New quality outcome indicators for bone metastases: expert consensus analysis of patients, their families and specialist healthcare professionals.

OBJECTIVES: As workload increases, surgical care for patients with bone metastases is increasingly decentralised, with a shift in management away from primary bone tumour units to local centres. We must ensure that patients have similar outcomes regardless of where they receive their treatment. The aim was to develop and validate a set of quality outcome indicators (QOIs) to evaluate treatment success for patients undergoing surgery for bone metastases. METHODS: Outcome recommendations were adapted from the literature and field tested in a retrospective patient cohort to determine feasibility. The provisional outcome indicators were assessed during a modified RAND/Delphi consensus process by a group of patients, relatives and healthcare professionals with validated targets added. RESULTS: 1534 articles were reviewed. 38 quality objectives were extracted and assessed for feasibility using clinical records for 117 patients. 28 provisional outcome indicators proceeded to expert consensus and were reviewed by a group of 22 panellists including 10 patients and 4 relatives/carers. After two rounds, 15 QOIs were generated, with validated targets based on expert consensus. These included specific statements such as 'surgery improves pain and reduces the need for morphine, target: at follow-up, pain is documented in 80% of individuals and 50% of these have reduced need for morphine'. CONCLUSIONS: The published evidence and guidelines were adapted into a set of outcome indicators validated by patients, their family/carers and healthcare professionals. These can be used to compare care between centres and identify units of excellence in maximising good outcome after surgery for bone metastases.

A national multicentre study of outcomes and patient satisfaction with the virtual fracture clinic and the influence of the COVID-19 pandemic: The MAVCOV study.

BACKGROUND: Virtual fracture clinics (VFCs) are advocated by the British Orthopaedic Association Standards for Trauma (BOAST). We aimed to assess the impact of the transition from face-to-face fracture clinic review and identify any change in clinical outcome and patient satisfaction. METHODS: A national, cross-sectional cohort study of VFCs across the UK over two separate two-week periods pre- and during the first UK COVID-19 lockdown was undertaken. Data comprising patient and injury characteristics, unplanned reattendance and complications within three months following discharge from VFC were collected by local collaborators. Telephone questionnaires were conducted to determine patient satisfaction and patient-reported outcome for patients discharged without face-to-face consultation. The primary outcome measure was the percentage of unplanned reattendances after direct discharge from VFC. RESULTS: Data was analysed for 51 UK VFCs comprising 6134 patients from the pre-pandemic group (06/05/2019-19/05/2019) and 4366 patients from the first UK lockdown (04/05/2020-17/05/2020). During lockdown, the rate of direct discharge from VFC increased significantly (odds ratio (OR) 2.01, p<0.001) from 30 % (n = 1856/6134) to 46 % (n = 2021/4366). The rate of compliance with BOAST guidance recommending fracture clinic review within three days increased (OR 1.93, p<0.001) from 82 % (n = 5003/6134) to 89 % (n = 3883/4366). There were no differences in the rates of unplanned reattendance (6 % pre- and 7 % during lockdown, p = 0.281) or complications (0.2 % for both, p = 0.815). There were 1527/3877 patients discharged without face-to-face review from VFC who completed telephone questionnaires (mean follow-up 18-months in pre-pandemic group and 6-months in lockdown group). Satisfaction was high in both cohorts (80 % pre- and 76 % lockdown, p = 0.093). Dissatisfaction was associated with an unplanned reattendance (p<0.001) or a missed injury (p<0.05). CONCLUSION: Despite a significant rise in direct discharge from VFC, there was no significant change in unplanned attendances, complications, or patient satisfaction. However, there are factors associated with dissatisfaction and these should be considered in the evolution of VFC.

The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST).

Aims: Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme. Methods: This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender. Results: All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience. Conclusion: This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training.

Acrometastasis of the Lower Limb Carries a Poorer Prognosis: A Retrospective Cohort Study.

BACKGROUND: Bony metastasis distal to the knee is rare and often reported alongside metastasis distal to the elbow. We sought to provide empirical evidence of the epidemiology, presentation, and prognosis of lower limb acrometastasis, alongside investigation of the distribution of metastases present while lower limb acrometastases form. METHODS: This retrospective cohort study identified 44 radiologically confirmed cases of lower limb acrometastasis from a single region. Case note review facilitated the extraction of data relating to the stated aims. Patients were grouped by extent of metastasis at primary diagnosis. Mann-Whitney U test compared metastatic burden, and Kaplan-Meier analysis compared survival. RESULTS: Prostate and breast carcinoma were the most commonly diagnosed primary tumors. Sixty-eight acrometastatic lesions were identified, of which 70% presented asymptomatically. Lower limb acrometastasis was associated with metastatic disease at a significantly greater number of sites than those presenting with metastasis proximal to the knee only (P = .007) and conveyed a significantly worse survival than metastasis proximal to the knee or nil metastasis (P < .001). Median survival from diagnosis of lower limb acrometastasis was 1.0 year. CONCLUSION: Lower limb acrometastasis is associated with a large metastatic burden and occurs in the terminal year of disease. Radiological identification of cases reveals a distinct cohort of acrometastatic lesions, more likely to present asymptomatically, and arises from alternate primary carcinomas than those in previous literature. LEVELS OF EVIDENCE: Level IV: Case series.

Mirels' score for upper limb metastatic lesions: do we need a different cutoff for recommending prophylactic fixation?

Hypothesis: The aim of this study was to investigate the reproducibility, reliability, and accuracy of Mirels' score in upper limb bony metastatic disease and validate its use in predicting pathologic fractures. Methods: Forty-five patients with upper limb bony metastases met the inclusion criteria (62% male 28/45). The mean age was 69 years (SD 9.5), and the most common primaries were lung (29%, 13/45), followed by prostate and hematological (each 20%, 9/45). The most commonly affected bone was the humerus (76%, 35/45), followed by the ulna (6.5%, 3/45). Mirels' score was calculated in 32 patients; with plain radiographs at index presentation scored using Mirels' system by 6 raters. The radiological aspects (lesion size and appearance) were scored twice by each rater (2 weeks apart). Intraobserver and interobserver reliability were calculated using Fleiss' kappa test. Bland-Altman plots compared the variances of both individual components and the total Mirels' score. Results: The overall fracture rate of upper limb metastatic lesions was 76% (35/46) with a mean follow-up of 3.6 years (range 11 months-6.8 years). Where time from diagnosis to fracture was known (n = 20), fractures occurred at a median 19 days (interquartile range 60-10), and 80% (16/20) occurred within 3 months of diagnosis.Mirels' score of ≥9 did not accurately predict lesions that fractured (fracture rate 11%, 5/46, for Mirels' ≥ 9 vs. 65%, 30/46, for Mirels' ≤ 8, P < .001). Sensitivity was 14%, and specificity was 73%. When Mirels' cutoff was lowered to ≥7, patients were more likely to fracture than not (48%, 22/46, vs. 28%, 13/46, P = .045); sensitivity rose to 63%, but specificity fell to 55%.Kappa values for interobserver variability were κ = 0.358 (fair, 95% confidence interval [CI] 0.288-0.429) for lesion size, κ = 0.107 (poor, 95% CI 0.02-0.193) for radiological appearance, and κ = 0.274 (fair, 95% CI 0.229-0.318) for total Mirels' score. Values for intraobserver variability were κ = 0.716 (good, 95% CI 0.432-0.999) for lesion size, κ = 0.427 (moderate, 95% CI 0.195-0.768) for radiological appearance, and κ = 0.580 (moderate, 95% CI 0.395-0.765) for total Mirels' score. Conclusions: This study demonstrates moderate to substantial agreement between and within raters using Mirels' score on upper limb radiographs. However, Mirels' score had a poor sensitivity and specificity in predicting upper extremity fractures. Until a more valid scoring system has been developed, based on our study, we recommend a Mirels' threshold of ≥7/12 for considering prophylactic fixation of impending upper limb pathologic fractures. This contrasts with the current ≥9/12 cutoff, which is recommended for lower limb pathologic fractures.

Intimate partner violence (IPV) in male and female orthopaedic trauma patients: a multicentre, cross-sectional prevalence study.

OBJECTIVES: Identify the proportion of patients attending fracture clinics who had suffered intimate partner violence (IPV) within the past year. DESIGN: Powered cross-sectional study using validated participant self-reported questionnaires. SETTING AND PARTICIPANTS: Adult trauma patients (no gender/age exclusions) attending one of three Scottish adult fracture clinics over 16-month period (from October 2016 to January 2018). PRIMARY OUTCOME MEASURE: Number of participants answering 'yes' to the Woman Abuse Screening Tool question: 'In your current relationship over the past twelve months, has your partner ever abused you physically/emotionally/sexually?' RESULTS: Of 336 respondents, 46% (156/336 known) were women with 65% aged over 40 (212/328 known). The overall prevalence of IPV within the preceding 12 months was 12% 39/336) for both male and female patients. The lifetime prevalence of IPV among respondents was 20% (68/336). 38% of patients who had experienced IPV within the past 12 months had been physically abused (11/29). None of the patients were being seen for an injury caused by abuse. Two-thirds of respondents thought that staff should ask routinely about IPV (55%, 217/336), but only 5% had previously been asked about abuse (18/336). CONCLUSIONS: This is the first study worldwide investigating the prevalence of IPV in fracture clinics for both male and female patients. 12-month prevalence of IPV in fracture clinic patients is significant and not affected by gender in this study. Patients appear willing to disclose abuse within this setting and are supportive of staff asking about abuse. This presents an opportunity to identify those at risk within this vulnerable population.

Metastatic bone disease: new quality performance indicator development.

OBJECTIVES: Patients with metastatic bone disease (MBD) should receive the same standard of care regardless of which centre they are treated in. The aim was to develop and test a set of quality performance indicators (QPIs) to evaluate care for patients with MBD referred to orthopaedics. METHODS: QPIs were adapted from the literature and ranked on feasibility and necessity during a modified RAND/Delphi consensus process. They were then validated and field tested in a retrospective cohort of 108 patients using indicator-specific targets set during consensus. RESULTS: 2568 articles including six guidelines were reviewed. 43 quality objectives were extracted and 40 proceeded to expert consensus. After two rounds, 18 QPIs for MBD care were generated, with the following generating the highest consensus: 'Patients with high fracture risk should receive urgent assessment' (combined mean 6.7/7, 95% CI 6.5 to 6.8) and 'preoperative workup should include full blood tests including group and save' (combined mean 6.7/7, 95% CI 6.5 to 6.9). In the pilot test, targets were met for 5/18 QPIs (mean 52%, standard deviation 22%). The median deviation from projected target was -14% (interquartile range -11% to -31%, range -74% to 11%). The highest scoring QPI was 'adults with fractures should have surgery within 7 days' (target 80%:actual 92%). CONCLUSIONS: The published evidence and guidelines were adapted into a set of validated QPIs for MBD care which can be used to evaluate variation in care between centres. These QPIs should be correlated with outcome scores to determine whether they can act as predictors of outcome after surgery.

Patient-reported assessment of outcome after surgery for bone metastases.

Regardless of prognosis, surgery is often considered in metastatic bone disease (MBD) as a palliative procedure to improve function and quality of life. Traditional focus on objective outcomes such as mortality is inappropriate in this group, and there is a drive to assess outcomes via patient-reported outcome measures (PROMs). This is an overview of current understanding of MBD outcomes and how this should influence future decision-making and research. The objectives of this review were to identify difficulties in measuring PROMs in the MBD patient population and explore alternatives to patientreported outcomes. We also provide an overview of current understanding of outcomes in MBD and how this should influence decision-making and direct research.

A multicentre national study of the effectiveness of virtual fracture clinic management of orthopaedic trauma during the COVID-19 pandemic (MAVCOV): a cross-sectional study protocol.

AIMS: Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines. METHODS: This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the 'second wave' (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation. ETHICS AND DISSEMINATION: The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit. Cite this article: Bone Jt Open 2021;2(3):211-215.

A prospective longitudinal study investigating outcomes including patient-reported outcome measures after surgery for metastatic bone disease.

AIMS: Surgery is often indicated in patients with metastatic bone disease (MBD) to improve pain and maximize function. Few studies are available which report on clinically meaningful outcomes such as quality of life, function, and pain relief after surgery for MBD. This is the published protocol for the Bone Metastasis Audit - Patient Reported Outcomes (BoMA-PRO) multicentre MBD study. The primary objective is to ascertain patient-reported quality of life at three to 24 months post-surgery for MBD. METHODS: This will be a prospective, longitudinal study across six UK orthopaedic centres powered to identify the influence of ten patient variables on quality of life at three months after surgery for MBD. Adult patients managed for bone metastases will be screened by their treating consultant and posted out participant materials. If they opt in to participate, they will receive questionnaire packs at regular intervals from three to 24 months post-surgery and their electronic records will be screened until death or five years from recruitment. The primary outcome is quality of life as measured by the European Organisation for Research and the Treatment of Cancer Quality of Life questionnaire (EORTC-QLQ) C30 questionnaire. The protocol has been approved by the Newcastle & North Tyneside 2 Research Ethics Committee (REC ref 19/NE/0303) and the study is funded by the Royal College of Physicians and Surgeons of Glasgow (RCPSG) and the Association for Cancer Surgery (BASO-ACS). DISCUSSION: This will be the first powered study internationally to investigate patient-reported outcomes after orthopaedic treatment for bone metastases. We will assess quality of life, function, and pain relief at three to 24 months post-surgery and identify which patient variables are significantly associated with a good outcome after MBD treatment. Cite this article: Bone Jt Open 2021;2(2):79-85.

The Metastatic Early Prognostic (MEP) score.

AIMS: The early mortality in patients with hip fractures from bony metastases is unknown. The objectives of this study were to quantify 30- and 90-day mortality in patients with proximal femoral metastases, and to create a mortality prediction tool based on biomarkers associated with early death. METHODS: This was a retrospective cohort study of consecutive patients referred to the orthopaedic department at a UK trauma centre with a proximal femoral metastasis (PFM) over a seven-year period (2010 to 2016). The study group were compared to a matched control group of non-metastatic hip fractures. Minimum follow-up was one year. RESULTS: There was a 90-day mortality of 46% in patients with metastatic hip fractures versus 12% in controls (89/195 and 24/192, respectively; p < 0.001). Mean time to surgery was longer in symptomatic metastases versus complete fractures (9.5 days (SD 19.8) and 3.4 days (SD 11.4), respectively; p < 0.05). Albumin, urea, and corrected calcium were all independent predictors of early mortality and were used to generate a simple tool for predicting 90-day mortality, titled the Metastatic Early Prognostic (MEP) score. An MEP score of 0 was associated with the lowest risk of death at 30 days (14%, 3/21), 90 days (19%, 4/21), and one year (62%, 13/21). MEP scores of 3/4 were associated with the highest risk of death at 30 days (56%, 5/9), 90 days (100%, 9/9), and one year (100%, 9/9). Neither age nor primary cancer diagnosis was an independent predictor of mortality at 30 and 90 days. CONCLUSION: This score could be used to predict early mortality and guide perioperative counselling. The delay to surgery identifies a potential window to intervene and correct these abnormalities with the aim of improving survival. Cite this article: Bone Joint J. 2020;102-B(1):72-81.

A prospective cohort study investigating the use of a surgical planning tool to improve patient fasting times in orthopaedic trauma.

OBJECTIVES: To improve surgical planning and reduce fasting times with a tool designed to predict average surgical times for the commonest orthopaedic trauma operations. METHODS: A prospective cohort study comprising two 2-week periods before and after introduction of a surgical planning tool. The tool was used in the post-intervention group to predict surgical times for each patient and the predicted end-time for each list. The study was conducted in a UK trauma unit with consecutive orthopaedic trauma patients listed for surgery with no exclusions. INTERVENTION: A surgical planning tool was generated by analysing 5146 electronic records for trauma procedure times. Average surgical times for the commonest 20 procedures were generated with 95% confidence intervals. The primary outcome measure was number of patients fasted for a single day. The secondary outcome measures were the day of surgery and total fast times for food and fluids. RESULTS: After introduction of the planning tool, patients were more likely to fast for only one day (65% 46/71 vs 53% 40/75, p < 0.05). Day of surgery food fast was significantly lower with use of the surgical planning tool (13:11 h to 11:44 h, p < 0.05). Fast times were lower for patients with hip fractures after the intervention, with a reduction in day of surgery fast from 8:25 h to 4:28 h (p < 0.05) and a total fluid fast of 13:00 h to 4:31 h (p < 0.001). CONCLUSIONS: Introduction of a surgical planning tool was associated with a decrease in fasting times for orthopaedic trauma patients with no patient cancelled for not being adequately fasted.

A prospective questionnaire-based study on staff awareness of intimate partner violence (IPV) in orthopaedic trauma patients.

AIMS: Investigate awareness in the multidisciplinary orthopaedic trauma team regarding intimate partner violence (IPV), willingness to ask patients and knowledge of available support. METHODS: Orthopaedic staff in several UK centres completed an anonymous online validated questionnaire reflecting their opinions on IPV in orthopaedics. Respondents from orthopaedic surgery, nursing, and physiotherapy participated. RESULTS: There were 121 respondents with a mean 10 years' experience. 52% of respondents had previously had a disclosure of IPV from at least one orthopaedic patient. Doctors and nurses were equally likely to have cared for IPV patients (50% versus 56%), but doctors thought abuse was less common (57% doctors compared to 15% nurses thought IPV affected less than 1% of trauma patients, p < 0.05). 74% of respondents reported asking patients about abuse (77/104 answered) but only 24% (29/121) knew about the support currently available. Staff who did not know about available support were less likely to ask about possible abuse (46% versus 22% respectively, p < 0.05). 74% of respondents felt it was important/very important to ask about IPV. CONCLUSIONS: This is the first study investigating IPV in UK orthopaedics. Although three quarters of the staff interviewed thought that it was important to ask trauma patients about IPV, only 2% routinely ask patients presenting with musculoskeletal injuries about IPV. Orthopaedic staff are well placed to identify vulnerable patients. This study highlights the need for training staff on how to identify IPV and manage disclosures of abuse given that the incidence of IPV is on the increase.