Assessing the Influence of Age, Weight, and Pirani Score on the Number of Casts During the Initial Phase of Clubfoot Treatment Using the Ponseti Method: A Prospective Study.

Background: Clubfoot, also known as congenital talipes equinovarus is a prevalent childhood ailment that, if untreated, can lead to long-term discomfort and impairment. The Ponseti technique, aimed at achieving corrected foot positioning, is widely accepted. This study investigated the influence of clubfoot severity (Pirani score), patient age, and initial manipulation and casting weight on the overall number of casts needed for effective treatment. Methods: A prospective study was carried out involving 40 idiopathic clubfoot patients where manipulation and casting were performed following the Ponseti method. Patient age, weight, and foot Pirani score were evaluated concerning the total number of casts needed to achieve 70° of abduction. Results: The majority of participants were male infants aged 4-6 months, with a median age of 4.5 months. Half of them weighed between 3.00 and 4.99 kg at their first hospital visit, with a median weight of 3.20 kg. Bilateral clubfoot involvement was common (57.5%). Children with Pirani HFCS 2.0-3 often required percutaneous tenotomy (87.5%, p value 0.05). On average, patients needed 5 casts (range 3-9). The mean total Pirani scores were 4.71 for the right foot and 4.61 for the left foot. The study reported a positive correlation between higher total Pirani scores and the required number of casts. Conclusions: The Pirani scoring system is highly accurate in assessing clubfoot severity and predicting treatment success. It emerged as the single most significant predictor for both the total number of casts and the need for percutaneous tenotomy.

Lack of regional pathways impact on surgical delay: Analysis of the Orthopaedic Trauma Hospital Outcomes-Patient Operative Delays (ORTHOPOD) study.

INTRODUCTION: Current practice following injury within the United Kingdom is to receive surgery, at the institution of first contact regardless of ability to provide timely intervention and inconsiderate of neighbouring hospital resource and capacity. This can lead to a mismatch of demand and capacity, delayed surgery and stress within hospital systems, particularly with regards to elective services. We demonstrate through a multicentre, multinational study, the impact of this at scale. METHODOLOGY: ORTHOPOD data collection period was between 22/08/2022 and 16/10/2022 and consisted of two arms. Arm 1 captured orthopaedic trauma caseload and capacity in terms of sessions available per centre and patients awaiting surgery per centre per given week. Arm 2 recorded patient and injury demographics, time of decision making, outpatient and inpatient timeframes as well as time to surgery. Hand and spine cases were excluded. For this regional comparison, regional trauma networks with a minimum of four centres enroled onto the ORTHOPOD study were exclusively analysed. RESULTS: Following analysis of 11,202 patient episodes across 30 hospitals we found no movement of any patient between hospitals to enable prompt surgery. There is no current system to move patients, between regional centres despite clear discrepancies in workload per capacity across the United Kingdom. Many patients wait for days for surgery when simple transfer to a neighbouring hospital (within 10 miles in many instances) would result in prompt care within national guidelines. CONCLUSION: Most trauma patients in the United Kingdom are managed exclusively at the place of first presentation, with no consideration of alternative pathways to local hospitals that may, at that time, offer increased operative capacity and a shorter waiting time. There is no oversight of trauma workload per capacity at neighbouring hospitals within a regional trauma network. This leads to a marked disparity in waiting time to surgery, and subsequently it can be inferred but not proven, poorer patient experience and outcomes. This inevitably leads to a strain on the overall trauma system and across several centres can impact on elective surgery recovery. We propose the consideration of inter-regional network collaboration, aligned with the Major Trauma System.

ORthopaedic trauma hospital outcomes - Patient operative delays (ORTHOPOD) Study: The management of day-case orthopaedic trauma in the United Kingdom.

INTRODUCTION: ORTHOPOD: Day Case Trauma is a multicentre prospective service evaluation of day-case trauma surgery across four countries. It is an epidemiological assessment of injury burden, patient pathways, theatre capacity, time to surgery and cancellation. It is the first evaluation of day-case trauma processes and system performance at nationwide scale. METHODS: Data was prospectively recorded through a collaborative approach. Arm one captured weekly caseload burden and operating theatre capacity. Arm two detailed patient and injury demographics, and time to surgery for specific injury groups. Patients scheduled for surgery between 22/08/22 and 16/10/22 and operated on before 31/10/22, were included. For this analysis, hand and spine injuries were excluded. RESULTS: Data was obtained from 86 Data Access Groups (70 in England, 2 in Wales, 10 in Scotland and 4 in Northern Ireland). After exclusions, 709 weeks worth of data representing 23,138 operative cases were analysed. Day-case trauma patients (DCTP) accounted for 29.1% of overall trauma burden and utilised 25.7% of general trauma list capacity. They were predominantly adults aged 18 to 59 (56.7%) with upper limb Injuries (65.7%). Across the four nations, the median number of day-case trauma lists (DCTL) available per week was 0 (IQR 1). 6 of 84 (7.1%) hospitals had at least five DCTLs per week. Rates of cancellation (13.2% day-case; 11.9% inpatient) and escalation to elective operating lists (9.1% day-case; 3.4% inpatient) were higher in DCTPs. For equivalent injuries, DCTPs waited longer for surgery. Distal radius and ankle fractures had median times to surgery within national recommendations: 3 days and 6 days respectively. Outpatient route to surgery was varied. Dominant pathways (>50% patients listed at that episode) in England and Wales were uncommon but the most frequently seen was listing patients in the emergency department, 16 of 80 hospitals (20%). CONCLUSION: There is significant mismatch in DCTP management and resource availability. There is also considerable variation in DCTP route to surgery. Suitable DCTL patients are often managed as inpatients. Improving day-case trauma services reduces the burden on general trauma lists and this study demonstrates there is considerable scope for service and pathway development and improved patient experience.

Bone mineral density in fracture neck of femur patients: What's the significance?

BACKGROUND: The National Institute for Health and Care Excellence (NICE) guidelines have advised further research is required into investigating the added prognostic value of bone mineral density (BMD) in the assessment of fracture risk with the Fracture Risk Assessment Tool (FRAX) score. AIM: To investigate the significance of BMD in fracture neck of femur patients and compare it to the outcome of the FRAX score. METHODS: Inclusion criteria for this study were all patients who underwent dual-energy X-ray absorptiometry (DXA) scan following fracture neck of femur between 2015 and 2017. Analysis of BMD, FRAX scores and patient demographic data was undertaken. RESULTS: A total of 69 patients were included in the study, mean age 74.1 years. There was no significant difference between mean BMD of the femoral neck in males (0.65) as compared to females (0.61) (P = 0.364). Analyses showed no significant correlation between BMD and menopause age (rs = -0.28, P = 0.090). A significant difference was seen of the femoral neck BMD between the different fracture pattern types (P = 0.026). A stronger correlation was observed between BMD of femoral neck and FRAX major score (rs = -0.64, P < 0.001) than with BMD of lumbar spine and FRAX major score (rs = -0.37, P = 0.003). CONCLUSION: This study demonstrated that BMD of the femoral neck measured by DXA scan is of added prognostic value when assessing patients for risk of fracture neck of femur in combination with the FRAX predictive scoring system.

Proximal femoral fracture outcomes in inpatients and community patients: A comparative study.

OBJECTIVES: 7% of proximal femoral fractures occur in patients admitted to hospital for unrelated medical and surgical presentations. This comparative study will assess morbidity and mortality in patients sustaining proximal femoral fractures both as inpatients and in the community. METHODS: Retrospective review of patients admitted to a regional specialist hip unit with fracture of the proximal femur sustained both from the community and other inpatient settings. Patient demographics, risk factors and outcomes were recorded and analysed - with focus on 30-day and 1-year mortality. RESULTS: 3445 patients were admitted over a 10-year period, 292 of which sustained proximal femoral fractures as an inpatient. 30-day and 1-year mortality was 23.7% and 47.9% respectively in the inpatient group, compared to 6.9% and 22.4% respectively in the community group. Mean time from presentation to operating room was 27.8 hours for the inpatient group, compared to 25.2 hours for the community group. CONCLUSION: Inpatients who sustain a proximal femoral fracture have significantly higher 30-day and 1-year mortality rates when compared to patients in the community sustaining the same injury. There is also a noted delay to theatre in this patient group.

After you Roux, what do you do? A systematic review of most successful advanced assisted ERCP techniques in patients with various altered upper gastrointestinal surgical anatomical reconstructions with particular focus on RYGB (last 10 years).

Access to the Common Bile Duct in patients with surgically altered UGI anatomy such as RYGB is exceptionally challenging. Previously, these patients could only be treated by open surgery; however, multiple new advanced assisted ERCP techniques such as EDGE, LA-ERCP, and DEA-ERCP have now been developed and indeed successfully used to treat these patients. Despite growing experience, these techniques have yet to become part of our mainstream practice and many clinicians remain unfamiliar or even unaware of them; as a result, they are unfortunately often overlooked. We conducted this systematic review to try and shed more light on them and understand which of these techniques resulted in the best patient outcomes. We conducted a systematic review of PubMed database publications between December 2008 and December 2018. Keyword variants of "EDGE, Enteroscopy-assisted & laparoscopy-assisted ERCP" and "altered surgical anatomy" were combined to identify relevant papers for inclusion. We identified 34 studies, comprising a total of 1848 advanced assisted ERCPs in patients with altered UGI anatomy from 12 different countries. These papers were critically appraised, summarised, and presented in table format. EDGE and LA-ERCP were associated with both the highest overall combined CBD cannulation rates (99.3% for both vs 74.6% for DEA-ERCP) and ERCP interventional success (98.3% for EDGE vs 97.4% for LA-ERCP and 67.6% for DEA-ERCP). Advanced ERCP is associated with excellent success rates and a higher safety profile than surgery; however, patient selection and identification of the exact surgical anatomy are key.

The use of ultrasound-guided platelet-rich plasma injections in the treatment of hip osteoarthritis: a systematic review of the literature.

Purpose: This review aims to determine whether ultrasound-guided platelet-rich plasma injection has any role in improving clinical outcomes in patients with hip osteoarthritis. Methods: A search of the National Institute for Health and Care Excellence database using the Healthcare Databases Advanced Search tool was conducted. The PubMed database was also utilised to search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index of Nursing and Allied Health and Allied and Complimentary Medicine databases. The Preferred Reporting Items for Systematic Review and Meta-Analysis methodology guidance was employed and a quality assessment was performed using the Jadad score. Results: Three randomised clinical trials met the inclusion criteria and were included for analysis. All three trials were of good quality based on the Jadad score. A total of 115 patients out of 254 received platelet-rich plasma injections under ultrasound guidance. The platelet-rich plasma recipient group included 61 males and 54 females with an age range from 53 to 71 years. Outcome scores show an improvement of symptoms and function maintained up to 12 months following platelet-rich plasma injection. Conclusions: Literature to date concludes that intra-articular platelet-rich plasma injections of the hip, performed under ultrasound guidance to treat hip osteoarthritis, are well tolerated and potentially efficacious in delivering long-term and clinically significant pain reduction and functional improvement in patients with hip osteoarthritis. Larger future trials including a placebo group are required to further evaluate these promising results. Level of evidence: Level I, a systematic review of level I studies.Purpose: This review aims to determine whether ultrasound-guided platelet-rich plasma injection has any role in improving clinical outcomes in patients with hip osteoarthritis. Methods: A search of the National Institute for Health and Care Excellence database using the Healthcare Databases Advanced Search tool was conducted. The PubMed database was also utilised to search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index of Nursing and Allied Health and Allied and Complimentary Medicine databases. The Preferred Reporting Items for Systematic Review and Meta-Analysis methodology guidance was employed and a quality assessment was performed using the Jadad score. Results: Three randomised clinical trials met the inclusion criteria and were included for analysis. All three trials were of good quality based on the Jadad score. A total of 115 patients out of 254 received platelet-rich plasma injections under ultrasound guidance. The platelet-rich plasma recipient group included 61 males and 54 females with an age range from 53 to 71 years. Outcome scores show an improvement of symptoms and function maintained up to 12 months following platelet-rich plasma injection. Conclusions: Literature to date concludes that intra-articular platelet-rich plasma injections of the hip, performed under ultrasound guidance to treat hip osteoarthritis, are well tolerated and potentially efficacious in delivering long-term and clinically significant pain reduction and functional improvement in patients with hip osteoarthritis. Larger future trials including a placebo group are required to further evaluate these promising results. Level of evidence: Level I, a systematic review of level I studies.

Giant colonic lipoma presenting with intermittent intestinal obstruction.

Lipomas of gastrointestinal (GI) tract are the common benign tumours. They are usually small and asymptomatic; however, large colonic lipoma is a rare tumour and may cause intestinal obstruction. A similar rare case of large lipoma, treated with laparoscopic right hemicolectomy, is reported here.