1
|
Akhtar H, Lorimer J, Gray R, Potluri S, Bhati R, Williamson J, Doorgakant A. How reconfiguration of a minor injuries unit has affected service delivery during the COVID-19 pandemic: a retrospective analysis. Ann R Coll Surg Engl 2023; 105:178-182. [PMID: 35442111 PMCID: PMC9889175 DOI: 10.1308/rcsann.2021.0359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Redeployment of orthopaedic consultants to a minor injuries unit (MIU) during the COVID-19 pandemic provided a unique opportunity to assess the impact of early senior specialist input on patient management. METHODS Patient demographics, diagnosis, location of injury and disposal method were compared between three 7-day periods: during the April 2020 COVID-19 lockdown (period A), one month prior to period A (period B) and one year prior to period A (period C). Orthopaedic consultants staffed the MIU during period A, and emergency nurse practitioners staffed the MIU during periods B and C. RESULTS Period A witnessed higher injury severity either due to modified activities or altered healthcare-seeking behaviour during lockdown. For fractures, compared with periods B and C, period A saw a lower rate of referral to fracture clinic (41% vs 100% vs 86%, p<0.001) and higher rate of discharge (38% vs 0% vs 9%, p<0.001). The median time to fracture clinic was also longer (15 days vs 6 days vs 10 days, p<0.001), indicating earlier institution of definitive care. There were no other significant differences between periods with radiology alerts and complaints received remaining largely unchanged. CONCLUSION Early senior orthopaedic input in the patient journey from MIU had clear benefits, this being most true for fracture diagnoses. Earlier definitive management planning was observed as lower rates of fracture clinic referral, higher rates of discharge and deferred first fracture clinic reviews. This study highlights the benefits of greater partnership between MIU and orthopaedics. As the pandemic subsides and redeployed staff return to normal duties, a modification of this model could be utilised to ensure this partnership is sustainable.
Collapse
Affiliation(s)
- H Akhtar
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK
| | - J Lorimer
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK
| | - R Gray
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK
| | - S Potluri
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK
| | - R Bhati
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK
| | - J Williamson
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK
| | - A Doorgakant
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, UK
| |
Collapse
|
2
|
Fontalis A, Doorgakant A, Zahra W, Blundell C. Midfoot Charcot Neuro-arthropathy Precipitated by First or Fifth ray Amputation. Foot Ankle Surg 2021; 27:673-676. [PMID: 33132011 DOI: 10.1016/j.fas.2020.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/04/2020] [Accepted: 08/31/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Charcot Neuro-arthropathy (CN) can occur spontaneously in a neuropathic foot but is often precipitated by an insult to the foot, such as trauma. We noted an association between 1st and 5th ray amputations and the development of midfoot CN in our clinics. We therefore set out to analyse our data over a 6-year period to evaluate and improve our practice. METHODS Our project encompassed all diabetic adults with peripheral neuropathy undergoing an amputation of the first or fifth ray between January 2013 and January 2019. Patient demographics, stump length, progression to CN, imaging reports, the need for further operative management, length of stay and operating specialty were collected. Cases that developed CN after 1st or 5th ray amputation ("CN group") were compared with a cohort composed of patients that did not ("non-CN group"). RESULTS We identified 92 patients (98 surgical episodes) who had previous 1st or 5th ray amputations [77 males (83.7%), 15 females (16.3%), mean age 61.5 ± 13.5]. Midfoot CN developed in 16 cases (17.4%; nine following 1st ray and seven following 5th ray amputation). This represented 30.9% of all our new CN cases. CN was diagnosed within six months in six cases and up to three years in the remaining 12. Five of the 1st ray amputations were conducted with a stump length of ≤10 mm from the tarsometatarsal joint and a further one had resorbed down to it before the Charcot process. Three of the 5th ray amputations were carried out leaving a stump length ≤25 mm. Receiver Operator Curve (ROC) analysis showed no obvious diagnostic value of stump length in predicting CN (area under the curve 0.42 (95% CI 0.26 - 0.59)). Following a logistic regression analysis into effect of age, gender and peripheral vascular disease, only age was found to significantly affect the risk of developing CN (Nagelkerke R2 = 0.122, p = 0.013). CONCLUSION This is the first report of midfoot CN developing after 1st or 5th ray amputations. The foot could be destabilised following these procedures, leading to increased pressures across the midfoot. Our small sample was unable to demonstrate a significant correlation between stump length and CN risk. However, more work is needed to ascertain this. Meanwhile, we believe this translates clinically into a need for enhanced foot protection following 1st and 5th ray amputations in our practice.
Collapse
Affiliation(s)
- Andreas Fontalis
- Trauma and Orthopaedics Department, Sheffield Teaching Hospitals NHS Trust, Herries Rd, Sheffield S5 7AU, UK; Academic Unit of Bone Metabolism, The University of Sheffield, Sheffield S10 2RX, UK.
| | - Ashtin Doorgakant
- Trauma and Orthopaedics Department, Warrington and Halton Hospitals NHS Foundation Trust, Lovely Ln, Warrington WA5 1QG, UK
| | - Wajiha Zahra
- Royal Berkshire Hospital, London Rd, Reading, RG1 5AN, UK
| | - Chris Blundell
- Trauma and Orthopaedics Department, Sheffield Teaching Hospitals NHS Trust, Herries Rd, Sheffield S5 7AU, UK
| |
Collapse
|
3
|
van den Heuvel SBM, Doorgakant A, Birnie MFN, Blundell CM, Schepers T. Open Ankle Arthrodesis: a Systematic Review of Approaches and Fixation Methods. Foot Ankle Surg 2021; 27:339-347. [PMID: 33419696 DOI: 10.1016/j.fas.2020.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/07/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA. METHODS A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation. RESULTS We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95-0.99) for the anterior, 96% (95% CI 0.92-0.98) for the lateral and 96% (95% CI 0.68-1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93-0.98) and plate-fixation 99% (95% CI 0.96-0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance. CONCLUSION This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA. LEVEL OF EVIDENCE Level IIa.
Collapse
Affiliation(s)
- Stein B M van den Heuvel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Ashtin Doorgakant
- Trauma and Orthopaedic Department, Warrington and Halton Teaching Hospitals NHS Foundation Trust, Warrington, United Kingdom
| | - Merel F N Birnie
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Chris M Blundell
- Sheffield Foot and Ankle Unit, Orthopaedic Department, Northern General Hospital, Sheffield, United Kingdom
| | - Tim Schepers
- Department of Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands.
| |
Collapse
|
4
|
Carter J, Doorgakant A, Rigby M, Robb C. A space suit modification for the COVID-19 era. Ann R Coll Surg Engl 2020; 102:756-757. [DOI: 10.1308/rcsann.2020.0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- J Carter
- Warrington Hospital, Warrington, UK
| | | | - M Rigby
- Warrington Hospital, Warrington, UK
| | - C Robb
- Warrington Hospital, Warrington, UK
| |
Collapse
|
5
|
Abstract
We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.
Collapse
Affiliation(s)
- Ashtin Doorgakant
- Foot and Ankle Unit, Northern General Hospital, Foot and Ankle Offices, Selby Wing, Herries Road, Sheffield S5 7AU, UK.
| | - Mark B Davies
- Northern General Hospital, Foot and Ankle Unit, Herries Road, Sheffield, S5 7AU, UK
| |
Collapse
|
6
|
Shelton J, Dorman S, Doorgakant A, Wood E. How well do we reduce ankle fractures intra-operatively: A retrospective 1 year review using Pettrone's criteria. Foot (Edinb) 2019; 40:46-53. [PMID: 31085446 DOI: 10.1016/j.foot.2019.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/27/2019] [Accepted: 03/11/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ankle ORIF is a common orthopaedic procedure. Assessment of the reduction is often performed by 'eyeballing' the intra-operative images. AIMS This study aimed to assess the radiographic reduction of all ankle fracture ORIFs at COCH over a 1-year period using Pettrone's criteria METHOD: Using the trauma database at the COCH all patients admitted for ankle ORIF over a 1 year period (n = 284) were identified. Each patient was retrospectively reviewed, duplicates or non-ankle fractures excluded and data collected on: patient demographics, Lauge-Hansen classification, time from injury to theatre, level of primary surgeon, type of fixation, reduction of medial, lateral or posterior malleolar reduction, syndesmosis reduction, date and satisfaction at last clinic appointment and complications. RESULTS After exclusions 187 patients were included in the study. The average age of patients was 49 years old (14-93). The most common Lauge-Hansen fracture classifications were SER (51.6% (98)) and PER (29.9% (57)). Registrars were first surgeon in 49.7% (93) of cases. 80% (111 of 139) of medial malleoli were reduced, 90% of lateral malleoli were reduced 11% (21) had residual talar shift. The syndesmosis was reduced in 76.4% (143) of cases. 19% (36) had further operations. There were 35 major complications in 25 (13.4%) patients. Not all malposition of fracture fixation were in the same ankles, 34.2% (64) ankle ORIFs had residual deformity after being fixed. CONCLUSION The implications of this study are very important. The authors aim to raise awareness of Pettrone's radiographic criteria of a successful ORIF of the ankle and subsequently improve the mal-reduction rate of post-fixation ankle ORIF.
Collapse
Affiliation(s)
- James Shelton
- Health Education North West (Mersey Sector), Summers Road, Liverpool, L3 4BL, UK.
| | - Sara Dorman
- Health Education North West (Mersey Sector), Summers Road, Liverpool, L3 4BL, UK
| | - Ashtin Doorgakant
- Health Education North West (Mersey Sector), Summers Road, Liverpool, L3 4BL, UK
| | - Edward Wood
- Department of Trauma & Orthopaedics, Countess of Chester Hospital, Chester, CH2 1UL, UK
| |
Collapse
|
7
|
Iqbal HJ, Doorgakant A, Rehmatullah NNT, Ramavath AL, Pidikiti P, Lipscombe S. Pain and outcomes of carpal tunnel release under local anaesthetic with or without a tourniquet: a randomized controlled trial. J Hand Surg Eur Vol 2018; 43:808-812. [PMID: 29871567 DOI: 10.1177/1753193418778999] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We conducted a prospective randomized controlled trial to investigate carpal tunnel decompression under local anaesthesia. Carpal tunnel decompression was performed in 37 wrists using local anaesthesia and an arm tourniquet and 36 without tourniquet but with a local anaesthetic mixture containing adrenaline. Patients who underwent carpal tunnel decompression using a tourniquet experienced a significantly greater degree of pain when compared with those who did not have a tourniquet. Pain and hand function improved to a similar degree in both groups. We conclude that carpal tunnel decompression performed with a tourniquet causes patients unnecessary pain with no additional benefit as compared with the wide-awake carpal tunnel decompression without use of a tourniquet. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Hafiz J Iqbal
- Department of Trauma and Orthopaedics, St Helens and Knowsley Hospitals NHS Trust, Prescot, UK
| | - Ashtin Doorgakant
- Department of Trauma and Orthopaedics, St Helens and Knowsley Hospitals NHS Trust, Prescot, UK
| | - Nader N T Rehmatullah
- Department of Trauma and Orthopaedics, St Helens and Knowsley Hospitals NHS Trust, Prescot, UK
| | - Ashok L Ramavath
- Department of Trauma and Orthopaedics, St Helens and Knowsley Hospitals NHS Trust, Prescot, UK
| | - Prasad Pidikiti
- Department of Trauma and Orthopaedics, St Helens and Knowsley Hospitals NHS Trust, Prescot, UK
| | - Stephen Lipscombe
- Department of Trauma and Orthopaedics, St Helens and Knowsley Hospitals NHS Trust, Prescot, UK
| |
Collapse
|
8
|
Abstract
The Ntcheu derotation splint is recommended as a tool to improve the care of patients in lower limb traction. It avoids the various problems associated with the traditional plaster boot that is routinely used (stiffness, pressure sores, cost and time). It is easy to make, is relatively low cost and uses widely available materials.
Collapse
|
9
|
Abstract
UNLABELLED We prospectively studied the inpatient management of closed femoral shaft fractures in adults over 10 months at Ntcheu District Hospital, Malawi. RESULTS We had 20 patients, who stayed for an average of 46 days in hospital. The average time to apply traction was 2.3 days. The average time from admission to X-ray was 1.1 days. We recorded 11 complications: seven pinsite infections; two leg length discrepancies of >2 cm; one delayed union; and one malunion. Owing to logistics, we were unable to survey late complications. Check X-rays (available in 17/20 patients) at discharge showed satisfactory callus in 16 patients and minimal callus in one. Ten showed improved radiological position but none had external clinical deformities. We therefore feel that, despite using far from modern techniques such as acute intramedullary nailing, overall the treatment in Ntcheu produced good results. We discuss some methods that might enhance the quality of this conservative care.
Collapse
|
10
|
Bhutta MA, Doorgakant A, Marynissen H. Tibial nerve impingement secondary to posterior cement extrusion after unicompartmental knee arthroplasty. J Arthroplasty 2010; 25:1168.e17-8. [PMID: 19819664 DOI: 10.1016/j.arth.2009.07.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 04/20/2009] [Accepted: 07/29/2009] [Indexed: 02/01/2023] Open
Abstract
Unicompartmental knee replacements have become increasingly popular with improved survivorship and clinical results. This has been combined with minimally invasive surgery to further improve patient recovery and rehabilitation. Despite improved instrumentation, it remains a technically demanding procedure. We present a previously unreported case of tibial nerve impingement as a consequence of posterior cement extrusion after a unicompartmental knee replacement.
Collapse
Affiliation(s)
- Mohammed A Bhutta
- Trauma and Orthopaedics, East Lancashire Hospitals NHS Trust, Cheadle, Cheshire, United Kingdom
| | | | | |
Collapse
|
11
|
Eardley WGP, Page PRJ, Doorgakant A, Parker PJ. Self assessment in trauma & orthopaedics II. J ROY ARMY MED CORPS 2009; 154:247-53. [PMID: 19496371 DOI: 10.1136/jramc-154-04-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
12
|
Abstract
INTRODUCTION Ankle fractures are common and 'stable' ankle fractures comprise 40-75% of this group. Studies show that these injuries can be managed successfully in a functional brace, with no need for further radiographs and minimal out-patient follow-up. We aimed to audit current practice and introduce change in order to improve treatment and produce financial savings. PATIENTS AND METHODS A retrospective 6-month audit was carried out to establish practice. Guidelines were then drawn up and widely distributed in the accident and emergency (A&E) and orthopaedic departments. These included criteria for diagnosis of stable ankle fractures, a management protocol for treatment of these injuries in a brace and also a follow-up algorithm in the out-patient clinic. A prospective 6-month audit was then carried out to assess the effectiveness of the guidelines. RESULTS Of patients presenting in the second 6-month period, 91% were managed in a functional brace. The mean number of out-patient follow-up appointments, weeks until discharge and repeat radiographs all decreased significantly (P < 0.05) after the implementation of the guidelines. The cost of treating a patient with a stable ankle fracture dropped from 310.75 pounds to 129.80 pounds. CONCLUSIONS Previous studies have shown that stable ankle fractures are more effectively treated in a functional brace than a plaster cast, do not displace and, therefore, do not need repeat radiographs. A previous audit demonstrated that 60% of patients with stable fractures could be treated in a brace. We have shown that, with effective and persistent education of colleagues, the vast majority (91%) of patients can be managed in this way and this results in a significant cost saving. We have also shown that an evidence-based treatment protocol can produce significant improvements in management for patients and savings for healthcare organisations.
Collapse
Affiliation(s)
- Nitin Jain
- Department of Emergency Medicine, North Tees and Hartlepool NHS Trust, Stockton on Tees, Cleveland, UK.
| | | | | | | |
Collapse
|
13
|
Abstract
Locking after total knee replacement is uncommon and is generally caused by the formation of fibrous tissue around the patella. We report an unusual cause of locking resulting from intermittent occlusion of the popliteal artery, which was tethered to cement at the posterior aspect of the tibial component.
Collapse
Affiliation(s)
- J Auyeung
- Northern Deanery, Postgraduate Institute for Medicine and Dentistry, 10/12 Framlington Place, Newcastle upon Tyne NE2 4AB, UK.
| | | | | | | |
Collapse
|