The Outreach Virtual Fracture Clinic - a Pilot Report of the Initial Nine Months.

The virtual fracture clinic (VFC) enables the safe, cost-effective delivery of high-quality patient-centred fracture care, whilst reducing hospital footfall. Within our institution, an Outreach VFC was launched, accepting a pre-defined range of trauma referrals from the outreach centre's emergency department (ED). The initial nine months' worth of cases referred to the Outreach VFC were assessed. The injury pattern, time to review, treatment plan and discharge destination of each referred patient were examined. A total of 822 patients were referred to the Outreach VFC during its initial nine months in operation. Owing to COVID-19-related alterations in the patient pathway, 58.1% of patients were referred on to fracture clinic/ED, with 34.4% of patients being referred for physiotherapy input. 44.9% of patients were reviewed at the Outreach VFC within 72 hours of ED presentation, with 88.6% of patients reviewed within 7 days. The Outreach VFC pilot initiative saved the Dublin Midlands Hospitals Group approximately €83,022 over nine months. The Outreach VFC model represents a novel approach to trauma care delivery with advantages for patient and hospital alike. Rural communities serve to benefit from its future implementation and the remote management of orthopaedic trauma. The Outreach VFC model provides a means of delivering safe and timely orthopaedic care whilst maintaining high levels of patient satisfaction.

The Effect of COVID-19 on 30-Day Mortality Rates Amongst Fragility Hip Fracture Patients.

Aim Fragility hip fracture patients have always been vulnerable to high rates of short term mortality, an issue that may have been exacerbated by the ongoing COVID-19 pandemic. To date, published data regarding Irish hip fracture patients in the era of COVID-19 is limited. This study aims to assess the effect of COVID-19 on 30-day mortality rates amongst a group of Irish hip fracture patients. Additionally, patient demographics, length of stay, admission haematological parameters, fracture type and surgical procedure will be assessed. Methods A multicentre, observational, retrospective study of hip fracture patients (n = 1,017) admitted to six Dublin teaching hospitals during the COVID-19 pandemic (4th February to 9th July 2020) was performed. For comparative purposes, equivalent data was retrospectively collected relating to hip fracture patients admitted to the same six teaching hospitals during the same time period in 2019. Results 481 patients were admitted during the specified timeframe in 2020, compared with 536 in 2019. The mean patient age was 77.6 years and 65.9% of patients were female. There was no statistically significant overall difference in 30-day mortality rates between the study and control groups, at 5.4% in 2020 and 4.3% in 2019 (p=0.338). There was an insignificant decrease in mean length of stay (17.85 days in 2020 vs. 18.82 days in 2019; p=0.106). Advancing age (p=0.021), male gender (p=0.019), low admission haemoglobin (p=0.024) and high admission white cell count (p=0.019) were all associated with increased 30-day mortality. Conclusion We found no significant difference in 30-day mortality rates amongst our cohort of hip fracture patients at the height of the COVID-19 pandemic in Ireland. Advancing age, male gender, anaemia at admission and leucocytosis at admission were associated with increased 30-day mortality. The continuation of COVID-19 related safety protocols in the treatment of hip fracture patients is essential in maintaining a safe hip fracture service.

Medium-term outcomes in single anaesthetic bilateral total knee replacement surgery: a single surgeon series.

BACKGROUND: The lifetime risk of developing symptomatic knee osteoarthritis (OA) is estimated to be 45%, with up to two thirds of patients presenting with bilateral knee symptoms. Patients presenting with end stage bilateral knee OA may benefit from single anaesthetic bilateral total knee replacement (SABTKR). Our study aim was to compare the outcomes of SABTKR with unilateral total knee arthroplasty (TKA) in a single surgeon series over a 20 year period. METHODS: We performed a retrospective review of a single surgeon's data from the New Zealand Joint Registry (NZJR) over a 20-year period from January 1999 to December 2018. This review reports on patient demographics, functional outcomes, revision rates and mortality rates. RESULTS: 1225 total knee replacements were performed by the senior author (995 TKAs and 115 patients underwent SABTKRs) over the 20 year period reviewed. The mean ages of the TKA and SABTKR groups were 67.7 and 66.7 years, respectively. There was 16.9% mortality rate for the TKA group versus 7.8% in SABTKR group. There were no revisions in the SABTKR group versus 17 revisions in the TKA group representing a revision rate of 0.23/100 component years which can be viewed against a 20 year revision rate of 0.48/100 component years (p < 0.05) for all comers in the NZJR. CONCLUSION: This NZJR study demonstrates excellent medium term survival outcomes for selected patients having simultaneous bilateral total knee replacements.

The opportunity cost of arthroplasty training in orthopaedic surgery.

INTRODUCTION: Training the next generation of surgeons is a crucial role fulfilled by consultant orthopaedic surgeons. However we are increasingly constrained by limited time and resources. We sought to compare operative time and length of stay (LOS) for total hip and total knee arthroplasties (THA, TKA) performed by a consultant orthopaedic surgeon with those performed by supervised trainees. MATERIALS AND METHODS: A prospective database of arthroplasty procedures performed from 2015 to 2018 was collated. Primary surgeon grade was recorded. Patient demographics, ASA grade, LOS and operative time were recorded. For THA both cemented and uncemented arthroplasties were used. SPSS version 23 was used for statistical analysis. RESULTS: 394 arthroplasty procedures were carried out during the study period. Trainee surgeons performed a high proportion of both THA (53.2%, n = 123) and TKA (44.8%, n = 73) surgeries. Trainees performed 57% of cemented THA procedures. LOS did not differ between consultant and trainee surgeons for THA (5.9 ± 4.8 days) or TKA (5.6 ± 4.1 days). Age had a significant effect on LOS (p < 0.001). For THA the mean operative time for trainees was 90.3 ± 19.23 min, 18.2 min longer than the consultant group. For TKA the mean operative time was 89.06 ± 18.87 min for trainees, 24.4 min longer than the consultant group. DISCUSSION: At our institution trainee surgeons can be expected to take between 18 and 24 min longer to perform arthroplasty procedures. This should be factored into resource planning, as the training of orthopaedic surgeons is crucial to sustaining and improving health service provision.

The Patient's Second Hip Fracture - One in Ten.

Introduction The number of fragility hip fractures (>60 years) are estimated to triple/quadruple by 2050. It is estimated that the prevalence of patient's contralateral hip fractures (HF2s) will increase also. Methods Single hospital, Retrospective review, 2013-2017, Radiograph review, n = 822. Results Management of patient's 2nd hip fractures accounted for 10.5% of all hip fracture surgeries. ~50% occurred within 3 years of the 1st hip fracture. There was no statistically significant difference in discharge destination, length-of-stay or mortality between the HF1 and HF2 cohorts. Discussion Patients with HF2s comprised a significant and stable proportion of all hip fractures treated. We advocate for the provision of a Fracture Liaison Service in each of the 16 hip fracture operating hospitals in Ireland to optimise the secondary prevention of hip fractures.

Hip Fracture and the Weekend Effect in an Irish Trauma Hospital

Aims We examined the relationship between the 1-year mortality (OYM) rate and (i) those admitted at the weekend, (ii) those who underwent surgery at the weekend and (iii) those admitted during the NCHD changeover months (January & July) for the management of hip fracture in Tallaght University Hospital (TUH). Methods Admissions to TUH (2013 - 2016) with hip fracture (> 60 years old) were retrospectively examined. Data from the Irish Deaths and Events Registry was analysed to identify death events at 1 year. Logistic regression analysis was performed with respect to OYM with the three variables above. Results 646 hip fracture patients were admitted (2013 ­ 2016). 178 (27.5%) were weekend admissions, 183 (28.4%) underwent weekend surgery and 93 patients (14.4%) were admitted during NCHD changeover months. There was no significant relationship between OYM and (i) weekend admission, (ii) weekend surgery or (iii) changeover admission in TUH. Conclusion This study offers the first examination of the weekend effect on fragility hip fractures and mortality in Irish patients and reports no significant weekend effect regarding 1-year mortality in this hip fracture cohort.

The aetiology of posterior glenohumeral dislocations and occurrence of associated injuries: a systematic review.

AIMS: The glenohumeral joint is the most frequently dislocated articulation, but possibly due to the lower prevalence of posterior shoulder dislocations, approximately 50% to 79% of posterior glenohumeral dislocations are missed at initial presentation. The aim of this study was to systematically evaluate the most recent evidence involving the aetiology of posterior glenohumeral dislocations, as well as the diagnosis and treatment. MATERIALS AND METHODS: A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane (January 1997 to September 2017), with references from articles also evaluated. Studies reporting patients who experienced an acute posterior glenohumeral joint subluxation and/or dislocation, as well as the aetiology of posterior glenohumeral dislocations, were included. RESULTS: A total of 54 studies met the inclusion criteria. In total, 182 patients were included in this analysis; study sizes ranged from one to 66 patients, with a mean age of 44.2 years (sd 13.7). There was a higher proportion of male patients. In all, 216 shoulders were included with 148 unilateral injuries and 34 bilateral. Seizures were implicated in 38% of patients (n = 69), with falls, road traffic accidents, electric shock, and iatrogenic reasons also described. Time to diagnosis varied across studies from immediate up to a delay of 25 years. Multiple associated injuries are described. CONCLUSION: This review provides an up-to-date insight into the aetiology of posterior shoulder dislocations. Our results showed that seizures were most commonly implicated. Overall, reduction was achieved via open means in the majority of shoulders. We also found that delayed diagnosis is common.

Subtrochanteric Femur Fractures in an Irish Trauma Centre over 9 years: How the Impact of Hospital Coding on Diagnosis of Subtrochanteric Femur Fractures Leads to Inaccurate Occurrence Rates

Aim Our aim was to assess the occurrence rates of subtrochanteric femur fractures in an orthopaedic tertiary referral centre and to assess the correlation of patient's actual diagnosis with national hospital inpatient enquiry data. Methods Retrospective data from 2005-2014 was collected from an orthopaedic tertiary referral centre. A revision of all fractures coded subtrochanteric was performed. The plain radiograph images of each case were reviewed by two orthopaedic surgeons and one radiologist, with a reassessment performed of the fracture coding based on the AO/OTA classification system for subtrochanteric fractures. Results One thousand, seven hundred and one patients were admitted to our centre from January 2005 to February 2014 with hip fractures. Using ICD-10 coding, 48 fractures were coded with the diagnosis subtrochanteric femur fractures. Upon application of AO/OTA classification this was revised to 8 cases of subtrochanteric fractures over this period. Discussion Hospital coding of subtrochanteric fractures needs to be accurate to assess this, and all, fractures. Incorrect coding can mislead figures for this type of fracture and give incorrect diagnosis. This study has shown discrepancies between coded data and actual diagnosis. Coding improvements are essential to improve epidemiology studies of subtrochanteric fractures and for accuracy with introduction of activity based funding in to hospitals.

Emergency Aeromedical Services in Ireland: A Single-Centre Study in 2014.

This retrospective analysis includes patients requiring Emergency Aeromedical Services (EAS) in 2014. The aim of this paper is to evaluate the HEMS service in a single centre and to accurately assess whether certain internationally validated criteria can predict admission rates better than the currently used criteria. Using the American College of Surgeons (ACS) trauma-related dispatch criteria, each case was retrospectively evaluated. Results showed the mean total criteria met were 2.73 (?=0.88) and 1.45 (?=0.82) in admitted and discharged patients respectively. The total criteria met had a significant predictive value on admission rates (p<0.05). Increased admission rates were shown in patients with a high Mechanism of Injury (MOI) (p<0.05). False positive rates of HEMS transfer were higher when applying the current criteria compared to the ACS criteria. ACS total criteria can predict admission in HEMS patients with a higher specificity than currently used guidelines.

Emergency aeromedical services in Ireland: a retrospective study for "MEDEVAC112".

AIM: This is a retrospective analysis of all consecutive patients requiring emergency aeromedical services (EAS) to a level II trauma centre. This analysis was performed to evaluate the new service to Tallaght Hospital in terms of: the criteria used for dispatch, an estimate of baseline efficiency of time critical management of patients, the cross-catchment transfer of patients. METHODS: Data were provided by the EAS with respect to the patients brought to Tallaght Hospital not including inter-facility transfers for the calendar year 2013. Using this information patient records were matched to the electronic database. Once patients were identified, their hospital journey was catalogued using chart review. Using Google Maps and the EAS data an estimated road-time was calculated. Specific dispatch criteria were unavailable, however, using five broad categories outlined by the American College of Surgeons (ACS) for trauma related dispatch criteria each case was evaluated. RESULTS: The EAS data had 52 cases which were reported to come to this unit. 48 patient records were accurately matched to this data. 25 % were discharged without speciality input. Seven patients died within 24 h only one of which was admitted under a speciality. 30 patients were admitted under specialist care with two requiring transfer to another centre. 80 % of admissions came under the primary management of the orthopaedic team. 11 patients required operative management, five required ICU management, three required chest drains and one patient required cardiac angiogram. Of the five dispatch criteria categories evaluated the mean number of criteria met was 3.1. CONCLUSION: 25 % of the patients were managed in the Emergency Department alone indicating an acceptable level of over-triage according to ACS guidelines. When comparing the dispatch criteria met for this 25 % there was no statistical difference compared with the other 75 %. Sensitivity and specificity analyses have looked at the question of dispatch criteria before and our data are comparable with international evidence. We suggest that further research be undertaken to develop this service to improve activation criteria and thereby the entire service delivered.

Surgical treatment of articular cartilage defects in the knee: are we winning?

Articular cartilage (AC) injury is a common disorder. Numerous techniques have been employed to repair or regenerate the cartilage defects with varying degrees of success. Three commonly performed techniques include bone marrow stimulation, cartilage repair, and cartilage regeneration. This paper focuses on current level of evidence paying particular attention to cartilage regeneration techniques.

High grade splenic rupture in an elite Rugby Union player.

The authors present the case of an amateur under-18 international squad Rugby Union player who sustained a Grade III splenic rupture while scoring a try. He was admitted to hospital and treated with strict bedrest following initial computed tomography (CT) evaluation. He maintained hemodynamic stability throughout and registered no drop in hemoglobin. A repeat CT scan five days later showed no radiological progression and he was discharged with instructions to avoid exercise for three months. A follow-up CT scan performed at 10 weeks after the injury showed radiological resolution but the decision was made to avoid physical contact for a further three months. The player made a full recovery and is now back playing representative rugby. This report reviews the management and raises the question as to when players should be allowed back to play contact sports following a splenic rupture.

Co-existent medial collateral ligament injury seen following transient patellar dislocation: observations at magnetic resonance imaging.

This study reports on a series of patients who were diagnosed as having had a transient lateral patellar dislocation by magnetic resonance imaging (MRI). The images were reviewed with specific reference to the medial collateral ligament (MCL), a heretofore undescribed concomitant injury. Eighty patients were diagnosed on MRI as having had transient lateral patellar dislocation. Their mean age was 23.9 years (SD 7.5). Forty patients (50.0%) had co-existent MCL injuries. These injuries were classified as grade 1 (n = 20), grade 2 (n = 17) and grade 3 (n = 3). These results suggest that MCL injury commonly accompanies transient lateral patella dislocation, most likely due to a shared valgus injury. It appears to occur more commonly in male patients and if unidentified may explain both delayed recovery and persistent morbidity in more severe cases. In this setting, without specifically excluding co-existent MCL injury, the current vogue for early rehabilitation should be adopted with caution.

Isolated proximal tibiofibular joint dislocation in an elite rugby union player.

The case is presented of a professional international rugby union player who sustained an isolated proximal tibiofibular dislocation in a training ground injury. Diagnosis was made based on clinical details, plain radiography and magnetic resonance imaging. An initial attempt at closed reduction failed. Open reduction and internal fixation were subsequently carried out. Following early rehabilitation, the patient made a successful try-scoring return to international rugby union.

Quantification of the coupled motion that occurs with axial rotation and lateral bending of the head-neck complex: an experimental examination.

The vertebrae of the cervical spine exhibit out-of-plane or coupled motion during axial rotation and lateral bending. Quantifying the range of motion (ROM) of this occurrence can aid the understanding of cervical spine injury mechanisms and disorders, as well as the development of new treatment methods. Previous studies have formulated ratios to describe coupled motion obtained from in-vitro examinations. The aim of the present study was to use in-vivo test data to develop mathematical relationships to quantify the coupled motion that occurs with axial rotation and lateral bending of the head-neck complex. Using a three-dimensional motion analyser it was possible to trace the coupling effect throughout the full range of unrestricted head-neck motion. Values for primary and coupled ROMs were obtained, showing no significant difference between male and female primary ROMs but a small disparity between male and female coupled ROMs. Regression equations were found to quantify coupled motion throughout the range of axial rotation and lateral bending. The present experimental study also examines the range of horizontally fixed axial rotation of the head to determine the minimum amount of coupled lateral bending that takes place, which has not been measured previously.

Fractures of the sternum: the influence of non-invasive cardiac monitoring on management.

Management of sternal fractures often involves a protracted hospital stay. This is often based on serial electrocardiography (ECG) and cardiac enzyme measurement (AST, CK, LDH). This retrospective study examined all cases of sternal fracture presenting to our institution between October 1998 and February 2003. Seventy-two cases were identified, 52 of which had isolated sternal fractures. Of these, 11 (21%) patients had an elevation in all cardiac enzymes. Twenty-three (44%) had an increase in some but not all. A single patient with ECG changes had no elevation in cardiac enzymes. Those patients with elevated cardiac enzymes had a significantly longer stay of 5.5 days compared with 3.7 days (P < 0.05). No adverse outcome was recorded in either group. We conclude that ECG and estimation of cardiac enzymes in these patients are of limited benefit and, when abnormal, appear to be associated with a significantly protracted and probably unnecessary hospitalisation.

Bertolotti's syndrome. A cause of back pain in young people.

Bertolotti's syndrome is characterised by anomalous enlargement of the transverse process(es) of the most caudal lumbar vertebra which may articulate or fuse with the sacrum or ilium and cause isolated L4/5 disc disease. We analysed the elective MR scans of the lumbosacral spine of 769 consecutive patients with low back pain taken between July 2003 and November 2004. Of these 568 showed disc degeneration. Bertolotti's syndrome was present in 35 patients with a mean age of 32.7 years (15 to 60). This was a younger age than that of patients with multiple disc degeneration, single-level disease and isolated disc degeneration at the L4/5 level (p

The usefulness of computed tomography following open reduction and internal fixation of acetabular fractures.

PURPOSE: To investigate the role of a supplemental imaging modality in postoperative assessment of acetabular fractures following open reduction and internal fixation. METHODS: Postoperative axial computed tomographic (CT) scans were compared with plain radiographs of 20 patients with regard to their sensitivity for detecting articular fracture reduction in terms of gap displacement and step deformity or offset. Three observers independently reviewed the plain radiographs and CT scans at 2 separate time points and categorised the outcome as either anatomical or non-anatomical. The inter-observer reliability and intra-observer reproducibility of these measurements was expressed as a kappa statistic. The radiological result was correlated with the clinical outcome measures using the Merle D'Aubigne scale, the Harris Hip Score, and the SF-36 score. RESULTS: Plain radiography was less effective in the detection of postoperative articular displacement (mean, 75.1% sensitive). The inter-observer and intra-observer agreement between reviewers was good to excellent in detecting reduction quality between the 2 modalities. Patient management was not altered by the findings of the CT scans. CONCLUSIONS: Although postoperative CT scanning of acetabular fractures in selective cases may be useful, issues such as higher cost, less effective allocation of resources, and excessive radiation doses do not support its routine use.

In-cement technique for revision hip arthroplasty.

The in-cement technique for revision hip arthroplasty involves retaining the original cement-bone interface. This has been proven to be a biomechanically stronger method than recementing after complete removal of the original cement mantle. This study reviewed a series of 54 consecutive revision hip arthroplasty procedures, using the in-cement technique, between November 1999 and November 2003. Clinical and radiological follow-up included functional assessment. There were 54 procedures performed in 51 patients, whose mean age at surgery was 70.3 years (45 to 85). A total of 42 were available at a mean follow-up of 29.2 months (6 to 51). There was no radiological evidence of loosening. Functional assessments were available for 40 patients who had a mean Harris hip score of 85.2 (51.9 to 98.5), a mean Oxford hip score of 19.6 (12 to 41), a mean UCLA activity profile score of 5.9 (3 to 8) and a mean SF-36 score of 78.0 (31.6 to 100). The in-cement technique provides consistent, high functional outcomes and should be considered in appropriately selected cases.

Trampoline injuries in children.

We reviewed the records of children referred to our hospital between April and September 2005 who had been injured whilst trampolining. Of 88 such children there were 33 boys and 55 girls with a mean age of 8 years 6 months (2 years 4 months to 15 years 9 months). Most of the injuries (53; 60%) occurred when bouncing and 34 (39%) were secondary to falls from the trampoline. The cause of injury was unknown in one child. The injured child was supervised in only 35 cases (40%). In 31 (35%) cases, the injury was related to the presence of others on the trampoline. A total of 36 (40%) children required surgery. Fractures of the upper limbs occurred in 62 cases (70%). Injuries related to the recreational use of trampolines are a significant cause of childhood injury. Our results suggest strongly that there is a need for clear guidelines on safe and responsible use of domestic trampolines.