453 Introduction of A Novel Online Learning Platform Increases Junior Doctors Confidence Prior To Starting Trauma & Orthopaedic On-Calls

Aim

Trauma and Orthopaedic (T&O) junior doctors are expected to manage on-calls involving a high volume of patients presenting with a wide variety of complex conditions. Despite this, many junior doctors feel poorly prepared at the start of their placements with individual hospitals providing variable levels of induction. We therefore aimed to provide a free ‘Introduction to T&O on-calls’ course for junior doctors.

Method

The online platform ‘Zoom’ was used to provide 13 interactive lectures by T&O trainees and consultants over a single day in July 2020. In total, 280 UK junior doctors attended with 91.1% completing feedback. Pre- and post-course questionnaires were used to establish improved knowledge.

Results

Only 7.4% of participants either had or were aware of a local trust induction covering T&O on-calls. The course had an overall satisfaction rating of 90%, with participants showing a 15.3% improvement in on-call knowledge from pre-course to post-course (p<0.05). Prior to the course only 35% of participants felt prepared to perform an on-call which increased to 77% after the course. Almost all participants (90%) agreed that similar courses in other surgical specialties (General surgery (79%), Urology (60%), Vascular surgery (60%), ENT 55%)) which are commonly cross covered by junior doctors would be hugely beneficial.

Conclusions

Our principal focus moving forward is to establish a formal national induction programme for T&O junior doctors that is recognised by the relevant T&O organisations. This will instil confidence in the junior doctors whilst achieving patient safety and excellence during busy T&O on-calls.

653 DRAFFT Dodging? Fixation Methods for Distal Radial Fractures Since 2014 In A UK Trauma Unit

Introduction

The 2014 randomised, controlled Distal Radius Acute Fracture Fixation Trial (DRAFFT) compared K-wires to internal fixation for management of dorsally displaced distal radius fractures. The authors found no clinical difference between the two fixation methods, concluding ‘The results of this trial will reverse the trend towards locking-plate fixation for this injury’. Our study aimed to measure local change in practice since 2014.

Method

From the DRAFFT CONSORT diagram, we calculated just 10.7% of eligible cases required locking plate fixation. 300 patients, 50 per year from 2014-19 meeting DRAFFT eligibility criteria undergoing fixation, were randomly selected from an electronic trauma database. Radiographs were reviewed to see whether patients received internal fixation or K-wires.

Results

Age and sex distributions of the study sample were not significantly different to the DRAFFT population (p < 0.05). Over 60% of recruited patients received internal fixation each year. No increasing trend in use of K-wires was detected (p = 0.27). No trend was observed in either fixation method adjusting for intra versus extra-articular fractures (p = 0.36).

Conclusions

Local practice remains unchanged in fixation of dorsally displaced distal radius fractures since 2014. Internal fixation remains the most prevalent surgery, and there has been no detectable increase in use of K-wires.

127 Standardising Access to Fracture Fixation Simulation for Core Surgical Trainees

Introduction

Simulation is increasingly being used to augment clinical experience. However, access to simulation varies geographically and national courses can be costly. The Severn School of Surgery aimed to provide a locally run, cost-neutral “Basic Principles in Fracture Fixation” course to standardise access to simulation for core surgical trainees (CSTs).

Method

The course ran from a district general hospital, accommodating lectures, case discussions, and practical stations (screw fixation, plate fixation, dynamic hip screw, and external fixation). Faculty donated their time and a devices company provided kit and dry bones. CSTs organised the course. Pre- and post-course self-rated Intercollegiate Surgical Curriculum Programme (ISCP) global competency ratings in the practical stations were recorded and usefulness of aspects of the course was recorded.

Results

32 candidates attended. Mean self-rated competency increased by at least one global rating in all practical stations (p < 0.05). All aspects of the course were deemed useful (pre-course reading by 27/28, lectures by 31/32, and case discussions by 31/32). No net cost was incurred.

Conclusions

Increases in self-rated competency in surgical skills can be obtained through a cost-neutral, trainee-organised, regional skills course. Pre-course reading, lectures, case discussions, and practical sessions are all useful. This model can be used by others to standardise the simulation curriculum.

Impact of the 2020 COVID-19 pandemic on the workload of the orthopaedic service in a busy UK district general hospital

INTRODUCTION

The COVID -19 outbreak has had a profound effect on the management of healthcare service provision in the UK. Orthopaedic departments have been no exception to this and have needed to adapt to the changing circumstances by releasing resources and focusing on 'essential' activity. The aim of this study is to quantify the reduction in trauma and, in addition, describe any changes in the type of referrals to the trust which may have been affected by the pandemic itself and the social distancing measures employed by the UK government.

METHODS

The study was performed in a UK District Hospital which is also a Trauma Unit providing trauma and orthopaedic care to a population of 625,000 people. The trust based electronic database of trauma referrals was used to compare the numbers of, and types of referral to our trauma service during the COVID-19 pandemic and the corresponding time periods in the previous 3 years.

RESULTS

The mean number of referrals per week to the service reduced by 33% in the time period following the confirmation of the outbreak as a pandemic (p<0.0001). Number of operations performed per week reduced by 26% (p = 0.001). There was no change in the number of referrals relating to domestic abuse or non-accidental injury. In addition, numbers of hip fractures, periprosthetic fractures and prosthetic joint dislocations were unchanged. There was a significant reduction in the number of referrals for simple fractures, native joint dislocations, wounds and soft tissue injuries. Within the paediatric population, similarly, a reduction in simple fracture referrals was demonstrated.

DISCUSSION

An association between the outbreak of the pandemic and a reduction in referral numbers to our department has been demonstrated. The direct cause of this may be multifactorial but proposing that it is, in part, due to the social distancing measures introduced by the government is certainly conceivable. The patterns of injury would reflect this also with low energy and fragility trauma persisting whilst injuries associated with younger people have reduced. We would suggest that information such as this could be useful in healthcare planning and resource allocation in future pandemic situations.

Measurements of in vivo intra-articular gentamicin levels from antibiotic loaded articulating spacers in revision total knee replacement

Previous in vitro studies have found high levels of antibiotic release in the days immediately following implantation of antibiotic loaded articulating spacers. However there are relatively few data describing the elution profile beyond this immediate period. This study was designed to measure if gentamicin levels continue to be clinically therapeutic after an extended period following in vivo implantation. Twelve patients received a gentamicin loaded articulating spacer between a 1st and 2nd stage revision total knee arthroplasty. At the 2nd stage procedure synovial fluid and blood samples were collected and assayed for the presence of gentamicin. The second stage revision occurred at a median of 99 days following spacer insertion. The median intra-articular gentamicin levels were 0.46 mg/L (0.24 to 2.36 mg/L) which would be considered therapeutic. There were no cases of reinfection. In this study, preformed articulating spacers containing gentamicin provided therapeutic concentrations in the synovial fluid surrounding the joint throughout the period of implantation. These data confirm the observations from in vitro studies, where a prolonged elution profile was observed for such spacers.

Comparison of MRI and wrist arthroscopy for assessment of wrist cartilage

In order to perform motion-preserving procedures for wrist arthritis rather than total joint fusion, it is important to determine the integrity of specific areas of wrist cartilage. This is generally performed using a wrist arthroscope and by directly visualising the cartilage. Twenty patients with wrist pain were investigated over a 1-year period with both MRI and wrist arthroscopy. Kappa analysis was used to compare the two methods of cartilage assessment. There is only a fair correlation (K = 0.38) between the two methods. With only a fair correlation between arthroscopy and MRI, it cannot be concluded that the two methods are equivalent for assessing wrist cartilage and, as such, wrist arthroscopy still has an important role to play in the assessment of a painful degenerative wrist.

Assessing leg length discrepancy following elastic stable intramedullary nailing for paediatric femoral diaphyseal fractures

INTRODUCTION

Femoral overgrowth is a recognised phenomenon following fractures of the femoral diaphysis in children. This study was designed to assess leg length discrepancy (LLD) following elastic stable intramedullary nailing (ESIN) and its clinical significance.

MATERIALS AND METHODS

A retrospective review of children who underwent ESIN with DePuy ACE Nancy nails between 1997 and 2001 for diaphyseal femoral fractures. Evaluation was by questionnaire, clinical examination and radiological measurement.

RESULTS

17/26 (65%) patients were followed up for a mean time of 48 months (21-77). Average age at surgery was 9 years. Mean operative time was 78 min with a mean hospital stay of 7.8 days. Mean time to union was 10 weeks. A statistically significant LLD of +3.2 mm is demonstrated in children aged 4-8 years (P = 0.05). LLD is not statistically significant in children over 8 years.

CONCLUSION

ESIN is a successful treatment for paediatric diaphyseal femoral fractures and allows early mobilisation and discharge. A statistically significant LLD is observed in children aged 4-8 years although clinically only one patient in the entire series was aware of a leg length discrepancy. In addition clinical methods of leg length measurement are sensitive for LLD and we conclude that routine radiographic follow up is not necessary unless clinically indicated.