The ORthopaedic Trauma Hospital Outcomes - Patient Operative Delays (ORTHOPOD) study

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Methods

Data capture was by collaborative approach. Patients undergoing procedures from 22 August 2022 and operated on before 31 October 2022 were included. Arm one captured weekly caseload and theatre capacity. Arm two concerned patient and injury demographics, and time to surgery for specific injury groups.

Results

Data was available from 90 hospitals across 86 data access groups (70 in England, two in Wales, ten in Scotland, and four in Northern Ireland). After exclusions, 709 weeks' of data on theatre capacity and 23,138 operations were analyzed. The average number of cases per operating session was 1.73. Only 5.8% of all theatre sessions were dedicated day surgery sessions, despite 29% of general trauma patients being eligible for such pathways. In addition, 12.3% of patients experienced at least one cancellation. Delays to surgery were longest in Northern Ireland and shortest in England and Scotland. There was marked variance across all fracture types. Open fractures and fragility hip fractures, influenced by guidelines and performance renumeration, had short waits, and varied least. In all, nine hospitals had 40 or more patients waiting for surgery every week, while seven had less than five.

Conclusion

There is great variability in operative demand and list provision seen in this study of 90 UK hospitals. There is marked variation in nearly all injuries apart from those associated with performance monitoring. There is no evidence of local network level coordination of care for orthopaedic trauma patients. Day case operating and pathways of care are underused and are an important area for service improvement.

The course and distribution of the infra patellar nerve in relation to ACL reconstruction

INTRODUCTION

A common complication after ACL (anterior cruciate ligament reconstruction) is injury to the infra-patellar branch of the saphenous nerve (IPBSN). Very little about its origin and course of this nerve has been described. The aim of this study was to understand the course of IPBSN in relation to surgery around the knee.

MATERIALS AND METHOD

The course of the nerve was dissected and traced in 25 knees from 14 cadaveric knees (10 males; four females). An incision was made posterior to the medial condyle of the tibia and continued deeper towards the saphenous nerve which is located under the sartorius muscle. The saphenous nerve branch was then followed to distally supply the anterior leg (IPBSN). The relationship of saphenous nerve and IPBSN to each other and the hamstrings were recorded.

RESULTS

Four paths of IPBSN, in relation to the sartorius muscle, were identified: (1) posterior--inferior posterior border of the muscle, (2) transmuscular--penetrating through the muscle, (3) anterior--anterior border of the muscle, (4) posterior patellar--posterior of the muscle at the level of the patellar bone and (5) combined. The posterior pathway of IPSBN was the most common (57%) and had the closest proximity to the tendons of semitendinosus and gracilis muscles. The terminal branches of the IPSBN crossed over the patellar tendon in every dissection.

CONCLUSIONS

A posterior path IPBSN is more prone to damage during a tendon harvest due to its proximity to the gracilis and semitendinosus muscle tendons.