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Implementing Mental Practice in Postgraduate Surgical Training for Minimally Invasive Surgery: A Systematic Review and Thematic Analysis.BACKGROUND: Unprecedented pressure on the National Health Service (NHS) has meant that there are increasing obstacles to surgical training. Simulation training is an option to improve surgical performance but is limited due to availability, accessibility and financial constraints. Mental practice (MP) has been proposed as a potential solution to supplement the traditional method of apprenticeship-style learning. Despite increasing evidence that MP may be a useful tool to improve surgical performance and reduce surgeon anxiety, it is not widely adopted. This systematic review and thematic analysis aims to identify key themes that would allow for the successful implementation of MP in postgraduate surgical training. METHODS: Medline, Embase and PsycINFO databases were systematically searched to identify articles that investigate the role of MP in improving surgical performance amongst surgical trainees. Retrieved papers were studied to inform thematic analysis of their content and studies were assessed for bias. RESULTS: A total of 321 studies were retrieved, of which 11 met the inclusion criteria. Overall risk of bias was assessed to be between critical and moderate for seven nonrandomized studies and between fair and good for four randomized studies. Key themes were identified and discussed using a thematic analysis approach. CONCLUSION: This study has identified that attaining high quality mental imagery is fundamental to success in mental practice and this can be augmented by the use of relaxation therapy and/or motivational imagery. Future research should focus on the application of MP in real-world surgical practice and breaking down complex procedures into fewer operative steps.
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Improving Patient Care and Streamlining Follow-Up: Compliance With National Institute for Health and Care Excellence (NICE) Guidelines for Pediatric Distal Radius Buckle Fractures.INTRODUCTION: Torus fractures, also known as buckle fractures, are among the most common types of fractures seen in children who present to the emergency department (ED). These injuries usually occur when a child falls onto an outstretched hand, resulting in the compression and buckling of the dorsal cortex of the radius while the volar cortex remains intact. These fractures generally have a good prognosis and heal well with simple immobilization with a low risk of complications. However, current treatment practices often involve using a rigid cast and scheduling multiple follow-up clinic visits, which increases the hospital's financial strain. MATERIALS AND METHODS: We conducted an initial audit that reviewed the practice in our unit between August and October 2017 at Queen's Hospital, Burton Upon Trent, United Kingdom. It included all children below the age of 16 who had radiograph images confirming distal radius buckle fractures and have been referred to the fracture clinic. Patient demographics, clinic visits, treating doctor grade/specialty, radiographs, initial and final treatment outcomes, and cast application were collected. After the initial audit, compliance with National Institute for Health and Care Excellence (NICE) guidelines was promoted through the education of healthcare providers. A second audit was performed within 12 months to reassess the compliance. RESULTS: This study looked at the management of pediatric distal radius buckle fractures in a cohort of 152 patients, of which 65 and 87 children were included in audit cycles I and II, respectively. In the ED, splint usage increased from 0% in the first cycle (all children initially treated in a back slab) to 20% following new recommendations. In the fracture clinic, there was a notable improvement in the use of splints over full plaster casts between the first and second cycles. Initially, in the first cycle, only 5% of patients were treated in a splint, with 95% receiving full plaster casts. Following recommendations, splint use increased significantly in the second cycle, rising to 53%, while cast use decreased to 47%. In the first audit, only 7.7% (five patients) were discharged at the first visit, compared to 44.8% (39 patients) in the second audit. In the first audit, 86.2% (56 patients) required a second visit, whereas in the second audit, this decreased to 55.2% (48 patients). Four individuals received a cast owing to splint size difficulties or patient preferences. CONCLUSION: Despite the improvement seen regarding compliance with NICE guidelines, work is still needed to further enhance compliance. Staff education and optimizing splint availability will be a priority to reduce the burden on fracture clinic resources by unnecessary follow-up appointments.
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Exploring the utility of ultrasound to assess disuse atrophy in different muscles of the lower leg.BACKGROUND: Skeletal muscle is a highly plastic tissue crucial for many functions associated with whole-body health across the life course. Magnetic resonance imaging (MRI) is the current gold standard for measuring skeletal muscle size. However, MRI is expensive, and access to facilities is often limited. B-mode ultrasonography (U/S) has been proposed as a potential alternative to MRI for the assessment of muscle size. However, to date, no work has explored the utility of U/S to assess disuse muscle atrophy (DMA) across muscles with different atrophy susceptibility profiles, an omission which may limit the clinical application of previous work. METHODS: To address this significant knowledge gap, 10 young men (22 ± years, 24.1 ± 2.3 kg/m2) underwent 15-day unilateral leg immobilization using a knee-brace and air boot. Cross-sectional area (CSA) and muscle thickness (MT) of the tibialis anterior (TA) and medial gastrocnemius (MG) were assessed via U/S before and after immobilization, with CSA and muscle volume assessed via MRI. RESULTS: With both muscles combined, there were good correlations between each U/S and MRI measure, both before (e.g., CSAMRI vs. MTU/S and CSAU/S: r = 0.88 and 0.94, respectively, both P < 0.0001) and after (e.g., VOLMRI vs. MTU/S and CSAU/S: r = 0.90 and 0.96, respectively, both P < 0.0001) immobilization. The relationship between the methods was notably stronger for MG than TA at each time-point (e.g., CSAMRI vs. MTU/S: MG, r = 0.70, P = 0.0006; TA, r = 0.37, P = 0.10). There was no relationship between the degree of DMA determined by the two methods in either muscle (e.g., TA pre- vs. post-immobilization, VOLMRI: 136 ± 6 vs. 133 ± 5, P = 0.08; CSAU/S: 6.05 ± 0.3 vs. 5.92 ± 0.4, P = 0.70; relationship between methods: r = 0.12, P = 0.75). CONCLUSIONS: Both MTU/S and CSAU/S provide comparable static measures of lower leg muscle size compared with MRI, albeit with weaker agreement in TA compared to MG. Although both MTU/S and CSAU/S can discern differences in DMA susceptibility between muscles, neither can reliably assess degree of DMA. Based on the growing recognition of heterogeneous atrophy profiles between muscles, and the topical importance of less commonly studied muscles (i.e., TA for falls prevention in older adults), future research should aim to optimize accessible methods to determine muscle losses across the body.
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Does long-term surveillance of primary linked total elbow arthroplasty identify failing implants requiring revision?BACKGROUND: Scoping review has identified a lack of evidence guiding long-term follow-up of elbow arthroplasty. We report the effectiveness of primary linked total elbow arthroplasty surveillance in identifying failing implants requiring revision. METHODS: A prospective database recording consecutive primary linked total elbow arthroplasty and subsequent surveillance in an elbow unit was analysed. Arthroplasties performed between 01.10.2013 and 31.07.2022 were included, with a minimum 1-year follow-up. Surveillance involves specialist physiotherapist review 1, 2, 3, 5, 8 and 10 years postoperatively. Patient-initiated review could occur between time points. Outcome measures include a number of surveillance reviews offered and attended; and the proportion that identified a failing implant requiring revision. RESULTS: Ninety-seven primary linked total elbow arthroplasties with minimum 1-year follow-up were performed (76 Discovery, 14 Nexel, 7 Coonrad/Morrey). Sixteen patients died prior to 31.07.2023, and three implants required revision <1 year postoperatively. 290 of 328 offered surveillance appointments were attended (88.4%). Five implants required revision ≥1 year post-operatively, with revision requirements identified by surveillance in all cases. Three failures occurred at 5 years postoperatively, and two failures occurred at 8 years postoperatively. Overall, 1.7% attended surveillance appointments identified a failing implant requiring revision. DISCUSSION: This is the first series reporting the effectiveness of primary linked total elbow arthroplasty surveillance in identifying implants requiring revision.
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Feasibility of embedding orthopaedic clinical trials into national registries: a pilot quality improvement study for the UK Non-Arthroplasty Hip Registry (UK-NAHR).The integration of 'Registry-based Randomised Control Trials' (RRCT) into national registries has the potential to catalyse prospective research, enhancing the evidence base for practice. The aim of this study was to assess the feasibility of embedding a trial within the UK Non-Arthroplasty Hip Registry. This was a national observational, multi-centre study. Six pilot sites within the UK were provided with additional support for data collection. We compared the ability of these pilot sites to collect data with the ability of centres where no additional support was provided. We collected information on patient compliance, efficacy and adverse events of drugs routinely used after hip preserving surgery. The primary outcome measure was compliance with data collection in these centres at 30 and 90 days after surgery. Our intention was to assess the feasibility of, and factors influencing, the capturing data for interventional registry trials in the future. Two hundred and twenty-eight patients were enrolled in the Non-Arthroplasty Hip Registry during the study period (114 within pilot centres and 114 in non-pilot centres). Pilot centres had a mean follow-up compliance of 79% (30 days) and 69.4% (90 days) in contrast to 55% (30 days) and 47% (90 days) in the non-pilot centres (P = 0.009/P = 0.0058). The study revealed that supplementary administrative support resulted in improved compliance. However, deficient administration systems negatively impacted follow-up, and surgeon motivation emerged as a crucial determinant in ensuring robust follow-up. The lessons learned from this feasibility trial could be useful for any national registry embedding prospective, registry-based trials.
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Structured training pathway for robotic colorectal surgery: Short-term outcomes from five UK centresAIM: The aim of this study was to assess the short-term outcomes of robotic colorectal surgery implemented through a structured, standardized training pathway in five colorectal centres in the United Kingdom. METHOD: A multicentre retrospective observational study was conducted, involving 523 consecutive patients who underwent robotic colorectal resection between 2015 and 2019. All participating centres followed the European Academy of Robotic Colorectal Surgery training pathway. Patient data, including demographics, operative details, postoperative outcomes and pathology results, were collected and analysed. RESULTS: The study included 447 rectal resections and 76 colonic operations. The median age of the patients was 64.7 years, with the majority of patients (70%) being men. The mean body mass index was 27.4 kg/m2, and 89.7% of the patients underwent surgery for malignancy. The overall conversion rate to open surgery was 4.2%. The median length of stay was 6 days and there was no 30-day mortality. The readmission and reoperation rates were 8.8% and 7.3%, respectively. The anastomotic leak rate was 4.1% for rectal resections and 3.9% for colonic resections. Pathological examination showed a positive circumferential resection margin rate of 2.6%. CONCLUSION: Through the implementation of a structured, standardized training pathway, the participating colorectal centres in the UK achieved safe and effective robotic colorectal surgery pathways with favourable short-term oncological and clinical outcomes. Further studies examining long-term and functional outcomes are needed to assess the broader impact of robotic surgery in colorectal procedures.
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Ambulatory management of acute uncomplicated diverticulitis (AmbUDiv study): a multicentre, propensity score matching study.INTRODUCTION: Recent studies have suggested that ambulatory management is feasible for acute uncomplicated diverticulitis (AUD); however, there is still no consensus regarding the most appropriate management settings. This study presents a multi-centre experience of managing patients presenting with AUD, specifically focusing on clinical outcomes and comparing ambulatory treatment with in-patient management. METHODS: A retrospective multi-centre study was conducted across four hospitals in the UK and included all adult patients with computed tomography (CT) confirmed (Hinchey grade 1a) acute diverticulitis over a 12-month period (January - December 2022). Patient medical records were followed up for 1-year post-index episode, and outcomes were compared between those treated through the ambulatory pathway versus inpatient treatment using 1:1 propensity score matching (PSM). All statistical analysis was performed using the R Foundation for Statistical Computing, version 4.4. RESULTS: A total of 348 patients with Hinchey 1a acute diverticulitis were included (260 in-patients; 88 ambulatory pathway), of which nearly a third (31.3%) had a recurrent disease. Inpatient management was dominant (74.7%), with a median of 3 days of hospital stay. PSM resulted in 172 patients equally divided between the two care settings. Ambulatory management was associated with a lower readmission rate (P = 0.02 before PSM, P = 0.08 after PSM), comparable surgical (P = 0.57 before PSM, 0% in both groups after PSM) and radiological interventions (P = 0.99 before and after PSM) within one year. In both matched and non-matched groups, a strong association between readmissions and inpatient management was noted in univariate analysis (P = 0.03 before PSM, P = 0.04 after PSM) and multivariate analysis (P = 0.02 before PSM, P = 0.03 after PSM). CONCLUSION: Our study supports the safety and efficacy of managing patients with AUD through a well-designed ambulatory care pathway. In particular, hospital re-admission rates are lower and other outcomes are non-inferior to in-patient treatment. This has implications for substantial cost-savings and better utilisation of limited healthcare resources.
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What Are the Most Clinically Effective Nonoperative Interventions for Thumb Carpometacarpal Osteoarthritis? An Up-to-date Systematic Review and Network Meta-analysis.BACKGROUND: Thumb carpometacarpal osteoarthritis (CMC-1 OA) is a common and debilitating condition, particularly among older adults and women. With the aging population, the prevalence of CMC-1 OA is expected to rise, emphasizing the need to find effective nonoperative strategies. So far, for determining the most effective nonoperative interventions in CMC-1 OA, two network meta-analyses (NMAs) have been published. However, these NMAs were limited to specific intervention types: one comparing multiple splints and the other comparing different intraarticular injections. Therefore, an NMA that compared all nonoperative intervention types is urgently needed. QUESTIONS/PURPOSES: This study aimed to assess and compare the effectiveness of available nonoperative interventions (both nonpharmacologic and pharmacologic) for CMC-1 OA to establish which nonoperative options are more effective than control in terms of (1) pain, (2) function, and (3) grip strength. METHODS: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) NMA guidelines (PROSPERO: CRD2021272247) and conducted a comprehensive search across Medline, Embase, CENTRAL, and CINAHL up to March 2023. We included randomized controlled trials (RCTs) and quasi-RCTs evaluating nonoperative interventions for symptomatic CMC-1 OA, excluding inflammatory or posttraumatic arthritis. Studies comparing ≥ 2 interventions or against a control, focusing on pain reduction, functional improvement, and grip strength, were selected. We assessed methodologic quality using the modified Coleman Methodology Score, including only studies scoring > 70. Risk of bias was evaluated with the Risk of Bias 2.0 tool, and evidence quality with Confidence in Network Meta-Analysis (CINeMA). Of 29 screened studies, 22 (21 RCTs and one quasi-RCT) were included, involving 1631 women and 331 men. We analyzed eight different nonoperative interventions, including splints, hand exercises, injections, and multimodal treatment (≥ 2 nonpharmacologic interventions or nonpharmacologic with a pharmacologic intervention). Six studies had a low risk of bias, eight had a high risk, and the remainder were moderate. We extracted mean and SD scores, and NMA and pairwise analyses were performed at short- (≤ 3 months) and medium-term (> 3 to ≤ 12 months) time points. Standardized mean differences were re-expressed into common units for interpretation, which were the VAS (range 0 to 10) for pain, the DASH test (range to 100) for function, and pounds for grip strength. Clinical recommendations were considered strong if the mean differences exceeded the minimum clinically important difference-1.4 points for VAS, 10 points for DASH, and 14 pounds for grip strength-and were supported by moderate or high confidence in the evidence, as assessed using CINeMA methodology. RESULTS: Our NMA (based on moderate or high confidence) showed a clinically important reduction in pain at the short-term time point for multimodal treatment and hand exercises versus control (mean difference VAS score -5.3 [95% confidence interval (CI) -7.6 to -3.0] and -5.0 [95% CI -8.5 to -1.5]). At the medium-term time point, only the rigid carpometacarpal-metacarpophalangeal (CMC-MCP) splint was superior to control (mean difference VAS score -1.9 [95% CI -3.1 to -0.6]) and demonstrated clinical importance. For function, only the rigid CMC-MCP splint demonstrated a clinically important improvement at the medium-term time point versus control (mean difference DASH score -11 [95% CI -21 to -1]). Hand exercises resulted in a clinically important improvement in short-term grip strength versus control (mean difference 21 pounds [95% CI 11 to 31]). CONCLUSION: This systematic review and NMA show that multimodal treatment and hand exercises reduce short-term pain and improve grip strength, while a rigid CMC-MCP splint enhances medium-term function. Future research should evaluate long-term efficacy. LEVEL OF EVIDENCE: Level I, therapeutic study.
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Factors influencing surgical treatment of De Quervain's tendinopathy: A retrospective cross-sectional observational study.BACKGROUND: The literature surrounding how different patient, sociodemographic, and anatomical factors influence surgical treatment of De Quervain's tendinopathy (DQT) is limited. PURPOSE: We hypothesised that different patient, anatomical, or sociodemographic factors influence the management of DQT with regard to non-operative vs. surgical management. METHODS: This retrospective cross-sectional study reviewed 155 cases of patients with DQT seen over a 10 year period. Patient-specific factors included age, gender, hand affected, dominant hand, steroid injection given and mean number of injections. Sociodemographic factors included ethnicity, employment, and deprivation, were measured using deprivation quintiles through The Index of Multiple Deprivation. Anatomical factors included the presence of subcompartmentalization, number of APL and EPB tendon slips, tendon thickening, exudative tenosynovitis, hypervascularization, and the presence of a sheath ganglion Patients were categorized into either non-operative or surgical cohort. Bivariate analysis was used to compare factors between the cohorts, and significant factors (p < 0.05) were included in the logistic regression model, used to predict factors influencing surgical management. RESULTS: Bivariate analysis detected a significant difference in the mean number of steroids given between the non-operative and surgical cohort (p = 0.001) patient factors. For sociodemographic factors, a significant difference was found between deprivation quintiles (p = 0.02). From the anatomical factors, the surgical cohort had more patients with multiple APL tendon slips (p = 0.02) and the presence of a tendon ganglion sheath ganglion (p = 0.02). For patient and sociodemographic factors, logistic regression identified that the number of steroids (per patient) and being in deprivation quintile 4 were associated with surgical treatment. For anatomical factors, multiple APL tendon slips and the presence of a tendon sheath ganglion were associated with the surgical treatment. CONCLUSION: This study suggests that several factors are associated with the need for surgical treatment of DQT, including the number of steroid injections received, social deprivation, and anatomical factors, such as the presence of multiple tendon slips and a tendon sheath ganglion. Our findings add to the growing body of literature exploring factors that may influence treatment pathways for patients with DQT.
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Predictors of appendicectomy one year after antibiotic treatment for acute appendicitis: Insights from a prospective, multicentre, observational study.BACKGROUND: Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited include the risk of recurrent appendicitis and the risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine the long-term efficacy of antibiotic versus operative management of appendicitis. METHOD: One-year follow-up of patients enrolled in the multicentre, COVID:HAREM cohort study during March-June 2020 was performed. Initial operative or non-operative management was determined on a case-by-case basis by the responsible surgeon. Outcomes were appendicectomy rate at 1-year, histology of removed appendix and predictors of unsuccessful antibiotic treatment. RESULTS: A total of 625 patients who had non-operative management were included. Emergency appendicectomy had been performed by 1-year in 24% (149/625), with a median time to appendicectomy of 12 days [IQR 1-77] from presentation. Thirty-one patients had elective appendicectomy. Normal histology was reported in 6% of emergency procedures and 58% of elective ones. There were 7 malignancies and 3 neuroendocrine tumors identified at histology. All patients with malignant histology had ≥1 risk factors for malignancy at initial presentation. Faecolithiasis (hazard ratios (HR) 2.3, 95% confidence intervals (CI) 1.51-3.49) and a high Adult Appendicitis Score (AAS >16; HR 2.44, 95% CI 1.52-3.92) were independent risk factors for unsuccessful non-operative management. CONCLUSION: At 1 year, 71% of patients managed non-operatively did not undergo an appendicectomy. Recurrence of appendicitis was associated with faecolithiasis and a high AAS. Patients at higher risk for appendiceal malignancy should have targeted follow-up. These factors should be considered when counseling patients on non-operative management.
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Role of Synovectomy in Rheumatoid Hand and WristSynovectomy refers to the removal of all or part of the hypertrophied soft tissue membrane on the inside of the joint capsule or around tendons. Historically, this was typically performed for rheumatoid arthritis and other inflammatory conditions of the hand, but following the development of more advanced medical treatments, the role of synovectomy has come into question. In this article, the authors outline the biologic basis for synovectomy and then consider its present and future role in the management of joint and tendon disease, followed by what further research is needed.
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Outcomes and Management of Dislocated Hip HemiarthroplastyPurpose and aims Hip hemiarthroplasty (HHA) is a common procedure undertaken to manage intracapsular neck of femur fractures. Dislocation of HHA is one of the most dreadful complications. There is a paucity of clinical evidence to guide decision-making for managing these patients. The aim of this study was to describe the operative management and outcomes of patients with dislocated hemiarthroplasties of the hip and outline a treatment strategy for their management. Methods We conducted a retrospective analysis of all the patients presenting to University Hospitals of Derby and Burton, UK with hip fractures between 2016-2022. We included all the patients who underwent a hemiarthroplasty for their fracture. We excluded patients who had malignancy and if clinical data was missing. Each operative intervention and subsequent dislocations were recorded. We recorded the following outcome measures: dislocation, surgical interventions, mortality, revision surgery, cognition status, residential status, and mobility. We also compare these outcomes with the patients who had HHA and did not sustain any dislocation. Results Of the 1134 patients treated with HHA during this period, 33 patients sustained dislocation. Of the 33 patients, 29 were female and 4 were male with mean ages of 87.4±7.4 and 89.25 ± 9.54, respectively. Following the first dislocation, 25 patients were treated with closed reduction, six patients had excision arthroplasty (EA), and two patients were treated non-operatively. About 21 patients went on to have second and third dislocations, none of these had EA and others had conversion to total hip replacement (THR). Nearly 80% of dislocations occurred within two months of the initial procedure. The mean mental test score was 7.91±2.01 (p=0.001) and was significantly higher in patients who underwent conversion to THR. The average ASA grade was significantly higher in patients who had closed reduction (2.93±0.25, p=0.001) and EA (3.28±0.46, p=0.002) compared to the patients who had no dislocation. Patients who underwent EA had significantly higher acute length of hospital stay 23.5±13.5 (p=0.02) and mortality (p=0.001) compared to other groups. We found no significant difference in dislocation rates where the initial procedure was carried out by registrars or consultants (p=0.567). Conclusion We concluded that the dislocation risk is higher in females and within the first two months of the index procedure. More than 80% of patients had a second dislocation following a successful closed reduction. In our cohort, 45% of patients had EA (Girdlestone procedure) and 36% had a conversion to THR. EA was associated with increased mortality rates, acute length of hospital stays, and significant change to premorbid mobility status. A multidisciplinary team (MDT) approach is necessary following the second dislocation to prevent further morbidity associated with recurrent dislocations.
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A 7-Year Retrospective Review of Flexor Sheath InfectionsBackground: Flexor sheath infections require prompt diagnosis, and management with intravenous antibiotics and/or surgical washout followed by hand therapy. Complication rates as high as 38% have been reported. Our unit takes a relatively conservative approach to the management of flexor sheath infections and select patients are managed non-surgically via our outpatient antibiotic service where they are clinically reviewed and receive a once daily dose of intravenous antibiotics. The aim of this study is to determine if outpatient management of flexor sheath infections was associated with an increased risk of complications compared to those admitted as an inpatient. Methods: A retrospective review was carried out with all patients clinically diagnosed with flexor sheath infection who were seen at our unit between January 2014 and December 2020. Age, gender, co-morbidities, cause of infection, management and subsequent complications were recorded. Results: A total of 128 patients with flexor sheath infections were treated. And 68% were male. Mean age was 50.4 years. A trend towards fewer presentations each year with animal bites, foreign bodies and penetrating trauma as the main cause of infection was noted. And 89% (n = 114) required admission with the other 11% (n = 14) treated as an outpatient. And 77% (n = 98) underwent surgical washout. And 6% (n = 8) suffered a complication. Conclusions: While flexor sheath washout continues to be standard practice, 23% of patients were safely managed with intravenous antibiotics and 11% purely via an outpatient service. Level of Evidence: Level IV (Therapeutic).
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Assessing the current role of AP and Bernageau view radiographs in measurement of glenoid bone loss in patients with recurrent shoulder dislocation: correlation with computed tomography, magnetic resonance imaging, and arthroscopy.BACKGROUND: Evaluation of glenoid bone loss following recurrent anterior shoulder dislocations is normally performed using cross sectional imaging. OBJECTIVES: To assess how anteroposterior (AP) and Bernageau view radiographs compare to computed tomography (CT), magnetic resonance imaging (MRI) and arthroscopy for evaluating glenoid bone loss in patients with recurrent anterior shoulder dislocation. MATERIALS AND METHODS: A prospective observational study was performed on 32 patients over two years at a tertiary orthopedic center. The loss of sclerotic glenoid rim (LSGL) on AP radiograph and the percentage relative glenoid bone loss on the Bernageau radiograph were assessed. The percentage glenoid bone loss and anterior straight line (ASL) were calculated using a best fit en face circle method using CT and MRI. Percentage glenoid bone loss was also calculated during arthroscopy in multiples of 5%. RESULTS: In our study, 90.6% (29) patients were males, while only 9.4% (3) were females. This can be attributed to the involvement of the males in outdoor activities and sports. Also, the maximum number of patients were found to belong to 21-30 years of age, with the mean age being 28.66 years. Of the 32 patients, loss of sclerotic glenoid line (LSGL) on AP radiographs correlated with glenoid bone loss on cross-sectional imaging in 27 patients. Three patients had equivocal LSGL and 2 patients with glenoid bone loss on CT did not demonstrate LSGL. The difference between the two modalities was not statistically significant (p value = 0.002). The glenoid bone loss on Bernageau view correlated with glenoid bone loss on cross sectional imaging in all but one patient. The bone loss as evaluated by radiograph Bernageau view was found to have strong correlation (correlation coefficient r = 0.948, p value < 0.0001). CONCLUSION: AP and Bernageau radiographic views for anterior shoulder dislocations demonstrate good correlation with glenoid bone loss on cross-sectional imaging. They may also be used as an adjunct to predict overall bone loss on CT and at arthroscopy.
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Assessing Patient Understanding and Satisfaction in Orthopedic Trauma and Elective Surgery AdmissionsBackground When seeking healthcare, patients often struggle to understand the information provided by healthcare professionals regarding their condition and treatment plan. Additionally, patient satisfaction with their experience can vary widely. Improved patient understanding and satisfaction are linked to better outcomes. This study aims to explore the factors influencing patient understanding to help healthcare professionals enhance these aspects. Objective This study evaluated the level of understanding and satisfaction among patients attending outpatient appointments. It also investigated factors influencing understanding by examining differences in results across various patient groups and analyzing these variations. Methods This study was conducted at Queens’ Hospital Burton, a level III trauma unit, over a three-week period in September 2023. Patients attending their orthopedic outpatient appointments were given a questionnaire, which included both bipolar 1-5 scale questions and open-ended text response questions. Results Patients generally reported high levels of understanding and satisfaction, averaging 90.34% and 96.20%, respectively. Those seen in a nurse-led clinic demonstrated significantly greater understanding of their condition compared to those seen by a physician (p = 0.0377). Additionally, trauma patients had a significantly higher level of understanding (p = 0.0167) and satisfaction (p = 0.0115). Conclusions To achieve better patient outcomes, it is crucial to optimize both patient understanding and satisfaction. Nurse-led clinics demonstrate higher levels of understanding, so identifying and incorporating the factors that contribute to this success into physician-led clinics is essential. These factors may include differences in communication methods, the resources provided, or the consultation setting. Additionally, the educational methods used with trauma patients appear more effective than those used for elective cases and should be evaluated to determine if they can enhance understanding and outcomes in other settings. Implementing evidence-based strategies for effective patient communication, such as maintaining good eye contact, avoiding medical jargon, and establishing rapport, could improve understanding and satisfaction and ultimately lead to better patient outcomes.
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The swallowing and speech after transoral robotic surgery—does the site impact the outcome?Transoral robotic surgery (TORS) has been introduced to head and neck surgery as a minimally invasive techqniques to improve the functional outcomes of patients. Compare the functional outcome for swallowing and speech in each site of TORS within the head and neck. Retrospective cohort study for patients who underwent TORS within the head and neck unit. Patients were assessed at four different time points (one day, one month, six months and twelve months, respectively) with bedside/office testing. Methods of testing for swallowing assessment were by the International Dysphagia Diet Standardization Initiative (IDDSI), and speech assessments were carried out using the Understandability of Speech score (USS). Outcomes were compared to patient-specific pre-treatment baseline levels. 68 patients were included. 75% and 40% of the patients resumed normal fluid intake and normal diet immediately after surgery. 8.8% required a temporary feeding tube, with 1% required gastrostomy. There was a steep improvement in diet between 3 and 6 months. Fluid and diet consistency dropped significantly following the majority of transoral robotic surgery with more noticeable diet changes. Early deterioration in diet is temporary and manageable with a modified diet. Rapid recovery of swallowing is achieved before the first year. There is no long-term effect on speech.
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Recurrent left main stem stenosis in a young female with Behçet's aortitis: a case reportBACKGROUND: Behçet's disease (BD) is a rare and complex vasculitis disorder renowned for its diverse clinical presentations. Cardiovascular involvement is reported to be present in 7-46% of the patients, with coronary arteries being involved in only 0.5%. The management of cardiovascular complications can be challenging due to the rarity of such cases and the absence of standardized guidelines regarding diagnosis and treatment. CASE SUMMARY: We report the case of a 27-year-old patient with BD with known aortitis and pulmonary arteritis, who presented with recurrent acute coronary syndromes related to critical left main coronary artery stenosis. She was initially managed with percutaneous coronary interventions twice. Following recurrent stent failure, she eventually underwent urgent coronary artery bypass surgery, together with aortic valve replacement and aortic root repair. She made an uneventful recovery and remains well 6 months following her operation. DISCUSSION: This case illustrates the significant challenges that can be encountered when managing coronary complications in patients with BD. Both percutaneous and surgical options have been reported in the literature with variable outcomes. Multi-disciplinary team involvement is of utmost importance in order to offer a balanced therapeutic strategy to these patients. Further research is required to shed light to the unknowns surrounding this rare cohort.
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Charcot Neuroarthropathy of the Shoulder Caused by Cervical Spondylotic Myelopathy: a case report and literature reviewCharcot neuroarthropathy (CN) is a chronic degenerative disorder of bones and joints, mostly associated with diabetes mellitus and human immunodeficiency virus. CN of the upper limb is rare, with only 58 case reports identified on PubMed with the majority of cases being closely associated with syringomyelia. Very rarely, cervical spondylotic myelopathy (CSM) is associated with CN of the upper limb; with very few literature reporting this association. This case report presents a rare case of Charcot arthropathy of the shoulder caused by CSM. A 57-year-old female presented to the emergency department following trauma to the right shoulder. On clinical examination, there was evidence of tenderness, extensive swelling, and bruising with a lack of range of motion along with numbness in the right arm and legs. Through radiographic and laboratory investigations, a diagnosis of CN secondary to CSM was made. A reverse total shoulder arthroplasty was performed however, this was complicated at two weeks with an atraumatic glenoid fracture and dislocation. First-stage revision surgery was then performed to allow fracture healing pending second-stage revision surgery. This report provides insight into the very rare possibility of the association of CN of the shoulder with CSM. A review of the literature suggests reverse shoulder arthroplasty is the gold standard for cases of severe bone and soft tissue damage. When undergoing investigations for Charcot neuroarthropathy, physicians must undertake a full detailed history along with a detailed neurological examination and imaging of the cervical spine to not miss the association with CSM.
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Experiences and outcomes in shoulder replacements in a district general hospital over 19 yearsBackground: This study aimed to evaluate the changing experiences of shoulder surgeons working in a district general hospital. Methods: A consecutive series of 395 shoulders (225 male, 170 female) over a 19-year period (2000-2019) with a minimum follow-up of 2 years were analyzed. Outcome measures were length of stay, operating time, satisfaction visual analog score (VAS), pain VAS, Oxford Shoulder Score (OSS), Constant-Murley score, range of movement, complications, and implant survival. Results: The incidence of a diagnosis of osteoarthritis as the surgical indication increased over time. The number of cases by surgeon per year increased from three cases in 2,000 to a peak of 33 in 2011. Up to seven implant manufacturers were used. The incidence of hemiarthroplasties decreased, and more numerous reverse polarity and anatomic arthroplasties were performed (P<0.001). More glenoid and humeral components were cemented and more short-stem implants were used in later years (P<0.001). Length of stay was a median of 1 day with a trend towards daytime surgery in recent years. Patients were satisfied (VAS 8/10) and OSS improved by 8 points on average throughout the observation period. Conclusions: Despite frequent introductions of new implants, patient outcome, satisfaction, and complication rates remained good. There appears to be a need for large-scale, generalizable studies to understand why technological advancements leading to changes in implants do not influence clinical outcomes. Level of evidence: III.
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Terminologia Anatomica, 2nd edition: perspectives from anatomy educators in the United KingdomEnglish anatomical terminology has evolved over the long history of anatomical practice, with major infuences from ancient Greek, classical Latin, Arabic, and post-classical Latin. Beginning in the nineteenth century, there have been various attempts to standardise and rationalise anatomical language, beginning in 1887, and culminating in the publication in 2019 of the second edition of the Terminologia Anatomica. This paper presents a brief historical overview of the development of anatomical terminology and usage in English, followed by a summary of the results of an anonymised survey of current practices that was sent out by email to anatomy educators at 45 medical schools in the United Kingdom. This is followed by personal refections by six senior academics and/or clinicians, reviewing their extensive experience of teaching, researching, and communicating the language of anatomy within United Kingdom medical and clinical institutions.
