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Traumatic injuries of the immature hip and pelvis.PURPOSE OF REVIEW: The pelvis and hip account for 0.3--4% of fractures of the immature skeleton, and generally result from high energy trauma. These fractures range in severity from apophyseal avulsions to complete disruptions of the pelvic ring. The purpose of this article is to review the presentation, diagnosis, treatment and complications of these injuries in order to inform clinicians involved in their management. There is a lack of evidence-based management protocols for fractures of the immature pelvis largely due to their rarity and lack of robust scientific literature on the topic. RECENT FINDINGS: Computed tomography/MRI is essential as up to 30% of pelvis and 70% of acetabular fractures are not identified on initial radiographs. A sub-optimal outcome is common in unstable fractures treated conservatively and adequate reduction and surgical stabilization is often required to avoid long-term morbidity. SUMMARY: A coordinated approach involves resuscitation and temporary stabilization with planned definitive fixation. It is generally accepted that these injures should be managed in paediatric trauma centres. Whilst injuries vary in pattern and severity, we present an overview that considers the evaluation and treatment of the paediatric patient with pelvic and hip fractures to ensure that these injuries are identified promptly and treated by surgeons familiar with contemporary management algorithms.
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Treatment of age-related macular degeneration with aflibercept using a treat, extend and fixed protocol; A 4-year study of treatment outcomes, durability, safety and quality of life (An extension to the MATE randomised controlled trial)Purpose: Data are limited pertaining to the long-term benefits of aflibercept treatment for neovascular age-related macular degeneration (nAMD). The aim of this study was to provide outcomes, safety, durability and quality-of-life data with aflibercept using a modified treat, extend and fixed regime over 4 years. Methods: Prospective, multicentre, single cohort observational study of treatment-naïve nAMD participants treated with aflibercept as 2-year extension of the MATE-trial that compared early and late Treat-and-Extend for 2 years. Refracted ETDRS best corrected visual acuity (BCVA), central retinal thickness (CRT), treatment interval and adverse events were assessed. Quality-of-life was measured using the Macular Disease Dependent Quality of Life (MacDQoL) and Macular Disease Treatment Satisfaction Questionnaires (MacTSQ). Results: Twenty-six of 40 participants completing the MATE-trial were enrolled with 20 completing the total 4-year study. Mean BCVA was 60.7 at Month 0 and 64.8 ETDRS letters at Month 48 while CRT decreased from 423.7 μm to 292.2 μm. Five participants discontinued treatment due to inactivity. The mean number of treatments and visits for the remaining participants was 27 and 30.0, respectively, with treatment intervals extended to 12 weeks in four participants at Month 48. Both AMD-specific QoL and treatment satisfaction remained stable between Months 0 and 48 and mean BCVA significantly correlated with AMD-specific QoL scores at Months 12, 24 and 48. Conclusions: Results suggest that BCVA can be maintained over 48 months when following a treat-extend-and-fix regimen of aflibercept with intervals out to 12 weeks, while maintaining AMD-specific QoL and treatment satisfaction.
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A Modified Technique for Lateral Column Lengthening as Part of Adult Acquired Flatfoot Deformity Correction: An Intact Medial Calcaneal Cortex, a Low-Profile Locking Plate with a Combination of Autologous Calcaneal Bone Graft and Demineralized Human Bone MatrixAdult acquired flatfoot deformity encompasses deformities of the entire foot and ankle, with most clinical presentations comprising of a flexible planovalgus deformity and forefoot abduction. Numerous operative procedures have been proposed, and a lateral column–lengthening procedure is advocated to correct the forefoot abduction. Autologous iliac crest bone graft is routinely inserted into the opening-wedge osteotomy at the anterior calcaneum. Fixation methods are also variable with increasing use of locking plates to achieve stability at this osteotomy. Harvesting the iliac crest graft exposes the patient to significant donor site morbidity. We describe a modified lateral column–lengthening technique, leaving the medial calcaneum cortex intact, packing a combination of autologous calcaneal bone graft, and demineralized bone matrix into the osteotomy site, fixed with a low-profile locking plate. In the short term, our technique offers reduced rates of wound complications, symptomatic hardware, nonunion, and deformity recurrence when compared with published rates.
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What you need to know about assessing a patient with diplopia.Diplopia occurs when two images are subjectively seen of a single object. It has a variety of causes, which range in severity from benign to sight or life threatening if left untreated. Clinical assessment of diplopia includes taking a comprehensive history to delineate the exact type of visual disturbance experienced by the patient and examination to pinpoint the aetiology, which is crucial for further management. This article discusses the causes of diplopia, along with risk factors and other associated symptoms, to facilitate diagnosis and management. Efficient and effective diagnosis is important, as some pathologies require immediate treatment to save the eyesight and/or life of the patient. This article will concentrate solely on binocular diplopia.
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TANDEM TRIAL: a factorial randomised controlled trial of dose and review schedule of bevacizumab (Avastin) for neovascular macular degeneration in the East MidlandsObjective: Neovascular age-related macular degeneration (nAMD) causes damage to the macula and severe vision loss. Bevacizumab is the most cost-effective nAMD treatment. The TANDEM trial was designed to determine whether, in patients with nAMD, low-dose bevacizumab is non-inferior to the standard dose in terms of visual deterioration and whether a bimonthly regimen is non-inferior to monthly, treatment as required, regimens. Methods: This was a multicentre, 2×2 factorial, double-masked, non-inferiority randomised trial with patients considered eligible if they met the National Institute for Health and Care Excellence criteria for nAMD treatment with ranibizumab. Participants were randomly assigned to standard (1.25 mg) or low (0.625 mg) dose bevacizumab and either monthly or bimonthly review regimen. The primary outcome was time to vision deterioration, defined as reduction of ≥15 letters (three lines) during the loading phase (visual acuity scores at visits B and C compared with the initial visit A), or ≥6 letters (one line) during the maintenance phase (visual acuity scores at subsequent visits compared with mean vision at visits A-C). Results: In total 812 participants (918 eyes) were randomised into the trial. The low dose showed some evidence of being non-inferior to standard dose (HR 1.07; 95% CI 0.80 to 1.42), however, there was no strong evidence of bimonthly review being non-inferior to monthly review (HR 1.45; 95% CI 1.09 to 1.94). There was no difference in visual acuity when assessed at 9 months and no major differences in the frequency of serious adverse events or reactions between the groups. Conclusion: The standard dose of bevacizumab can be halved without compromising efficacy. Bimonthly review cannot be considered to be no worse than monthly review.
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A Review and Comparison of the Efficacy of Prophylactic Interventional Radiological Arterial Occlusions in Placenta Accreta Spectrum Patients: A Meta-analysisRationale and objectives: Placenta accreta spectrum (PAS) disorders are increasingly common and associated with significant maternal and neonatal morbidity and mortality due to the associated risk of massive haemorrhage. Currently prophylactic interventional radiology (IR) arterial occlusion is being performed occluding either the internal iliac artery (IIA), abdominal aorta (AA) or uterine artery (UA) in order to prevent this blood loss. The aim of this meta-analysis is to identify whether these IR procedures are effective in reducing estimated blood loss (EBL) and hysterectomy rates and if so which method achieves the optimal results METHODS: A literature search was conducted to acquire case-control studies assessing EBL and hysterectomies performed following IR arterial occlusion in PAS patients, yielding 16 results. Studies were analyzed together and later split into groups dependent on the artery occluded. The results of these were then inputted into forest plots to identify their overall estimated effect with confidence intervals. Results: Prophylactic IR arterial occlusion was proven to reduce both EBL and hysterectomies. When separated by artery, IIA achieved the worst outcomes with no proven effect on EBL and a minimal reduction in hysterectomies. UA scored in the middle with a modest reduction in both outcomes, whilst AA occlusion had the most significant reduction in both EBL and hysterectomies. Conclusion: Prophylactic IR arterial occlusion should be routinely considered in PAS patients to reduce both EBL and rates of hysterectomies. Current literature promotes the use of IIA occlusion; however the findings of this analysis propose that AA and UA occlusion should be favoured.
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Manipulation of distal radius fractures: a comparison of Bier's block vs haematoma blockIntroduction: Displaced distal radius fractures often require manipulation under anaesthesia. Many anaesthetic techniques are described, with the two most commonly used being Bier's block (BB) and haematoma block (HB). Despite national guidance preferring a BB, an HB is often performed instead. This study aims to compare the analgesic properties of a BB with those of an HB when manipulating distal radius fractures. Methods: This is an observational cohort study comparing the management of displaced distal radius fractures requiring reduction across two National Health Service trusts. Patients aged over 18 with isolated, displaced distal radius fractures were recruited. Patient demographics, AO fracture classification and grade of clinician performing the procedure were recorded. A numeric rating scale (NRS) pain score was obtained for each patient after manipulation. The quality of reduction was judged against standardised anatomical parameters. Results: Some 200 patients were recruited (100 HB, 100 BB). There were no differences in age (BB: median 66.5 years, interquartile range [IQR] 55-74; HB: median 67 years, IQR 55-74; p = 0.79) or fracture characteristics (p = 0.29) between cohorts. Patients undergoing BB had significantly lower pain scores with a lower IQR than those undergoing HB (p < 0.005). Patients undergoing BB manipulation were more likely to have the fracture reduced and normal anatomy restored (p < 0.005). BBs were performed mainly by Foundation Year 2 junior doctors, whereas HB manipulations were performed by a range of clinicians from emergency nurse practitioners to consultants. Conclusions: BB provides better analgesia than an HB. This can be performed successfully and reliably by Senior House Officer-level junior doctors.
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Age and the anaesthetist: considerations for the individual anaesthetist and workforce planningThere is clear evidence of a growing workforce gap and this is compounded by demographic data that show the current workforce is ageing. Within the current workforce, more doctors are taking voluntary early retirement and the loss of these experienced clinicians from departments can have wide-ranging effects. Older doctors are at risk of age-related health problems (e.g. sight, musculoskeletal, menopause) and are more susceptible to the effects of fatigue, which may increase the risk of error and or complaint. The purpose of this working party and advocacy campaign was to address concerns over the number of consultants retiring at the earliest opportunity and whether a different approach could extend the working career of consultant anaesthetists and SAS doctors. This could be viewed as ‘pacing your career’. The earlier this is considered in a clinician's career the greater the potential mitigation on individuals.
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Is it safe for extended-role radiographers to measure migration percentage in children with cerebral palsy?.Introduction In the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration.The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals. Results The inter-rater reliability between radiographers was 0.938 (95% CI 0.914–0.991). The intra-rater reliability was 0.941 (95% CI 0.931–0.949).The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889–0.957). Conclusion The reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy. Implications for practice We recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.
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Adding evidence of the effects of treatments into relevant wikipedia pages: a randomised trialBackground Wikipedia is among the most popular sites on the internet, and around a fifth of all healthcare searches online directs to a Wikipedia page. In recent years steps have been taken to enhance the quality of their healthcare pages, such as the creation of the WikiProject Medicine initiative. In 2014 a partnership was formalised between Wikipedia and Cochrane Collaboration with similar aims. Three years ago, a group of medical students helped to formulate a protocol for the first ever randomised trial, whose aim was to test the value of Wikipedia in informing users about healthcare. Objectives To investigate the effects of adding high-grade quantitative evidence of outcomes of treatments into relevant Wikipedia pages on further information-seeking behaviour by the end-user. Methods: We randomised 70 Wikipedia pages, identified as highly relevant to up-to-date Cochrane Schizophrenia systematic reviews that contained a Summary of Findings table. Eligible Wikipedia pages in the intervention group (35) were seeded with tables listing best evidence of the effects of treatment, and hyperlinks to the source Cochrane review. Eligible pages in the control group (35) remained unchanged. Results The main outcome measures were routinely collected data on access to the full text and summary web page of the relevant Cochrane reviews (after 12 months). There was 100% follow-up of the 70 randomised pages. Six of the 35 in the intervention group had the tabular format deleted by other Wikipedia users during the course of the study, but all pages continued to report the same data within the text. The study found no evidence of significant effect on either of the co-primary outcomes: full text access adjusted ratio of geometric means 1.30, 95% CI: 0.71 to 2.38; page views 1.14, 95% CI: 0.6 to 2.13. Results were similar for all other outcomes, with the exception of Altmetric score for which there was evidence of clear effect (1.36, 95% CI: 1.05 to 1.78). Conclusions The pursuit of fair balance within Wikipedia healthcare pages is impressive and its reach unsurpassed. Enriching Wikipedia content is, potentially, a powerful way to improve health literacy among the public, and it is possible to test the effects of seeding pages with evidence. Though increased traffic to Cochrane reviews in the intervention group lacked statistical significance, there was nonetheless consistently an increase in all outcome measures. For every person that sought and clicked the reference on the 'intervention' Wikipedia page to seek more information (the primary outcome), many more are likely to have been informed by the page alone; the inclusion of high-quality data may have lessened the desire to click out to the original source. If demonstrated that the end-user becomes more informed as a result of such intervention, the potential as a tool for dissemination could be invaluable. Future studies should take such factors into consideration, and aim to replicate, expand and further develop our trial. Trial registration number IRCT2017070330407N2
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What influences nurses' decision to mobilise the critically ill patient?Background: Despite the known benefits of mobilising critically ill patients, bed rest is still a common practice in intensive care units. The reasons for this are not fully understood. Early mobilisation can reduce the length of stay in the intensive care unit and in hospitals as well. However, the decision to mobilise a patient can be delayed while health professionals decide whose role it is to implement it. Aim and objectives: The aim of this study was to explore the ways in which nurses make decisions to mobilise critically ill patients and what factors influence the decision-making process. Study design and method: This was a qualitative study involving semi-structured interviews with 12 critical care nurses at a large urban district hospital. Interpretative phenomenological analysis was used to analyse verbatim transcripts of the interviews. Results: The findings demonstrated inconsistencies in the nurses' knowledge of the benefits to mobilising patients and that mobilisation was deemed to be a low priority. Decision-making was influenced by time constraints, staffing levels, and unit demands. A lack of communication and collaborative working was identified, along with uncertainty and role ambiguity, with regard to who decides to mobilise a patient. Mobilisation was found to be complicated by existing cultural influences and by previous experiences of complex mobilisation. Conclusion: Re-education strategies are needed to re-enforce the benefits of mobilisation, along with multidisciplinary training sessions to clarify roles and overcome collaborative working issues. Relevance to clinical practice: This study has provided a greater understanding of the influencing factors on nurses' decision-making with regard to mobilising critical ill patients.
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A prospective study of two methods of analgesia in shoulder arthroscopic procedures as day case surgeryBackground & purpose: The recent advances in anaesthesia and analgesia have significantly improved the early recovery and effective post-operative pain control in day care surgery e.g. shoulder arthroscopic procedures. Adequate analgesia improves the early rehabilitation for a better outcome. We prospectively evaluated the post-operative pain relief following the two methods of analgesia i.e. regional Inter-scalene block (ISB) vs Intra-articular (IA) injection using 0.5% Chirocaine in various therapeutic arthroscopic shoulder procedures. Methods: A prospective comparative study was performed on a group of 105 patients (ASA grade I or II) who underwent the following procedures at two different hospitals: diagnostic arthroscopy, subacromial decompression (SAD) alone, SAD in combination with mini open cuff repairs or distal clavicle excision, anterior stabilization (Bankart's repair) and inferior capsular shift. A successful Inter-scalene block (0.5% Chirocaine-30mls) preceded the general anaesthesia (Group 1-52 patients). Local intra-articular infiltration (0.5% Chirocaine - 20 mls) was given postoperatively (Group 2-53 patients). Post operatively visual analogue scores (VAS) from 0 (no pain) to 10 (severe pain) were assessed in post-anaesthesia care unit (PACU), at 4hrs, at 24hrs and at 48 h. The amount of morphine consumption for the first 2 days after surgery was recorded. Results: Patient characteristics were similar in both groups at both the hospitals. The median postoperative pain score of VAS <3 was observed in both groups. Significant difference (p < 0.0001) was observed in the VAS scores between the two groups at all the time intervals. The mean length of adequate sensory block in group 1 was significantly higher than in group 2 [20.5 h: 4.2 h] (p < 0.001). The mean analgesic (morphine) consumption was lower in Group 1 as compared to Group 2 [4.6 mg/24 h: 18.8mg/24 h](p < 0.0001). Bone shaving procedures e.g. SAD, SAD + Rotator Cuff repair, SAD + Lateral clavicular excision required significantly higher analgesia in both groups compared to the soft tissue procedures. Conclusion: Single dose ISB provided longer and effective postoperative analgesia. The bone shaving procedures required more analgesia in IA Group as compared to ISB Group.
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Radiofrequency denervation of the lumbar facet joints: guidelines for the RADICAL randomised controlled trialBackground and aim: The RADICAL trial has been funded by the National Institute for Health Research (NIHR) to evaluate the clinical and cost-effectiveness of radiofrequency denervation (RFD) for low back pain. Recommendations have been published which aim to standardise selection of patients and RFD technique. However, it is important to ensure these recommendations are acceptable to clinicians within the context of the trial. The aim of this work was to develop standardised criteria for the trial entry and RFD technique for implementation within the RADICAL trial. Methods: Fourteen pain clinicians completed a survey, which involved reviewing the current recommendations and indicating whether they disagreed with any of the recommendations and if so why. Responses were collated and presented at a half-day workshop with 14 attendees. During the workshop, the National Low Back and Radicular Pain Pathway (NLBRPP) guidelines for patient selection and an article by Eldabe and colleagues presenting recommendations on the RFD technique were reviewed. Attendees discussed whether each component of the recommendations should be mandatory, mandatory with alteration or clarification or optional within the RADICAL trial. Results: Attendees agreed during the workshop that 5 of the 10 criteria for patient selection described in the NLBRPP should be mandatory within the RADICAL trial. Three were agreed as mandatory criteria but required further clarification, one of which involved defining a positive response to a diagnostic medial branch block as ⩾60% pain relief. Two criteria had optional components. After reviewing the recommendations on the RFD technique from Eldabe and colleagues, seven components were agreed as mandatory, three were mandatory with alterations and three were optional. Conclusion: When evaluating complex interventions, such as RFD, it is important to ensure agreement and clarity on the clinical protocol, so that the intervention can be reproduced, if found to be effective.
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Prospective observational cohort study on grading the severity of postoperative complications in global surgery researchBackground: The Clavien-Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien-Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods: This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien-Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results: A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien-Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion: Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.
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Low trauma posterior native hip dislocation with acute longitudinal transverse myelitis due to SARS-CoV-2 - A case-reportBackground: Native hip dislocations are most commonly seen after high energy trauma. While there are documented cases of hip dislocation with associated stroke, we present a case of posterior hip dislocation in the context of acute longitudinal transverse myelitis due to a rare presentation of SARS-CoV-2. Case report: A 60-year-old male presented with bilateral lower limb weakness with a shortened internally rotated left leg. Plain radiographs revealed a posteriorly dislocated native left hip and MRI of the spine showed acute longitudinal transverse myelitis of the cervical and thoracic regions. His nasopharyngeal swab was positive for SARS-CoV-2. His hip was reduced, and he was treated with intravenous steroids. His neurological symptoms improved with follow-up MRI showing resolution of the transverse myelitis. Conclusion: This case illustrates a classic orthopaedic emergency in the context of a rare presentation of SARS-CoV-2, and the vigilance that orthopaedic doctors must have when examining patients with lower limb neurological deficit.
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Does Patellar Resurfacing Matter? Midterm Follow-Up of MRK Total Knee ReplacementBackground: Many designs of TKR have been developed to optimize the kinematics and improve satisfaction, including the 'medial rotating' philosophy. The purpose of this study is to report the mid-term clinical outcome of MRK knees and evaluate whether resurfacing the patella makes any difference in outcome. Methods: A retrospective analysis was done of 104 MRK total knee replacement done between 2008 and 2017. Patients were called for a review for evaluation of OKS, Baldini and Feller scores. Demographics of the patients, clinical outcome, complications were assessed. Results: 62 had patellar resurfacing. Mean follow-up was 74.45 months in non- resurfaced and 54.93 months in resurfaced group. Mean flexion range in both groups at final follow-up was 101.45. Median OKS at follow-up was 36 (12-47) in non-resurfaced and 37 (9-48) in resurfaced group. Patella scores were better in resurfaced group-Baldini score median (range) was 90 (25-100) in non-resurfaced v/s 100 (30-100) in resurfaced, Feller score median (range) was 25 (12-30) in non-resurfaced v/s 28 (10-30) (p 0.042) in resurfaced. The patellofemoral component of the OKS (Q5 + Q7 + Q12) median showed an improvement from 3 (1-11) to 6.5 (3-11) in non-resurfaced and from 3 (0-12) to 8 (2-12) (p 0.039) in resurfaced group. There were five complications overall (4.8%). Conclusion: These results show a satisfactory outcome at mid-term follow-up. We found a statistically significant difference in Feller score and in the patellofemoral component of OKS between the groups of MRK knee suggesting specific benefits of patellar resurfacing with this implant.
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Fire safety and emergency evacuation guidelines for intensive care units and operating theatres: for use in the event of fire, flood, power cut, oxygen supply failure, noxious gas, structural collapse or other critical incidents: Guidelines from the Association of Anaesthetists and the Intensive Care SocietyThe need to evacuate an ICU or operating theatre complex during a fire or other emergency is a rare event but one potentially fraught with difficulty: Not only is there a risk that patients may come to harm but also that staff may be injured and unable to work. Designing newly-built or refurbished ICUs and operating theatre suites is an opportunity to incorporate mandatory fire safety features and improve the management and outcomes of such emergencies: These include well-marked manual fire call points and oxygen shut off valves (area valve service units); the ability to isolate individual zones; multiple clear exit routes; small bays or side rooms; preference for ground floor ICU location and interconnecting routes with operating theatres; separate clinical and non-clinical areas. ICUs and operating theatre suites should have a bespoke emergency evacuation plan and route map that is readily available. Staff should receive practical fire and evacuation training in their clinical area of work on induction and annually as part of mandatory training, including 'walk-through practice' or simulation training and location of manual fire call points and fire extinguishers, evacuation routes and location and operation of area valve service units. The staff member in charge of each shift should be able to select and operate fire extinguishers and lead an evacuation. Following an emergency evacuation, a network-wide response should be activated, including retrieval and transport of patients to other ICUs if needed. A full investigation should take place and ongoing support and follow-up of staff provided.
