Authors:
J Barrett-Lee, H Fraig, D Avis, T Ardolino

Hospital:
Hampshire Hospitals NHS Foundation Trust

Background
Predicting orthopaedic trauma burden on trusts is often challenging and impacts patient flow. It is recognised that peaks and troughs will occur, and the ideal system would account for this. Practice in many organisations involves using rolling lists to gauge trauma workload, however this is easily underappreciated by management. The prioritisation tool aimed to improve this process, allow greater visualization of workload, and better pre-empt ebbs and flows.

Methods
The trauma prioritisation tool comprises three components: injury priority, in-patient workload, and case complexity. Orthopaedic injuries were assigned a ‘fix-time’, according to national guidelines and consultant consensus, representing the time in which fractures should be definitively managed to avoid suboptimal outcomes. Outstanding cases were reviewed daily and ordered using a traffic light system: green – surgery within fix-time, amber – within 72hrs, and red – beyond. An escalation policy was created to trigger one of three responses: 1 – planned trauma cancellation and use of CEPOD, 2 – cancel elective, and 3 – site response.

Results
Following implementation, we saw more efficient responses to surges in trauma and were better able to predict theatre requirements. During new year period 2022, a bed crisis triggered a critical incident and management pushed to amalgamate trauma and CEPOD theatres. A level 3 response was generated, which prevented loss of trauma theatre capacity.

Conclusions
The prioritisation tool improved planning and generated appropriate responses to fluctuating workloads. Consequently, more patients were treated in accordance with national guidelines and demands on the department were better visualised.

Authors:
O Townsend, S Abouzied, M Mahmoud, L Venkatachalam, S Stapley

Hospital:
Queen Alexandra Hospital, Portsmouth

Introduction
The volume of trauma is increasing as population demographics evolve, and inpatient bed capacity is squeezed from a variety of influences. We undertook to evaluate our current use of Day Surgery for the management of Orthopaedic trauma, with a view to streamlining processes to improve inpatient bed capacity for other orthopaedic work.

Methods
Electronic theatre databases were interrogated for all orthopaedic trauma cases performed in 2022. Adult patients admitted through Day Surgery Unit were identified, and data were collected on time of admission, date and time of discharge, operation performed and reason for failed day case discharge.

Results
2430 trauma cases were identified, of which 513 cases were brought in for attempted day case management (21.1%). These were overwhelmingly upper limb cases, particularly hand and wrist procedures, with ankle fracture ORIF the most common lower limb day case procedure.
Of these 513 cases, 430 were treated and discharged home the same day (83.8%). 83 patients required at least one night in hospital (16.2%). Of those with recorded reason for failure to discharge the same day, uncontrolled pain was the primary reason. Of those discharged the same day, over half were discharged out of hours (after 5pm).

Conclusions
Although over 20% of trauma can already be considered for day case management, there may be scope to increase this. Pathways need refining to reduce ‘failed discharge’ rates of almost 1 in 6 patients. This is likely to require improved analgesia prescribing protocols and efficient trauma list scheduling.

Authors:
L Kilbane, R Haasbroek, N Evans

Hospital:
Salisbury NHS Foundation Trust

Aims
Since 2014 hospitals are required to publish information on nursing staff levels against safe staffing guidelines. Despite recommendations by the Royal College of Physicians in 2018, no similar legislation or guidelines have been published. Hospital departments consistently face staff shortages across different grades and roles including within trauma and orthopaedics. Our aims are to compare staffing numbers across the UK from which to drive change.

Methods
Questions were sent to 138 NHS trusts through a Freedom of Information request. Staffing numbers at different grades (consultant, SAS, AS, registrar, junior doctor, specialist nurses and trauma coordinators) were surveyed together with metrics of bed numbers and admissions from which to generate a scaled comparison. Admissions and per consultant could infer the output of the department with the admissions per SHO inferring the workload on junior doctors.

Results
96/138 (69%) trusts responded with 73 providing sufficient data to be included. 13 MTC Centres, 54 Trauma Units, 5 Local Emergency Hospitals. Mean admissions per consultant=267 and theatre sessions per consultant=2.6. Mean admissions per SHO=415. The mean Consultant to SpR Ratio was 1.48. Trauma coordinators were employed by 83% of trusts.

Conclusion
There are significant differences across the UK trusts in staffing levels. Most notably at SHO level who are responsible for much of the daily ward work and clinical contact for patients. Trusts could use our data to leverage additional funding to increase staffing levels and improve patient safety.

Authors:
S Kohli, S Baker, S Markham, O Mitchell, L McMenemy, C Senior, P Ward

Hospital:
Dorset County Hospital

Background
Hospital inpatient stay following arthroplasty has reduced substantially over the past decade. This is partly due to an evolution in surgical and anaesthetic techniques. Consequently, day case arthroplasty is feasible. Literature suggests increased patient satisfaction and reduced complications with reduced hospital stay, as well as benefit to the hospital bed pressures. This study aimed to assess the day case arthroplasty service at our district general hospital.

Methods
Patients were identified during Orthopaedic outpatients and referred onto a specialist anaesthetic assessment service to confirm suitability and preoperatively prepare patients for day case arthroplasty. On the day, patients follow standardised anaesthetic and post-operative protocols.
Data was collected on type of anaesthetic, procedure, time to mobilisation and discharge, and reasons for delay in discharge.

Results
Over 6-months, 49 cases were identified, (20 TKRs, 27 THRs, 1 reverse shoulder replacement). 82% of patients had a spinal anaesthetic with the majority receiving heavy Levobupivicaine. 58% of THRs, 20 % of TKRS, and all shoulders went home the same day. Reasons for delayed discharge included 29% not mobilised within 4-6 hours, with 56% of these due to the spinal still active and 21% due to unavailability of physiotherapists.

Discussion
Although there are some challenges that need to be overcome, such as an increase in physiotherapy cover out of hours, day case arthroplasty is a feasible pathway. Patients who underwent THRs were more likely to be successful than TKRs for same day discharges. This service has the potential to aid in reducing hospital bed pressures.

Authors:
A Chowdhury, H Imran, H Colaco

Hospital:
Hampshire Hospitals Foundation Trust

Introduction
The NHS is responsible for a vast carbon footprint, with annual carbon dioxide emissions estimated at over 20 million tonnes, comparable to the national emissions of Sri Lanka. Operating theatres contribute up to 25% of a hospital’s emissions. We aimed to rationalise the composition of the single-use convenience packs in arthroscopic and open shoulder surgery, to reduce the annual carbon footprint.

Methods
The individual material composition of all items in the single-use shoulder arthroscopy and open shoulder convenience packs was considered. The carbon footprint of each item was calculated by the application of best available cradle-to-grave emission factors. The items in the packs were then rationalised by consensus (of surgeons and scrub team), removing, reducing, or altering unnecessary items. Two new standardised packs were designed, and a predicted annual carbon footprint reduction was calculated.

Results
In the 2022/2023 financial year, 296 arthroscopic and 154 open shoulder procedures were performed. This resulted in the use of 810.7kg of single-use non-recycled plastic. The new rationalised packs will result in an estimated annual carbon footprint reduction of 607.5 kgCO2e.

Conclusion
Through a simple method of single-use convenience pack rationalisation, we can reduce the annual carbon footprint of shoulder surgery by the equivalent of 1,557 miles driven in an average petrol car. This is an underestimate of saving, as the reduction in waste disposal has not been considered. Ongoing work includes expansion to all orthopaedic procedures, assessment of waste disposal and the adoption of sterilisable/sustainable alternatives.

Authors:
A Denning, S Saleem

Hospital:
Hampshire Hospitals Foundation Trust

Introduction
An orthopaedic surgeon’s grip is integral to operating and using surgical instruments. During hip arthroplasty, cementing and stem placement are crucial steps, yet we continue to use cement guns surgeons notoriously struggle with. We measured grip strength in our registrar population at different distances to try to understand why the cement gun is so troublesome. With increasing diversity within orthopaedics we also identify any discrepancy between sexes or hand sizes.

Methods
We measured the grip strength of orthopaedic registrars with a dynamometer at 4cm, 5cm, 6cm, 7cm and 8cm. We noted the participants demographics and attitudes towards orthopaedic surgical instruments.

Results
We included 26 orthopaedic registrars. 50% felt the cement gun was the most difficult instrument to use, with a higher proportion of female registrars noting this. When measuring the grip strength of participants at various distances, at 4cm the average was 31kg, at 5cm it was 46kg, at 6cm it was 49kg, at 7cm it was 46kg and at 8cm it was 37kg. Males were stronger than females throughout. However, every single surgeon lost grip strength above 7cm. Inter-prong distance of the cement gun handle is 7.5cm.

Conclusion
All surgeons lose grip strength above 7cm, some much lower. The inter-prong distance of a cement gun handle is 7.5cm. This explains its difficulty to use. In our attempt to identify why surgeons, particularly women and smaller hand size surgeons experienced issues cementing, we discovered the inter-prong distance of cement guns was creating difficulties for all of us.

Authors:
R Ormiston, E Unwin

Hospital:
University Hospital Southampton NHS trust

Introduction
Higher surgical training in the UK generally adopts a Master-Apprentice model which relies on high contact hours. The EWTD, Covid-19 pandemic and a rise for consultant delivered care threaten this system. Computer-based simulation (CBS) is one form of augmenting surgical training. In orthopaedics, CBS is established in arthroscopic surgery, but not yet in fracture fixation surgery, which makes up more than 50% of the orthopaedic surgical curriculum.

Methods
Four databases ‘Web of Science’, ‘Embase’, ‘Medline’ and ‘OrthoSearch’ were searched using the terms ‘orthopaedic’, ‘fracture’, ‘simulation’ and ‘education’. Two relevant journals, two conferences and two registries were hand searched. All searches were between Jan 2010 and April 2022. Selected articles underwent a backwards and forwards citation search. 1,285 articles were identified and screened for selection. Two reviewers independently extracted outcome data and completed a risk of bias analysis. Selected studies were included in a direction of effect synthesis and appropriate studies were included in a meta-analysis.

Results
15 studies totalling 350 participants, measuring the development of participants’ knowledge, skills, and competencies, were included for direction of effect analysis. 86% (13/15) favoured CBS over traditional preparation. A meta-analysis of 4 studies, totalling 62 participants, measuring OSATS score favoured CBS, Standard Mean Difference = 1.06 (95% CI; -0.34, 2.45) (Z=1.48)(P=0.14).

Conclusions
Participants in this systematic review range from medical students to fellows; outcomes measure knowledge, skills and competencies and the control groups are varied. Despite this heterogenicity CBS is favoured consistently, and the heterogenicity of these results means this evidence is generalisable to a wide educational context within orthopaedic fracture surgery.

Authors:
S Williams, A Stoneham, J Hardie, G Neal-Smith, F Guerreiro

Hospital:
University Hospital Southampton NHS trust

Mistakes in surgery are exceptionally common; they can harm surgeons as well as patients and are a major burden on healthcare systems in terms of wasted resources and the cost of litigation. Surgeons are not prone to seeking support for their mistakes and there are few forums available for them to discuss them with their peers.

We conducted an all-day peer-to-peer session aimed at Speciality Registrars in the Wessex region. It was organised by senior trainees and overseen by an experienced, recently retired NHS Consultant. There were guest speakers, including GP and professional whistle-blower Dr Phil Hammond, and trainees were encouraged to share their mistakes and dissect the learning points.

A pre-course survey showed that all ST3-ST8 trainees had experienced at least one and up to 10 “serious” mistakes in their careers to date. The commonest cited contributing factor was lack of familiarity with equipment. Seven registrars presented specific cases which ranged from technical equipment issues to misplaced implants and wrong site surgery.

Course feedback was overwhelmingly positive and there was a strong feeling that this should be incorporated into the regular Registrar teaching syllabus regionally, if not nationally. Participants came away comforted that they were not alone in their mistakes, more aware of how to spot and avoid errors, and better informed as to what to do when one occurs.

Authors:
S Kohli, J Smith, R Clowes, S Davis, J Vincent, C Senior

Hospital:
Dorset County Hospital

Aim
In response to the elective orthopaedic backlog created by the Covid19 pandemic, we developed a secondary care community clinic service outside of the main hospital site. The facility provides a holistic, multidisciplinary alternative to the standard outpatient clinic model for Orthopaedic patients, in order to improve the quality and efficiency of the experience. This study describes patient satisfaction and experience of using the new temporary facility to inform the development of a permanent outpatient centre utilising the same model of care.

Methods
Two surveys were created to evaluate the environment, design, flow, and experience of patients and staff who attended the community clinic. Data was collected from 05/01/2022 to 28/02/2022 and 01/08/2022 to 31/08/2022.

Results
A total of 296 responses were collected. The significant majority (82-96%) of patients and staff rated the overall environment as good or very good and would recommend the service to family or friends. Key atmospheric themes include positive remarks on a collaborative feel, welcoming and a spacious environment.

Conclusions
The community outpatients centre has had a significant impact on the care we deliver patients. The large open space with clinical hubs provides flexibility to develop new patient pathways and services. Patient and staff feedback from the experience has been very positive, with a high-cost efficiency.

Authors:
S Shamoon, E Thompson, A Qureshi, J Round, N Hancock

Hospital:
University Hospital Southampton NHS trust

Introduction
Circular frames are fundamental to lower limb reconstruction, particularly in open fractures. During the pandemic, use of circular frames in our unit decreased in keeping with BOA guidelines “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plates and IM nailing).
This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy.

Methods
Retrospective review of complex lower limb injuries treated before, during & after lockdown, External fixation as definitive treatment vs internal fixation performed by senior authors. Deformity/correctional & DCO frames excluded.

Results
77 Frame and 116 internal fixation cases were identified. A notable reduction in the number of circular frames applied was observed. Data suggest comparable outcomes between circular frames and alternative techniques, Frame fixation was associated with more outpatient review and the associated implications for resource management. 4 patients underwent amputation, 2 in Frame Group, 2 in Internal Fixation Group. None from the Covid period. 4 patients from the Covid Internal Fixation Group failed and required conversion to Circular Frame Fixation

Conclusion
Alternatives to traditional techniques have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted.