​Author(s): Joseph F.; Wolfendale H.; Hyatt R.; Holmes A.
Source: Osteoporosis International; Dec 2018; vol. 29
Publication Date: Dec 2018
Publication Type(s): Conference Abstract
Abstract:Background: Vertebral fractures (VF) are themost common osteoporotic fracture; however around 70% are undiagnosed. VF are powerful predictors for further fracture (relative risk 2.8 for hip; 5.4 for further VF) (1). Method(s): CT scans containing the spine of patients aged >50 years from December 2015-October 2016 were analysed for VF using the Optasia Aspire?service; a commercial case-finding service combining machine learning with radiologist over-read. Diagnosed fractures were graded (2) and only moderate or severe VF included. The data were also interrogated for clinical variables.A combination of case notes, clinical portal and FLS database were used. Result(s): 47/325 (14.5%) scans showed moderate-severe VF. 18/47 patients had died by commencement of this audit; in 5, data were insufficient. Data was collected from March-April 2018. 13 (54%) of patients were female; 7 (29%) were aged 50-69; 12 (50%) 70-89; 5 (21%) were 90-100. Patients had 1-12 comorbidities (average 6.4). 54%(13) had prior fracture(s); of these, 46% had VF. 6 (25%) were on bone sparing treatment; but only 2 (8%) known to FLS. 6 (25%) of reports used the terms: Bosteoporotic fracture/loss of vertebral height/wedge fracture; 18 (75%) made no mention of VF. 8 (33%) had prior spinal X rays, of which 6 (75%)were reported as VF. 3 (12%) were admitted with fragility fractures after the CT scan. Discussion(s): The majority of CT reports made no mention of VF. VF was more frequently reported on plain X-ray. Most patientswere over 70; with multiple comorbidities. The majority had prior fractures; many VF. Only a minority were on bone sparing treatment and few known to FLS. Significant numbers were admitted with fragility fracture after their CT. Conclusion(s): This sample confirms that VF is common; and important to detect. A significant number of patients were admitted shortly after the CT with a further fragility fracture, potentially preventable. Although we have FLS locally; it has recruited few patients with VF. This study will prompt it to expand its scope to cover vertebral fractures. The trust is also looking at implementing a VF assessment and treatment pathway.
Database: EMBASE

​Author(s): Staal J.; Peters A.; Kariki E.; Hyatt R.; Javaid K.; Russell E.; O'Neill T.; Poole K.; Chappell D.; Rajak R.
Source: Osteoporosis International; Dec 2018; vol. 29
Publication Date: Dec 2018
Publication Type(s): Conference Abstract
Abstract:Objectives: Vertebral Fragility Fractures (VFFs) are an early manifestation of osteoporosis. VFFs may triple the risk of future hip fracture1 yet VFF patients are often underrepresented in Fracture Liaison Services (FLSs). We assessed the rate of opportunistic VFFs in Computed Tomography (CT) scans of the Thorax, Abdomen and Pelvis and reviewed whether they had been previously reported.We also investigated whether the identified VFF patients had been referred to an FLS. Materials andMethods:We retrospectively audited pseudonymised CT scans of patients 50 years and older, containing the spine. The scans were performed over a 12-month period at 5 NHS hospitals in the UK (Cambridge, Croydon, East Lancashire, Oxford and Salford). We used the Optasia Medical ASPIRETM service, a commercial VFF case-finding service combining machine learning with radiologist over-read (EK). VFFs were classified using the Genant-SQ method2 and only moderate and severe VFFs were included. We compared our findings with the original radiology reports. Result(s): We collected meta-data from 47,889 scans (50.1% female) and used a sample of 1,638 scans for analysis. Of these, 237 patients (53.4% female) had VFFs (14.5% +/- 1.7%, 95% CI). VFF prevalence between sites was not significantly different. Four sites (Cambridge, Croydon, East Lancashire, Oxford) checked the original radiology reports and FLS referral. The median reporting rate was 67.7% (IQR 55.7%, 74.5%) and the median FLS referral was 13.3% (IQR 10.8%, 22.0%). Conclusion(s): On average, 1 in 7 patients had at least one moderate VFF with a median of only 13.3% being seen by the FLS. Whilst men are underrepresented in FLSs3, nearly as many men as women in this cohort were found to have VFFs. Opportunistic diagnosis of VFF can greatly increase the number of patients referred to FLSs, potentially protecting the patients' quality of life and decreasing the economic burden of osteoporosis4.
Database: EMBASE
 

​Author(s): Green, Carl M.; Zeiton, Moez; Foulkes, Katherine; Barrie, Jim
Source: Journal of Patient Safety; Dec 2018; vol. 14 (no. 4); p. 202-205
Publication Date: Dec 2018
Publication Type(s): Academic Journal
Abstract:Objectives: This study assesses fall prevention measures and subsequent incident reporting of falls resulting in an "inpatient fracture neck of femur (FNOF)" within a single NHS Trust, with the aim of identifying potential areas of improvement and changing practice within a Trust. Methods: Forty patients (mean age, 82.6 years) sustained an injury while being treated in hospital for an unrelated cause between January 2012 and June 2013. Case notes and incident reports were analyzed retrospectively. Results: Thirty-three (82.5%) of 40 patients had at least 1 fall screen on admission, with 27 patients (81.8%) identified as a fall risk. Fifteen patients (37.5%) had at least one fall before sustaining a FNOF. Fifteen falls occurred between midnight—0500 hours and only 4 falls were witnessed. Thirty-nine of 40 falls were reported, but none were rated as "severe" injuries. Twenty-eight (71.8%) of 39 patients had a root cause analysis performed for the injury, but only 10 root cause analyses (25.6%) produced an action plan. Fifty percent of patients died within 1 year of injury. Conclusion: Accurate fall risk assessments and adequate patient supervision are essential to minimize risks of falls, as the inpatient FNOF is linked to a higher mortality rate than patients injured in the community. A standardized method of analyzing such incidents and dissemination of the results of investigation are also required to reduce the risk of similar incidents from occurring within the hospital environment.
Database: CINAHL

Author(s): Hill, Daniel S.; Marynissen, Hans
Source: Spine (03622436); Oct 2018; vol. 43 (no. 20)
Publication Date: Oct 2018
Publication Type(s): Academic Journal
Abstract:
Study Design: A retrospective cross-sectional analysis.

Objective: The aim of this study was to describe the provision of a spinal service using an electronic platform to direct management from an external spinal unit, and to quantify the time taken to obtain definitive management plans while under prescribed spinal immobilization.

Summary Of Background Data: Most attending district general hospitals following spinal trauma will have stable injuries and normal neurology, with only a small proportion requiring urgent transfer to a specialist center.

Methods: A retrospective review of 104 patients admitted following vertebral trauma during a 12-month period. The British Orthopaedic Association Standards for Trauma consensus that "spinal immobilisation is not recommended for more than 48 hours" was the standard of care measured against.

​Results: One hundred patients occupied a total of 975 hospital inpatient bed days. One hundred and seventeen radiological investigations were requested after the point of external referral [47 computed tomography (CT)-scans, 37 magnetic resonance imaging (MRI)-scans, and 33 weight-bearing radiographs]. The period between initial referral to the regional spinal service and then receiving a definitive final management plan had a median value of 72 hours and a range of 0 and 33 days. Patients will have been under some form of prescribed spinal immobilization until the definitive management plan was communicated. Thirty-four patients (34% of the overall cohort) had a definitive management plan in place within 48 hours. Eighty patients had vertebral injuries (73 stable, six unstable), three patients had prolapsed intervertebral disks, one had metastatic disease, and 17 did not have evidence of an acute injury following evaluation.

​Conclusion: Patients are being placed under prescribed immobilization for longer than is recommended. Delays in obtaining radiological imaging were an important factor, together with the time taken to receive a definitive management plan. Limitations in social care provision and delays in arranging this were additional barriers to hospital discharge following the final management plan.
Database: CINAHL

​Author(s): Honnenahalli Chandrappa M.; Hajibandeh S.
Source: Journal of Clinical Orthopaedics and Trauma; Nov 2017; vol. 8
Publication Date: Nov 2017
Publication Type(s): Review
Abstract:Objectives Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the outcomes of open versus arthroscopic methods of ankle fusion. Methods In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing outcomes of arthroscopic and open ankle arthrodesis. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. Results We identified one prospective cohort study and 5 retrospective cohort studies, enrolling a total of 286 patients with ankle arthritis. Our analysis showed that open ankle fusion was associated with a lower fusion rate (OR 0.26, 95% CI 0.13-0.52, P = 0.0002), longer tourniquet time (MD 16.49, 95% CI 9.46-23.41, P Copyright © 2017
Database: EMBASE

​Author(s): Nie K.; Rymaruk S.; Paton R.W.
Source: Bone and Joint Journal; Nov 2017 (no. 11); p. 1533-1536
Publication Date: Nov 2017
Publication Type(s): Article
Abstract:Aims A clicky hip is a common referral for clinical and sonographic screening for developmental dysplasia of the hip (DDH). There is controversy regarding whether it represents a true risk factor for pathological DDH. Therefore a 20-year prospective, longitudinal, observational study was undertaken to assess the relationship between the presence of a neonatal clicky hip and pathological DDH. Patients and Methods A total of 362 infants from 1997 to 2016 were referred with clicky hips to our 'one-stop' paediatric hip screening clinic. Hips were assessed clinically for instability and by ultrasound imaging using a simplified Graf/Harcke classification. Dislocated or dislocatable hips were classified as Graf Type IV hips. Results The mean age at presentation was 13.8 weeks (12.8 to 14.7). In all 351 out of 362 children (97.0%) had Graf Type I hips (normal) that required no treatment. Nine children (2.5%) had Graf Type II hips but all resolved to Graf Type I hips on follow-up scans. One child (0.3%) had Graf Type III hip dysplasia and one child (0.3%) had an irreducible hip dislocation. The two pathological hips were associated with unilateral limited hip abduction. Mean referrals increased from 12.9 to 23.3 each year (p = 0.002) from the first decade of the study to the second, driven by increasing primary care referrals (5.5 versus 16.7 per year, p < 0.001). Conclusion Most clicky hips required no treatment other than reassurance to parents. Clicky hips with a normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However, an abnormal hip examination including unilateral limited hip abduction should prompt urgent further investigations.
Database: EMBASE

​Author(s): Javed S.; Sadozai Z.; Javed A.; Din A.; Schmitgen G.
Source: Journal of Orthopaedic Surgery; 2017; vol. 25 (no. 3)
Publication Date: 2017
Publication Type(s): Article
Available  at Journal of orthopaedic surgery (Hong Kong) -  from EBSCO (MEDLINE Complete)
Abstract:Introduction: Steroid and local anaesthetic injection to the acromioclavicular joint (ACJ) is a very common diagnostic and therapeutic procedure, which is often performed in the outpatient department. However, it can be difficult to localize this joint because of its small size, presence of osteophytes and variable morphology in the population. We performed a study to determine whether the use of an image intensifier (X-ray guidance), in theatre, improves the accuracy of this injection. Methods: This was a prospective study carried out between March 2014 and March 2015. The injections were performed by two senior orthopaedic surgeons. First, we clinically palpated the ACJ and marked the area over this point as A. Then, with the use of a needle and an image intensifier in a single plane, we identified the actual location of the ACJ and marked this point as B. We measured the distance between A and B in millimetres (mm) and determined the accuracy of the injections. Further analysis taking into account the ACJ capsular attachments was also performed. Results: In total, 45 patients and 50 injections were included in the study; five patients had repeated injections at different times. We found that only 12 injections (24%) were palpated to be correct with no discrepancies between A and B (95% confidence interval: 14-37%). For the remaining 38 injections (76%), the use of an image intensifier had significantly improved the accuracy of ACJ location (p Copyright © The Author(s) 2017.
Database: EMBASE

Author(s): Dwan K.; Kirkham J.; Paton R.W.; Morely E.; Newton A.W.; Perry D.C.

Source: Cochrane Database of Systematic Reviews; Jul 2017; vol. 2017 (no. 7)

Publication Date: Jul 2017

Publication Type(s): Article

Abstract:This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To determine the role of splinting and the optimal treatment strategy for the non-operative management of DDH in children under six months of age. To identify if there are particular subgroups of patients for whom the optimal management strategy may differ.Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Database: EMBASE

Author(s): Choudry, Qaisar; Paton, Robin W

Source: Journal of pediatric orthopedics. Part B; Mar 2017

Publication Type(s): Journal Article

Abstract:In the UK, the Pavlik harness is generally the accepted treatment technique for the treatment of neonatal and infant pathological developmental dysplasia of the hip. In 2013, the success rate of the Pavlik harness became an outcome measure from the British Society of Children's Orthopaedic Surgery for appraisal and revalidation with the GMC for paediatric orthopaedic surgery. The standard set requires an 80% success rate, with less than 20% requiring surgery. This study evaluated the outcomes of Pavlik harness treatment in neonates/infants with 'pathological hips' diagnosed by ultrasound imaging in a district general hospital setting. In a 10-year prospective observational longitudinal cohort study, modified Graf type III and IV hips (excluding those presenting with irreducible hip dislocation) were classified as pathological and splinted. A total of 2826 neonates/infants underwent ultrasound assessment in the paediatric orthopaedic 'screening clinic'. Neonates and infants were referred as 'at-risk' or as clinically unstable by the Paediatric Department and by general practitioners. Thirty-one Graf type III and 95 Graf type IV hips were identified and treated with a Pavlik harness. One Graf type III (30/31=success rate 96.8%) and three clinically unstable Graf type IV hips progressed to irreducible hip dislocations (92/95=96.8%). The success rate of the Pavlik harness in Graf type III and IV dysplasia was 96.8%, with 3.2% requiring surgery because of progression of the condition, confirming acceptable results for this technique in a district general hospital setting.
​
Database: Medline

Author(s): Honnenahalli Chandrappa M.; Hajibandeh S.

Source: Journal of Clinical Orthopaedics and Trauma; Jan 2017

Publication Date: Jan 2017

Abstract:Objectives: Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the outcomes of open versus arthroscopic methods of ankle fusion. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing outcomes of arthroscopic and open ankle arthrodesis. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. Results: We identified one prospective cohort study and 5 retrospective cohort studies, enrolling a total of 286 patients with ankle arthritis. Our analysis showed that open ankle fusion was associated with a lower fusion rate (OR 0.26, 95% CI 0.13-0.52, P = 0.0002), longer tourniquet time (MD 16.49, 95% CI 9.46-23.41, P. <. 0.00001), and longer length of stay (MD 1.60,95% CI 1.10-2.10, P. <. 0.00001) compared to arthroscopic ankle fusion; however, there was no significant difference between two groups in terms of infection rate (OR 2.41, 95% CI 0.76-7.64, P = 0.14), overall complication rate (OR: 1.54, 95% CI 0.80-2.96, P = 0.20), and operation time (MD 4.09, 95% CI -2.49-10.66, P = 0.22). The between-study heterogeneity was high for tourniquet time but low or moderate for other outcomes. The direction of the effect sizes remains unchanged throughout sensitivity analyses. Conclusions: The best available evidence demonstrates that arthroscopic ankle fusion may be associated with a higher fusion rate, shorter tourniquet time, and shorter length of stay compared to open ankle fusion. We found no significant difference between two groups in terms of infection rate, overall complication rate, and operation time. The best available evidence is not adequately robust to make definitive conclusions. Long-term results of the comparative efficacy of arthroscopic ankle fusion over open ankle fusion are not currently available. Further high quality randomised controlled trials that are adequately powered are required.Copyright © 2017.

Author(s): Chandrappa M.H.; Hajibandeh S.

Source: Journal of Clinical Orthopaedics and Trauma; Jan 2017; vol. 8 (no. 1); p. 14-20

Publication Date: Jan 2017

Publication Type(s): Review

Abstract:Objectives Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the effect of initial varus or valgus displacement of proximal humerus on the outcomes of patients with proximal humerus fractures treated with open reduction and internal fixation. Methods In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing postoperative outcomes associated with initial varus versus initial valgus displacement of proximal humerus fracture. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. Results We identified two retrospective cohort studies and one retrospective analysis of a prospective database, enrolling a total of 243 patients with proximal humerus fractures. Our analysis showed that initial varus displacement was associated with a higher risk of overall complication (RR 2.28, 95% CI 1.12-4.64, P = 0.02), screw penetration (RR 2.30, 95% CI 1.06-5.02, P = 0.04), varus displacement (RR 4.38, 95% CI 2.22-8.65, P < 0.0001), and reoperation (RR 3.01, 95% CI 1.80-5.03, P < 0.0001) compared to valgus displacement. There was no significant difference in avascular necrosis (RR 1.43, 95% CI 0.62-3.27, P = 0.40), infection (RR 1.49, 95% CI 0.46-4.84, P = 0.51), and non-union or malunion (RR 1.37, 95% CI 0.37-5.04, P = 0.64). Conclusions The best available evidence demonstrates that initial varus displacement of proximal humerus fractures is associated with higher risk of overall complication, screw penetration, varus displacement, and reoperation compared to initial valgus displacement. The best available evidence is not adequately robust to make definitive conclusions. Further high quality studies, that are adequately powered, are required to investigate the outcomes of initial varus and valgus displacement in specific fracture types. Level of evidence Level II.Copyright © 2016
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Database: EMBASE