdomen in Multiply Injured Patients

OBJECTIVE

To investigate the safety and feasibility of performing definitive fracture fixation in multiply injured patients in the presence of an open abdomen after laparotomy.

DESIGN

Retrospective observational cohort study.

SETTING

Level-I academic trauma center.

PATIENTS

Adult polytrauma patients with the presence of an open abdomen after "damage control" laparotomy and associated major fractures of long bones, acetabulum, pelvis, or spine, requiring surgical repair (n = 81).

INTERVENTION

Timing of definitive fracture fixation in relation to the timing of abdominal wall closure.

MAIN OUTCOME MEASURE

Incidence of orthopedic surgical site infections.

RESULTS

During a 15-year time window from January 1, 2000 until December 31, 2014, we identified a cohort of 294 consecutive polytrauma patients with an open abdomen after laparotomy. Surgical fixation of associated fractures was performed after the index laparotomy in 81 patients. In group 1 (n = 32), fracture fixation occurred significantly sooner despite a concurrent open abdomen, compared with group 2 (n = 49) with abdominal wall closure before fixation (mean 4.4 vs. 11.8 days; P = 0.01). The incidence of orthopaedic surgical site infections requiring a surgical revision was significantly lower in group 1 (3.1%) compared to group 2 (30.6%; P = 0.002).

CONCLUSIONS

Definitive fracture fixation in the presence of an open abdomen is performed safely and associated with a significant decrease in clinically relevant surgical site infections, compared with delaying fracture fixation until abdominal wall closure. These data suggest that the strategy of imposing a time delay in orthopaedic procedures while awaiting abdominal wall closure is unjustified.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Temporary transarticular K-wire fixation of critical ankle injuries at risk: a neglected "damage control" strategy?

High-energy ankle fracture-dislocations are at significant risk for postoperative complications. Closed reduction and temporary percutaneous transarticular K-wire fixation was first described more than 50 years ago. This simple and effective "damage control" strategy is widely practiced in Europe, yet appears largely forgotten and abandoned in the United States. Anecdotal opposing arguments include the notion that drilling K-wires through articular cartilage may damage the joint and contribute to postinjury arthritis. This article describes the experience in a US academic level I trauma center with transarticular pinning of selected critical ankle fracture-dislocations followed by delayed definitive fracture fixation once the soft tissues are healed. Median patient follow-up of 2 years showed that the transarticular pinning technique was performed safely, not associated with increased postoperative complication rates, and characterized by good subjective outcomes using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcome Score questionnaire.

Developing a weekly patient safety and quality meeting in a medium-sized GI surgical unit in the United Kingdom

Background

Morbidity and Mortality (M&M) meetings are advocated as part of good surgical practice, but have been criticised as a method of improving patient outcomes. Several groups have re-designed the format of M&M meetings to improve reporting of complications, near misses and maximise learning points. As a medium sized department of 8 GI surgeons in the UK, we wished to explore and discuss the complications encountered in our clinical practice in more detail than currently available in our monthly M&M/audit meeting, in order to try and improve the quality of care we deliver to our patients. This article describes the practicalities of introducing a weekly meeting and reports on the initial data generated from the patients discussed.

Methods

Four groups of general surgical patients (both elective and acute) are discussed in depth at the weekly meeting- a) patients whose length of in-patient stay is greater than 7 days (as a surrogate marker of a complicated surgical episode), b) unplanned patient readmissions to our hospital (under any specialty) within 30 days of a previous discharge from the GI surgical service, c) all GI surgical inpatient deaths and d) returns to theatre within the same admission (either planned or unplanned).

Results

The initial data generated from the meeting first six months of the meeting are presented e.g.– 302 length of stay greater than 7 days patient episodes (attributable to complications in 26%, normal variant of disease in 59% and social reasons delaying discharge in 15%).

Conclusions

We feel that these weekly meetings can be helpful in addressing both patient safety and quality issues in more depth than the traditional M&M format, as well as being a valuable training resource for both surgical trainees and consultants alike.

Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients

BACKGROUND

Inflation bone tamps are becoming increasingly popular as a reduction tool for depressed tibial plateau fractures. A number of recent publications have addressed the technical aspects of balloon inflation osteoplasty. However, no study has yet been published to describe the technical limitations, intraoperative complications, and surgical bailout strategies for this new technology.

METHODS

Observational retrospective study of all patients managed with inflatable bone tamps for depressed tibial plateau fractures between October 1, 2010 and December 1, 2012. The primary outcome parameter was the rate of complications, which were stratified into "minor" and "major" depending on the necessity for altering the surgical plan intraoperatively, and based on the risk for patient harm. This study was approved by the Institutional Review Board of the State of Colorado.

RESULTS

A consecutive series of 20 patients were managed by balloon inflation osteoplasty for depressed tibial plateau fractures during the 15 months study period. The mean age was 42.8 years (range 20-79), with 9 females and 11 males. A total of 13 patients sustained an adverse intraoperative event (65%), with three patients sustaining multiple technical complications. Minor events (n = 8) included the burst of a balloon with extrusion of contrast dye, and the unintentional posterior wall displacement during balloon inflation. Major events (n = 5) included the intra-articular injection of calcium phosphate in the knee joint, and the inability to elevate the depressed articular fragment with the inflatable bone tamp.

CONCLUSION

The observed intraoperative complication rate of 65% reflects a steep learning curve for the use of inflation bone tamps to reduce depressed tibial plateau fractures. Specific surgical bailout options are provided in this article, based on our early anecdotal experience in a pilot series of 20 consecutive cases. Patients should be advised on the benefits and risks of this new technology as part of the shared decision-making process during the informed consent.

Skin grafts provide durable end-bearing coverage for lower-extremity amputations with critical soft tissue loss

Lower-extremity amputations in the presence of soft tissue loss represent an unresolved conundrum because surgeons must consider sacrificing bone length to obtain adequate soft tissue coverage. Local flaps and microvascular soft tissue transfers are established strategies for maintaining residual limb length. However, the use of skin grafts remains controversial due to the presumed inferiority compared with flaps with regard to enabling prosthetic fitting and full weight bearing. The current study was designed to test the hypothesis that split-thickness skin grafts represent a safe and feasible option to preserve bone length in lower-extremity amputations with critical soft tissue loss.

Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective

Background

With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.

Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.

Discussion

The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.

In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.

Summary

It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.