Lessons From the Virtual Fracture Clinic: An Efficient Model With Satisfied Patients

Introduction The virtual fracture clinic (VFC) can be an effective means of managing specific musculoskeletal injuries, including through protocol-driven direct discharge from the emergency department (ED) or minor injury unit (MIU). This study aimed to measure the efficiency of the VFC triage process while quantifying patient satisfaction after direct discharge from the VFC without routine face-to-face review. Methods We conducted a retrospective analysis of a prospectively collected database to ascertain VFC outcomes for 9064 patients from February 2017 to July 2018. We analysed consultant variation in VFC review and the mean time taken per patient. Patient satisfaction was investigated in 100 chronological patients initially managed via the VFC. Results The mean time to triage each patient was 74 seconds, and a mean of 503 patients was triaged each month. The telephone helpline received a mean of 0.9 calls per week. Seventy-seven percent of patients stated they were happy to be managed without a fracture clinic appointment, and 82% of patients received virtual leaflets in the ED or MIU as per protocol. The number of fracture clinic appointments was reduced by 24% as patients were discharged directly or seen instead by allied health professionals. The median patient satisfaction with VFC management was 90%, and the mean satisfaction with VFC communication was 80%. Conclusion Virtual review of fracture clinic referral enables stratification of patients according to clinical urgency and saves patients from attending unnecessary appointments. This is achieved in a patient population generally satisfied with their overall management. Our study results support the growing trend of VFCs as pivotal systems in streamlining the care of musculoskeletal injuries while adhering to British Orthopaedic Association Standards for Trauma guidelines for Fracture Clinic Services.

Predictors of Positive Outcomes and a Scoring System to Guide Management After Fasciotomy for Chronic Exertional Compartment Syndrome

Background:

Chronic exertional compartment syndrome (CECS) of the lower limb usually responds well to fasciotomy in patients with failed nonoperative treatment. Careful history taking and compartment pressure testing are both required to accurately diagnose CECS.

Purposes:

To evaluate patients with CECS after fasciotomy to establish predictive criteria of positive outcomes and to develop a scoring system to aid clinicians in their management of such patients.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We reviewed data from 28 patients who underwent fasciotomy between 2017 and 2019. All patients had undergone preoperative dynamic intracompartmental pressure (ICP) monitoring. For each patient, subjective preoperative and postoperative pain scores were gained via a questionnaire. The point biserial and Pearson correlation coefficients were used to calculate the association between multiple diagnostic criteria and a reduction in visual analog scale (VAS) pain scores after fasciotomy.

Results:

A reduction in VAS pain scores was strongly correlated with a peak ICP >40 mm Hg (r = 0.71; P = .0007) and an area under the receiver operating characteristic curve for an intraexercise ICP >22,000 mm Hg·s² (r = 0.76; P = .0002). A moderate correlation was found between a history of CECS pain (r = 0.61; P = .005), a duration of symptoms of <30 minutes after stopping exercise (r = 0.60; P = .006), and a gradient in the intraexercise ICP >10 mm Hg (r = 0.60; P = .006). When combined into an objective, weighted scoring system (2 points for factors with r > 0.7; 1 point for r = 0.5-0.7), a score of ≥4 points (of 7) had a strong correlation (r = 0.85; P < .00001) with postoperative improvement in the VAS pain score. Linear regression of this score demonstrated a good fit (R² = 0.61; P < .0001), indicating a degree of predictive power.

Conclusion:

We identified diagnostic criteria in the history and examination of patients with CECS that can be used to help predict positive outcomes after fasciotomy. We propose a scoring system to aid clinicians in their management of such patients. We recommend taking these results forward in prospective trials to test the efficacy of predictive scoring.

Humeral shaft fractures: how effective really is functional bracing?

BACKGROUND

The aim of this study was to assess the effectiveness of functional bracing in the treatment of humeral shaft fractures and identify factors that increased the risk of delayed or non-union.

METHODS

All patients with humeral shaft fractures treated at Musgrove Park Hospital between 2010 and 2017 were identified. Patient electronic records were reviewed to identify demographic data, as well as outcomes and complications following treatment. Radiographs were reviewed to identify fracture pattern and location as well as fracture displacement and angulation.

RESULTS

In total, 65 patients were treated with functional bracing of which 22 patients (34%) had a delayed or non-union. Fracture displacement and angulation were significantly associated with delayed or non-union. In particular, patients with fractures displaced more than 30 mm or angulated more than 30° had a significantly higher risk of delayed or non-union. Fracture location or pattern was not significantly associated with delayed or non-union.

CONCLUSION

Functional bracing is an effective treatment modality for the majority of patients with humeral shaft fractures, but patients with markedly displaced or angulated fractures are at a higher risk of failure of conservative treatment and therefore early operative intervention should be considered.

Simulation Learning: Effectiveness and Stressfulness in Medical Student Teaching

This article was migrated. The article was not marked as recommended. Introduction: The aims of this study were to assess the effectiveness of different modalities of simulation learning in medical students and the resulting stress response. Methods: Students were randomised into two groups for simulation learning, on the assessment and management of acutely ill patients. Group 1 performed assessments in a static individual format, whilst group 2 performing assessments in a dynamic group format. The stress response was measured by heart rate monitors worn by students, and performance was graded by a final simulator assessment. Results: The stress response did not significantly vary between groups, but there was a significant increase in heart rate in all students during the simulation learning; with a mean increase of 34 beats per minute in group 1 and 38 beats per minute in group 2. Performance in the final simulator assessment was significantly better in group 2, with a mean score of 21.5 points, compared to 16.2 points in group 1. Conclusion: A dynamic group simulation learning strategy is more effective in teaching medical students than simulations performed individually. Simulation learning, however; results in a significant stress response in all students, which must be carefully managed when delivering this type of learning.

Prophylactic biological mesh reinforcement versus standard closure of stoma site (ROCSS): a multicentre, randomised controlled trial

BACKGROUND

Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site.

METHODS

In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.

FINDINGS

Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43-0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26-0·69; p<0·001). There was also a reduction in symptomatic hernia (16%, 52 of 329 vs 19%, 64 of 331; adjusted relative risk 0·83, 0·60-1·16; p=0·29) and surgical reintervention (12%, 42 of 344 vs 16%, 54 of 346: adjusted relative risk 0·78, 0·54-1·13; p=0·19) at 2 years, but this result did not reach statistical significance. No significant differences were seen in wound infection rate, seroma rate, quality of life, pain scores, or serious adverse events.

INTERPRETATION

Reinforcement of the abdominal wall with a biological mesh at the time of stoma closure reduced clinically detectable incisional hernia within 24 months of surgery and with an acceptable safety profile. The results of this study support the use of biological mesh in stoma closure site reinforcement to reduce the early formation of incisional hernias.

FUNDING

National Institute for Health Research Research for Patient Benefit and Allergan.

Triceps tendon rupture: repair and rehabilitation

Triceps tendon ruptures are rare injuries and are frequently missed on initial presentation to the emergency department. In cases of complete rupture, surgical repair is recommended but no guidelines exist on the optimum reconstructive technique or rehabilitation. We present a surgical technique and rehabilitation programme for the management of these injuries. A midline posterior incision is performed, the ruptured triceps tendon is identified and mobilized, and the tendon footprint is prepared. The tendon is then repaired using bone suture anchors, with a parachute technique, and held in 40° of flexion. The rehabilitation programme is divided into five phases, over a period of 12 weeks. Range of movement is gradually increased in a brace for the first 6 weeks. Rehabilitation is gradually increase in intensity, progressing from isometric extension exercises to weight-resisted exercises, and finally plyometrics and throwing exercises. Our surgical technique provides a solid tendon repair without the need for further metalwork removal. The graduated rehabilitation programme also helps to protect the integrity of the repair at the same time as enabling patients to gradually increase the strength of the triceps tendon and ultimately return to sport activities.

Analysis of a paediatric orthopaedic network: a six-year experience in the South West of the United Kingdom

PURPOSE

We report our experience of a paediatric orthopaedic network, based on a 'hub and spoke' model, covering the South West of the United Kingdom. We identify the areas of most clinical concern, the effect of the network on stream-lining patient management and the benefits of the network to the clinician.

METHODS

Prospective data were collected from the minutes of the bi-annual meetings of the South West Paediatric Network (UK) between November 2006 and May 2012. Data collected included details of the condition, previous treatment, problems, complications and advice given. Cases continue to be followed up in subsequent meetings.

RESULTS

In total 131 cases were included and hip conditions were discussed most frequently (35.1%). The most common indication for discussion was to support and confirm the local management plan. In total, a mean average of 8.75 cases in total were presented per consultant during the study period, with those within ten to 12 years of starting independent practice presenting the majority. The clinical outcome for patients discussed in this forum was local provision of care in 74%, with transfer to the regional centre in 15.7%. Following advice, 14% of direct referrals were given appropriate advice and avoided a journey to the tertiary centre.

CONCLUSION

The network has enabled local provision of care, reduced the burden of travel on patients and prevented unnecessary referrals to the tertiary centre. Additionally, it provides a mechanism to reassure and educate clinicians.

Reduced length of stay with minimally invasive repair of ruptured achilles tendon

Minimally invasive techniques to repair ruptured achilles tendons have been developed to enhance recovery following tendon repair and decrease wound complications associated with open repair. We investigated outcomes of minimally invasive and open repair of acutely ruptured achilles tendons at our institution. We compared all cases of achilles tendon repair at our department, using open techniques and minimally invasive techniques with the Achillon device, over a two year period. Length of stay and operating time was recorded, as were any complication rates, including tendon re-rupture. Post-operatively functional outcome questionnaires were sent to all patients. In total 39 patients underwent open repair and 26 underwent minimally invasive repair. Length of stay was significantly shorter in the minimally invasive group, with 58% of minimally invasive cases performed as a day case, compared to 31.1% of open cases (p = 0.02). There was no difference in complication rates, including re-rupture, or functional outcome scores. Minimally invasive repair of ruptured achilles tendons results in reduced length of stay, compared to open repair. There is no evidence of weaker tendon repairs with minimally invasive techniques. Overall functional outcomes between both groups appear similar. Level of Evidence : III.

Intratendinous ganglion cyst of the extensor digitorum longus tendon: A case report

INTRODUCTION

Ganglion cysts are benign lesions, common in the hand and wrist. Intratendinous ganglion, however, are rare. We present the first reported case of an intratendinous ganglion cyst in an extensor digitorum longus (EDL) tendon of the foot.

CASE REPORT

A 35-year old presented with a left-sided painful dorsolateral foot swelling. Ultrasound suggested a ganglion cyst in proximity to the EDL tendon of the 5th toe. Two distinct swellings were identified on surgical exploration, including a 6×1cm ganglion lying within the EDL tendon substance that had resulted in tendon splitting. The lesions were excised and EDL tendon repaired. Histological analysis confirmed that both lesions were ganglion cysts. Post-operative recovery was uneventful.

DISCUSSION

Intratendinous ganglion cysts are rare lesions that pose a unique set of diagnostic and treatment challenges. Unlike conventional ganglion, their diagnosis may not be possible until surgical exploration. They have been reported to increase the risk of spontaneous tendon rupture. As such, a lower operative threshold should be applied to prevent their progression. A high index of suspicion should be applied to any ganglion reported radiologically to be in close contact with tendons. If diagnosed upon surgical exploration, it is essential that the operating surgeon is prepared to appropriately modify the procedure to involve primary tendon repair, tendon transfer or tenodesis.

Case Report of Iliac Osteomyelitis in A Child, Presenting as Septic Arthritis of the Hip

Introduction:

Osteomyelitis of the pelvis can be a difficult condition to diagnose and can present in a number of different ways. The ilium is the bone most frequently affected and staphylococcus aureus is the organism most commonly responsible.

CaseReport:

This case report describes a six year old girl, who presented with right sided hip pain, fevers and altered weight bearing. She was initially diagnosed with septic arthritis of the hip and underwent open joint washout. A magnet resonance imaging scan was subsequently performed which confirmed the diagnosis of iliac osteomyelitis with abscesses of the iliopsoas and iliacus. The patient underwent further operative debridement and required prolonged antibiotic therapy but she eventually made a full recovery.

Conclusion:

Pelvic osteomyelitis can present very similarly to hip septic arthritis and early magnetic resonance imaging is beneficial in diagnosing the condition. Surgical intervention can be required if there is abscess formation, although recovery is usually very good and the incidence of long term complications is rare.