Jon Simmons

Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of Major Trauma Networks and national guidelines

AIMS The management of open lower limb fractures in the United Kingdom has evolved over the last ten years with the introduction of major trauma networks (MTNs), the publication of standards of care and the wide acceptance of a combined orthopaedic and plastic surgical approach to management. The aims of this study were to report recent changes in outcome of open tibial fractures following the implementation of these changes. PATIENTS AND METHODS Data on all patients with an open tibial fracture presenting to a major trauma centre between 2011 and 2012 were collected prospectively. The treatment and outcomes of the 65 Gustilo Anderson Grade III B tibial fractures were compared with historical data from the same unit. RESULTS The volume of cases, the proportion of patients directly admitted and undergoing first debridement in a major trauma centre all increased. The rate of limb salvage was maintained at 94% and a successful limb reconstruction rate of 98.5% was achieved. The rate of deep bone infection improved to 1.6% (one patient) in the follow-up period. CONCLUSION The reasons for these improvements are multifactorial, but the major trauma network facilitating early presentation to the major trauma centre, senior orthopaedic and plastic surgical involvement at every stage and proactive microbiological management, may be important factors. TAKE HOME MESSAGE This study demonstrates that a systemised trauma network combined with evidence based practice can lead to improvements in patient care.Aims The management of open lower limb fractures in the United Kingdom has evolved over the last ten years with the introduction of major trauma networks (MTNs), the publication of standards of care and the wide acceptance of a combined orthopaedic and plastic surgical approach to management. The aims of this study were to report recent changes in outcome of open tibial fractures following the implementation of these changes. Patients and Methods Data on all patients with an open tibial fracture presenting to a major trauma centre between 2011 and 2012 were collected prospectively. The treatment and outcomes of the 65 Gustilo Anderson Grade III B tibial fractures were compared with historical data from the same unit. Results The volume of cases, the proportion of patients directly admitted and undergoing first debridement in a major trauma centre all increased. The rate of limb salvage was maintained at 94% and a successful limb reconstruction rate of 98.5% was achieved. The rate of deep bone infection improved to 1.6% (one patient) in the follow-up period. Conclusion The reasons for these improvements are multifactorial, but the major trauma network facilitating early presentation to the major trauma centre, senior orthopaedic and plastic surgical involvement at every stage and proactive microbiological management, may be important factors. Take home message: This study demonstrates that a systemised trauma network combined with evidence based practice can lead to improvements in patient care. Cite this article: Bone Joint J 2016;98-B:420–4.

Assessing functional mobility after lower limb reconstruction: a psychometric evaluation of a sensor-based mobility score.

OBJECTIVE To develop and validate a robust, objective mobility assessment tool, Hamlyn Mobility Score (HMS), using a wearable motion sensor. BACKGROUND Advances in reconstructive techniques allow more limbs to be salvaged. However, evidence demonstrating superior long-term outcomes compared with amputation is unavailable. Lack of access to quality regular functional mobility status may be preventing patients and health care staff from optimizing rehabilitation programs and evaluating the reconstructive services. METHODS In this prospective cohort study, 20 patients undergoing lower limb reconstruction and 10 age-matched controls were recruited. All subjects completed the HMS activity protocol twice under different instructors at 3 months postoperatively, and again at 6 months, while wearing an ear-worn accelerometer. Demographic and clinical data were also collected including a short-form health survey (SF-36). HMS parameters included standard test metrics and additional kinematic features extracted from accelerometer data. A psychometric evaluation was conducted to ascertain reliability and validity. RESULTS The HMS demonstrated excellent reliability (intraclass correlation coefficient >0.90, P < 0.001) and internal consistency (Cronbach α = 0.897). Concurrent validity was demonstrated by correlation between HMS and SF-36 scores (Spearman ρ = 0.666, P = 0.005). Significant HMS differences between healthy subjects and patients, stratified according to fracture severity, were shown (Kruskal-Wallis nonparametric 1-way analysis of variance, χ = 21.5, P < 0.001). The HMS was 50% more responsive to change than SF-36 (effect size: 1.49 vs 0.99). CONCLUSIONS The HMS shows satisfactory reliability and validity and may provide a platform to support adaptable, personalized rehabilitation and enhanced service evaluation to facilitate optimal patient outcomes.

Free‐flap telemonitoring to the surgeon's handheld device: Proof of concept

Techniques for free-flap monitoring traditionally rely on clinical examination and experience. A survey of 60 British microsurgical head and neck units suggested that clinical monitoring is the only technique that is universally used. However, 91% used additional tests, including handheld Doppler (55%), temperature probes (50%), laser Doppler flowmetry (5–10%), and near infrared spectroscopy (>5%). Besides the benefit of providing a means to monitor “buried” flaps, such technologies provide quantitative indicators of flap viability in the early postoperative period. However, like clinical monitoring, such measurements may still require experience to interpret fully. Postoperative monitoring needs to be continuous, including when the senior/experienced consultant surgeon is out of the hospital. Consequently, it is often the case that for the first few nights postoperatively, the only on-site surgeon is a junior clinician whose interpretation of the flap status is reliant on a limited amount of experience. In-hospital and community-based cardiac telemetry has proved successful in early recognition of lifethreatening cardiac events and improves survival. Reflecting on this, we sought to create and test a prototype free-flap telemonitoring system for the surgeon using similar technology. We set out to utilize a hospital wireless network (WiFi) and remote desktop software to transmit quantitative data from an electronic flap-monitoring device (the O2C device, LEA Medizintechnik, Germany) to a handheld computer device (personal tablet or smartphone) at the surgeon’s residence. The O2C device has been shown to be a reliable and objective noninvasive technique for free-flap monitoring. It uses laser Doppler and spectrophotometry to

Lower Limb Trauma

Requires joint and simultaneous orthopaedic and plastic surgical management to achieve the best outcome. Amputation can be a good reconstructive option. Recognition Treat as a polytrauma using ATLS guidelines. Primary then secondary survey to identify and manage injuries. Initial evaluation and treatment may have to occur simultaneously. External bleeding should be managed with direct pressure.

Variations in Clinical Audit Collection: A Survey of Plastic Surgery Units Across the British Isles

INTRODUCTION Clinical audit is a requirement of good medical and surgical practice and is central to the UK Governments plans to modernise the NHS. MATERIALS AND METHODS A survey was conducted to assess clinical audit data collection and collation within plastic surgery departments across the UK. The survey identified a variety of different data collection and collation methods, with extensive differences between plastic surgery departments. Those responsible for data collection and its funding were also identified by the survey. RESULTS Results were obtained from 45 plastic surgery departments. Of the 45 departments surveyed, 12 collect data prospectively, whereas 26 units collect data retrospectively. The remaining departments collect data using a combination of methods. Of the units surveyed, 28 collect data on paper-based systems, with only 13 units using electronic applications. The personnel responsible for data collection were identified as being junior doctors. Departments collecting data prospectively do so from a greater number of sources than those collecting data retrospectively. CONCLUSIONS This survey has focused on plastic surgery. The authors believe that similar results would be obtained from a survey of other surgical specialties. A huge variation in all parameters relating to the collection and collation of clinical audit data is seen. There are few standards within this specialty for data collection. Much work must be done in order to reach targets set by the UK Government.

Complex Wounds: Pressure Sore

The last thing to consider in pressure sore management is the wound. Need to optimise all other factors first. Surgery rarely indicated. Recognition Consider pressure areas relative to the individual patient. Elderly bed-bound patient vs. young patient in a wheelchair. Approximately 3% of hospitalised patients have a pressure sore (Fig. 20.1).

Hand with Inflammatory Arthropathy

Surgery is the last resort once medical treatments have failed but should not be shied away from. Recognition Typical arthropathic hand position, splints, walking aids. Obvious synovitis, previous surgical procedures; scars over MCPJ, CMCJ and dorsal wrist. Involvement of other joints (neck/shoulders/knees/hips) (Fig. 16.1).

Hand with Nerve Palsy

Focus on addressing specific functional deficits, not trying to recreate all of the nerve’s function. Recognition Recognise by hand posture: Ulnar – hypothenar flat/wasted; little and ring finger claw (MPJ hyperextended +/− flexion of DIPJ/PIPJ depending on high/low lesion) (Fig. 15.1) Median – thumb in plane of hand, thenar flat/wasted Median and ulnar – both of the above, hand looks flat Radial – wrist drop, fingers in flexion

Dupuytren’s Disease

Benign fibroproliferative disease of unknown aetiology. Important to identify the patient with a diathesis/aggressive disease. The patient must realise that no interventions can cure, they only buy a variable disease-free interval.

Lump in the Neck

A primary tumour can usually be identified in all but 0.5–1%. Patients with positive lymph nodes and an UNKNOWN primary have a better prognosis. Recognition Patients often present to the Head and Neck surgeons first, but they always require multidisciplinary input (includes surgeons (ENT/maxillofacial/plastic), pathologist, radiologist, radiotherapist, oncologist, speech therapist, psychologist, clinical nurse specialist and dietician (Fig. 19.1).