Preventable deaths in hospitalized trauma patients.

AIM: To study the preventable trauma deaths of hospitalized patients in the United Arab Emirates and to identify opportunities for improvement. METHODS: We analyzed the Abu Dhabi Emirate Trauma Registry data of admitted patients who died in the emergency department or in hospital from 2014 to 2019. A panel of experts categorize the deaths into not preventable (NP), potentially preventable (PP), and definitely preventable (DP). RESULTS: A total of 405 deaths were included, and 82.7% were males. The majority (89.1%) were NP, occurring mainly in the emergency department (40.4%) and the intensive care unit (49.9%). The combined potentially preventable and preventable death rate was 10.9%. The median (Interquartile range) age of the DP was 57.5 (37-76) years, compared with 32 (24-42) and 34 (25-55) years for NP and PP, respectively (p = 0.008). Most of the PP deaths occurred in the intensive care unit (55.6%), while the DP occurred mainly in the ward (50%). Falls accounted for 25% of PP and DP. Deficiencies in airway care, hemorrhage control, and fluid management were identified in 25%, 43.2% and 29.5% of the DP/PP deaths, respectively. Seventy-two percent of the Airway deficiencies occurred in the prehospital, while 34.1% of hemorrhage control deficiencies were in the emergency department. Fluid management deficiencies occurred in the emergency department and the operation theater. CONCLUSIONS: DP and PP deaths comprised 10.9% of the deaths. Most of the DP occurred in the emergency department and ward. Prehospital Airway and in-hospital hemorrhage and excessive fluid were the main areas for opportunities for improvement.

Arthroscopic Fixation of Symptomatic Meso-Type Os Acromiale: Technical Note.

Symptomatic Os acromiale can cause pain, impingement, and reduced range of movement. Disruption of the syndesmosis can result in significant pain and functional impairment; this may occur after trauma. Symptomatic Os acromiale is treated by either excision or fixation. Fixation via open technique is the mainstay of surgical intervention; however, recently, arthroscopic methods were used. In this technical note, we discuss the modification for all arthroscopic Os acromiale fixation; the fixation screws are introduced in anteroposterior fashion, employing the advances in orthopaedic fixation devices. Arthroscopic fixation is not widely adopted, possibly due to availability of implants and perceived difficult learning curve. We report this technique and demonstrate reproducibility with excellent results.

Surgical training fit for the future: the need for a change.

Postgraduate training in surgical specialties is one of the longest training programmes in the medical field. Most of the surgical training programmes require 5-6 years of postgraduate training to become qualified. This is usually followed by 1-2 years of fellowship training in a subspecialised interest. This has been the case for the last 20-30 years with no significant change. The surgical practice is transforming quickly due to the advances in medical technology. This transformation is not matched in the postgraduate training, there is minimal exposure to the new technological advances in early years of postgraduate training. The current postgraduate training in surgical specialties is not fit for the future. Early exposure to robotic and artificial intelligence technologies is required. To achieve this, a significant transformation of surgical training is necessary, which requires a new vision and involves significant investment. We discuss the need for this transformation in the postgraduate surgical specialties training and analyse the threats and opportunities in relation to this transformation.

Functional bracing is a safe and cost effective treatment for isolated Weber B fracture.

BACKGROUND: Despite the current recommendations that stable Weber B ankle fractures can be treated with functional bracing and weightbearing as tolerated, some reluctance exists among trauma surgeons to follow these recommendations. This paper reports on our institution's experience in managing these injuries and compare it to the national guidelines. PATIENTS AND METHODS: This is a retrospective cohort study. Consecutive patients with isolated Weber B fractures referred to the local outpatient clinic over the period of six months were included in the study. Radiographs and clinic letters were examined, the patients were interviewed via telephone to obtain outcome scores [Olerud and Molander score]. Method of immobilisation, weight-bearing status, radiological fracture union, clinical outcomes and complications were all assessed and analysed. RESULTS: One hundred and twenty-three patients with isolated Weber B fractures were identified. This cohort of patients did not show clinical or radiographic evidence of instability, they were deemed stable and were initially treated non-operatively. Minimum follow-up period was six months. Sixty-two patients were treated in plaster and were non-weight bearing on the affected limb, while 61 were treated with functional bracing in a boot and were allowed early weight bearing. Three patients showed displacement requiring surgical fixation. All fractures progressed to union and patients were discharged irrespective of the method of immobilisation or weightbearing status during treatment. There was no statistically significant difference in the functional outcome measures between the two groups. The protocol of functional bracing and weightbearing was associated with fewer outpatient clinics and a reduced number of radiographs obtained in the clinic and fewer complications. CONCLUSION: Isolated trans-syndesmotic Weber B ankle fractures, that are clinically and radiologically stable, can be safely treated with functional bracing in a boot and weightbearing as tolerated.

Does Hyaluronan improve pain or function following Arthroscopic Subacromial decompression (ASD) surgery of Shoulder? Results of a level 1 RCT.

BACKGROUND: Sodium hyaluronate (hyaluronan) can be used as a synovial fluid substitute following arthroscopic surgery. In this study, we examined its effect on pain and function following arthroscopic subacromial arthroscopic decompression (ASAD). METHODOLOGY: A prospective, randomized, and single-blinded design was used (13/LO0427) to compare the effect of a single postprocedure subacromial instillation of 10 ml hyaluronan, against 10 ml saline control. All patients had interscalene block along with general anesthesia and followed standard postoperative rehabilitation protocol. A power calculation for a 6-point difference in Oxford Shoulder Score (OSS) indicated a minimum sample size of 44. Participants were assessed preoperatively, and at 12 weeks using the following outcome measures -Oxford Shoulder Score (OSS), visual analog score (VAS), European quality of life score (EUROQOL), and Disability of the arm, shoulder, and hand (DASH) scores. RESULTS: 46 patients were included for analysis. Both groups showed a mean improvement in OSS of 9 points (P = 0.0001), DASH (10 points, P < 0.05), and EUROQOL (0.13, P < 0.05). No significant difference was observed between groups in any of the recorded outcomes. Apart from one case of frozen shoulder in each group, no other complications were noted. CONCLUSION: While both groups showed improved pain and function scores after ASAD, no significant difference was seen between groups receiving placebo or hyaluronan. The intervention is safe but, in this study, has not been shown to improve postoperative pain or function over ASAD alone. Level of evidence: I.

More than 40 years' follow-up of an unconstrained metal lunate replacement for the treatment of Kienböck's disease.

Kienböck's disease is characterised by avascular necrosis of the lunate bone, and over the years it has been a challenging disease to manage, with differing opinions on the best intervention. We present an interesting case of a metallic unconstrained lunate replacement that is still functioning well in a patient 40 years after surgery. This case report represents the longest follow-up of any such prosthesis.

Augmentation and repair of tendons using demineralised cortical bone.

BACKGROUND: In severe injuries with loss of tendon substance a tendon graft or a synthetic substitute is usually used to restore functional length. This is usually associated with donor site morbidity, host tissue reactions and lack of remodelling of the synthetic substitutes, which may result in suboptimal outcome. A biocompatible graft with mechanical and structural properties that replicate those of normal tendon and ligament has so far not been identified. The use of demineralised bone for tendon reattachment onto bone has been shown to be effective in promoting the regeneration of a normal enthesis. Because of its properties, we proposed that Demineralised Cortical Bone (DCB) could be used in repair of a large tendon defect. METHODS: Allogenic DCB grafts in strip form were prepared from sheep cortical bone by acid decalcification and used to replace the enthesis and distal 1 cm of the ovine patellar tendon adjacent to the tibial tuberosity. In 6 animals the DCB strip was used to bridge the gap between the resected end of the tendon and was attached with bone anchors. Force plate analysis was done for each animal preoperatively and at weeks 3, 9, and 12 post operatively. At week 12, after euthanasia x-rays were taken and range of movements were recorded for hind limbs of each animal. Patella, patellar tendon - DCB and proximal tibia were harvested as a block and pQCT scan was done prior to histological analysis. RESULTS: Over time functional weight bearing significantly increased from 44% at 3 weeks post surgery to 79% at week 12. On retrieval none of the specimens showed any evidence of ossification of the DCB. Histological analysis proved formation of neo-enthesis with presence of fibrocartilage and mineralised fibrocartilage in all the specimens. DCB grafts contained host cells and showed evidence of vascularisation. Remodelling of the collagen leading to ligamentisation of the DCB was proved by the presence of crimp in the DCB graft on polarized microscopy. CONCLUSION: Combined with the appropriate surgical techniques, DCB can be used to achieve early mobilization and regeneration of a tendon defect which may be applicable to the repair of chronic rotator cuff injury in humans.

Acute compartment syndrome of the forearm as a rare complication of toxic epidermal necrolysis: a case report.

INTRODUCTION: Toxic epidermal necrolysis lies within the spectrum of severe cutaneous adverse reactions induced by drugs, affecting skin and mucous membranes. Toxic epidermal necrolysis is considered a medical emergency as it is considered to be potentially fatal and carries a high mortality rate. To the best of our knowledge the association of toxic epidermal necrolysis and compartment syndrome has been rarely mentioned in the literature. In this case we treated the compartment syndrome promptly despite the poor general condition and skin status of our patient. Despite the poor skin condition, wound healing was uneventful with no complications. CASE PRESENTATION: A 62-year-old Caucasian man with a generalized macular-vesicular rash involving 90% of his body surface area and mucous membranes, as well as impaired renal and hepatic functions following ingestion of allopurinol for treatment of gout, was admitted to our hospital. Skin biopsies were taken and he was started on a steroid infusion. Within hours of admission, he developed acute compartment syndrome of the dominant forearm and hand. CONCLUSIONS: Despite its rare incidence, toxic epidermal necrolysis is a condition with a high incidence of complications and mortality. Patients with severe conditions affecting a large degree of the skin surface area should be treated as promptly and effectively as patients with burns, with close monitoring and the anticipation that rare musculoskeletal complications might arise. The association of compartment syndrome and toxic epidermal necrolysis might lead to a rapid deterioration and fatal systemic involvement and multiple organ failures.

Patient satisfaction with postoperative follow-up by a hand therapist.

PURPOSE: There has been a move to reduce and, indeed, stop postoperative appointments for uncomplicated surgical procedures within the National Health Service. The purpose of this study was to measure patient satisfaction with postoperative follow-up conducted by a hand therapist, with no routine postoperative follow-up by the surgeon. METHODS: A total of 124 patients were recruited over two years. Fifty patients post-simple trapeziectomy and 74 patients post-single-digit Dupuytren's fasciectomy were prospectively surveyed for their opinion on their postoperative care and whether or not they would have liked to be reviewed by the surgeon in a routine postoperative follow-up appointment. All patients included in this study had their operations performed by one surgeon in one hospital. All patients were reviewed by a hand therapist within two weeks of surgery. RESULTS: A total of 116 patients completed the study, of whom 106 patients (91%) were satisfied with their postoperative management and 99 patients (85%) did not want to be reviewed by the surgeon in a postoperative outpatient follow-up appointment. DISCUSSION: This study reflects the successful application of postoperative follow-up by a hand therapist.