Does the Nottingham Hip Fracture Score Help Predict Which Patients Will Benefit From a Modern Modular Hemiarthroplasty for the Treatment of Intracapsular Proximal Femoral Fractures?

Introduction: Hemiarthroplasty for the management of intracapsular neck of femur fractures is common but current practice in the UK still varies regionally and individually. Guided by the National Institute of Health and Care Excellence (NICE) we have observed a move towards modern, modular prostheses such as the Exeter V40 Stem but the use of older, monoblock prostheses such as the Thompsons Hemiarthroplasty remains controversial. Use of the Nottingham Hip Fracture Scores (NHFS) can help surgeons stratify patients according to risk and select the most appropriate prosthesis to meet their individual needs. Materials and Methods: 765 hip hemiarthroplasties were analysed over a 28-month period at a single, high-volume, orthopaedic department in the UK. We calculated the NHFS and recorded the choice of prosthesis. Patients were then followed up for at least a year. Outcomes were mortality and change in residential status. Results: Six hundred and forty-six (446) patients were treated with monoblock prostheses (mean age=85.6; range 62-105). 319 patients received modular prostheses (mean age=81.0; range 61-98). Patients who were selected to receive a monoblock prosthesis were over twice as likely to be dead at a year (32.87% vs. 13.65%) and over twice as likely to require increased assistance with living (50.12% vs. 23.81%). Amongst patients with equivocal NHFS, those who receive a monoblock stem suffered worse outcomes in all but the very highest risk group, who experienced lower mortality (OR=0.71, CI 0.52-0.96) and change in residential status (OR=0.76, CI 0.58-0.99). Conclusion: Nottingham Hip Fracture Score (NHFS) can confer predictable outcomes in hip fracture patients treated with modular stems. Modular stems should be the default choice when performing hemiarthroplasties for intracapsular neck of femur fractures. However, in keeping with other studies, we found that in very old, frail, or co-morbid patients, modular stems are not associated with better survival or return to pre-morbid function.

The Impact of the First Wave of Covid 19 on Orthopaedic Surgeries in a Tertiary Care Teaching Hospital

Background: The Covid 19 was declared a global pandemic that had a sizeable impact on the health care services in the surgical field including the orthopaedic department. There was additionally a decreased accessibility to healthcare personnel and facilities reallocated to manage the Covid patients. The study was mainly conducted to find out the impact of the first wave of COVID-19 on the orthopaedic surgeries. Aim: The main aim of the study is to find out the alteration in the number, type of surgeries, financial implications, duration of hospital stay, delay in surgery during the first wave of the COVID-19 pandemic. Study Design: Retrospective crossectional study. Methods: All the surgeries conducted in the orthopaedic department in the year 2019 and 2020 following first peak in March including pre-op and post-op COVID cases are included in the study. The procedure conducted, date of admission, date of surgery, date of discharge, investigations done and the cost expenses are the various parameters that are taken into consideration. The results are analysed for each year and comparisons are made using statistical methods. Results: The comparative analysis of the data collected from the years 2019 and 2020 showed an increase in the duration of hospital stay, delay in surgery, additional expenditure, back log in the number of elective surgeries done during the Pandemic.

764 Is Consent Valid in Common Orthopaedic Surgeries?

Aim Consent is at the heart of the doctor-patient relationship. Valid consent should be voluntary, informed and the patient must have the capacity to make the decision. It is the doctor’s responsibility to ensure the patient can make an informed decision. The aim of this audit is to assess the validity of consent within Salford Royal Foundation Trust Orthopaedic department. Method We retrospectively reviewed 225 consent forms for four common orthopaedic trauma procedures: 44 wrist ORIF, 48 ankle fixation, 71 hip hemiarthroplasty and 62 fixations with DHS. BOA-endorsed OrthoConsent and SRFT-produced leaflets were utilised as a standard for reported surgical risks and complications. Collated patient consents were compared against these standards. Exclusion criteria included consent four and polytrauma patients. Results 96 forms were excluded leaving 129 consent forms. In all four procedures, 86%-100% had documented infection, nerve injury and bleeding. Compartment syndrome was not documented for any wrist ORIF patients. CRPS was recorded in only 57% of wrist and 31% of ankle ORIF patients. Wound healing complications was documented in 17% of ankle ORIF. In 71% of DHS and 64% of hemiarthroplasty patients, risk of death was not recorded. Conclusions Targets for achieving satisfactory consent form documentation were not met and showed significant variation amongst clinicians. It suggests that patients are not being fully informed of benefits and risks of surgery. Recommendations include the introduction of posters and encouraging printing off patient information leaflets and improving education on valid consent for rotational doctors.

1373 Semi-Elective Trauma Patients Pathway and Medical Clerking Proforma, Closed Loop Audit

Introduction Semi-elective Trauma care is a service provided by the Trauma and Orthopaedic department for patients who sustain fractures to the upper and lower limbs requiring surgical intervention, are still ambulatory and can be cared for safely at home until the date of operation. Aim To assess patients’ referral pathway and clerking documentation against the Standards for the Clinical Structure and Content of Patient Records, published by the RCSEng. Method We performed a closed loop audit on the clerking documentation and the referral pathway for these patients. We collected data retrospectively for three months, assessing the clerking documentation against the guidelines. The data was analysed and presented at our Clinical Governance meeting. We then implemented the Semi-Elective Trauma Pathway and the Medical Clerking Proforma. Afterwards, data was collected prospectively to complete the audit cycle. Results A sum of 181 patient were included. Before the use of our changes, only 36% of patients had a complete clerking documentation, with two cases of near misses, and no comprehensive referral pathway for these patients. Post implementation of the Pathway and the Clerking Proforma, 88% of patients had complete clerking documentation, no near misses and 95% of them went properly through the pathway we introduced. Conclusions These patients present an important part of any trauma list. This Audit shows that having a comprehensive referral pathway and a clerking proforma will make sure that patients will have full medical history taken and are ready for the operation on the day of surgery and decrease the number of near misses.

206 Audit of Time to Surgical Fixation of Distal Radial Fractures Compared to British Orthopaedic Association Standard for Trauma (BOAST) Guidelines at Busy District General Hospital

Aim BOAST guidelines state that intra-articular distal radial fractures should be operated on within 72 hours of injury and extra-articular distal radial fractures which require surgical management should be operated on within 7 days. The aim of this audit was to see how the orthopaedic department at a busy district general hospital compared to these guidelines. Method Retrospectively looked at operations carried out over a 10-month period. All Manipulation Under Anaesthesia, K wire and Open Reduction Internal Fixations of distal radial fractures were included. Results Over the 10-month period, 49 intra-articular and 60 extra-articular fractures were operated on. 65% of intra-articular fractures were fixed within 72 hours and 82% of extra-articular fractures were fixed within one week. Mean time from date of injury to operation was 3.88 days for intra-articular and 2.98 days for extra-articular fractures. Mean time from decision of surgery to operation was 2.32 days for intra-articular and 2.18 days for extra-articular fractures. Conclusions Clearly, the management of extra-articular fractures is closer to the standards set by BOAST guidelines. It can be difficult to establish from an x-ray whether a fracture is extending into a joint surface - this can delay the fracture clinic appointment and the operation. The difference between the mean time of injury to operation and mean time of decision of surgery to operation for intra-articular fractures show that once the decision to operate has been made, it is carried out quickly. Educating A+E and orthopaedic staff on recognising intra-articular fractures could expedite the time to surgery.

360 The Impact COVID-19 Has Had on Paediatric Supracondylar Fractures: A Closed Loop Audit Demonstrating How Compliance to BOAST 11 Guidelines Has Changed in An Orthopaedic Department

Aim Supracondylar fractures of the humerus in the paediatric patient is a common orthopaedic injury. Resultantly, strict guidelines were created by the British Orthopaedic Association of Standards in Trauma 11 (BOAST 11). In 2020, the COVID-19 pandemic, drastically affected the way medicine was practised. This audit aims to highlight, the extent to which compliance with BOAST 11 changed. Method Children with a supracondylar fracture of the humerus (Gartland 2 or 3) were included in this study. Standards from BOAST 11 were selected and the orthopaedic department were audited against these over a period of 2 years. After the first audit cycle, an information booklet was created and distributed to all doctors within the department. At the end of 2020, the department was re-audited, comparing pre-COVID results (2019) with COVID results (2020). Results Compliance improved within five BOAST 11 domains assessed on re-audit. With significant changes in neurovascular status being appropriately assessed and documented in clerking notes (improvement of 28%); and 2mm k-wire being used and documented in operation notes (improved by 23%). However, significant regression in results in patient’s being operated on within 24hours. Conclusions Global improvement of results during the national pandemic in 2020 demonstrates that our department did not compromise patient care despite limited resources but in fact strived for clinical excellence. The reason for a regression in compliance with regards to patients not being operated on within 24hours was likely due to protect paediatric patients from unnecessary stay in hospital, in a strategy to reduce COVID-19 transmission rates.

828 STITCH And B**** - A Novel Programme Combining Pastoral Support and Surgical Skills

Aim Foundation training can be a challenging time for Junior doctors; though help and support is offered, it is not always taken up. This programme aims to create a safe environment to facilitate discussion and provide pastoral support alongside teaching them new surgical skills. Method Four different sessions were organised over the period of four months (August 2020 – November 2020) and FY1/FY2 doctors working in the Orthopaedic department at the GWH, Swindon were invited to attend. Each session focussed on assorted suturing techniques and knot tying. In addition, the facilitator directed conversation towards opportunities to discuss frustrations, challenges, queries as well as positive occurrences. A questionnaire was distributed at the final session to evaluate participant experience. Results 100% of attendees agreed or strongly agreed that they found their FY1 rotation challenging so far. 100% also scored 9/10 when asked how comfortable they were talking about concerns, worries or issues at these sessions. All the participants recorded ‘yes’ when asked if the session provided them with a listening ear, helpful advice, feeling supported, understanding/empathy and reassurance. 100% of the attendees scored that their confidence at suturing had improved (average: 4 points on a scale of 1-10). Conclusions Through these sessions, practical changes and improvements were achieved in the running of the Trauma and Orthopaedic department. Placement feedback was obtained, suggestions on things to improve or change and key issues were escalated to supervisors. There do not appear to be any similar programmes run that combine directed pastoral support and surgical skills teaching.

939 Two Is Not Always Better Than One: A Quality Improvement Project Assessing Efficiency and Financial Implications Associated with Using Two Different Electronic Systems in A Busy Orthopaedic Department

Introduction Ensuring correct documentation and safe handover is key to the running of a successful surgical department. At Imperial College Healthcare Trust, this process has been made easier through various electronic systems available to our Orthopaedic department: our in-house CERNER system and out-of-house system eTrauma, the latter of which is predominantly used. The aim of this project was to assess our efficiency in terms of time management between the two systems, as well as financial implications of saved time. Method Multiple members of the Orthopaedic team timed themselves when entering information regarding a referral or an admission into both systems. This allowed us to estimate the financial implications of moving away from eTrauma. Results An average referral took 165 seconds (n = 27) to input information onto eTrauma, versus 38 seconds (n = 25) for CERNER. Time taken to document an admission was 127 seconds (n = 33) and 26 seconds (n = 31) respectively. The current hourly wage for our junior members is £22.84 per hour or 38p per minute. Moving away from eTrauma to CERNER will save around £1.50 for every 2 referrals and 2.5 admissions, solely from documentation. This is excluding the other benefits of CERNER, such as quick access to relevant clinical information, pathology results and imaging. Conclusions Leaving eTrauma behind will reduce the time spent on documentation by orthopaedic junior doctors. This will result in increased efficiency and will lessen the financial burden on an already overstretched budget. Our formal data will contribute to decision making and future resource allocation in our local Trauma and Orthopaedic Department.

1674 Training Opportunities and Safe Staffing Levels – Loop Closure Audit

Aim It is not uncommon to find rota gaps at junior doctors’ level across many NHS Trusts within United Kingdom – especially in district general hospitals. In the trauma and orthopaedic department at Huddersfield Royal Infirmary, there were significant rota gaps that frequently relied on locum doctors to provide adequate service coverage. The aim of the audit was to determine whether rota gaps had any impact on safe staffing levels, training of core surgical trainees (CSTs) and costs to the department. Method Retrospective audit - assess daily staffing levels as per rota for three weeks before and after implementation of recommended better utilisation of the department’s Advanced Clinical Practitioners (ACPs) to cover trauma wards. The audit took place over October 2018 – December 2018. Results There were safe staffing levels daily in both audits. Audit 1 demonstrated locum doctors were required to cover 36.6% of ward duties and 42.9% of oncall shifts – costing the department £25, 190. Following implementation of recommendation, where ACPs were rostered to cover trauma, audit 2 reduced the requirements of locum doctors for coverage of ward duties and oncalls to 23.7% and 33.3%, respectively. Protected theatre allocation of CSTs remained less than 1 day/week. The cost of locum doctors in audit 2 was reduced to £17, 050. Conclusions Through better utilisation of the department’s ACPs to cover trauma wards, we managed to significantly reduce cost of locum doctors by £8, 140 over a three-week period. We believe CST theatre allocation will also improve from this intervention.

DESCRIPTIVE STUDY OF POST OPERATIVE INFECTION IN OPEN ORTHOPAEDIC INJURIES

Background: In this study, we studied the pattern of bacterial isolates in all cases of open fractures of extremities that came to our hospital. Methods: This descriptive study was to be conducted on open orthopaedic injuries being admitted to the orthopaedic department, from June 2019 to June 2020 after obtaining institutional ethical committee clearance. Results: Culture analysis showed an increase in growth of Gram-negative bacteria, namely Pseudomonas aeruginosa (26.3%) and Escherichia coli (10.5%) while Gram-positive bacteria were Staphylococcus aureus (52.6%) and Klebsiella pneumoniae (10.5%). Conclusion: Unlike surgery in other orthopedic areas, the predicting factors for infection in fracture patients were found to be significantly influenced by open fracture rather than the underlying disease or anatomical features of the patient. However, only the correlation with simple open fracture has been confirmed. Therefore, further studies on the cause of open fracture and the mechanism of open fracture are necessary to determine the risk of infection. Keywords: Infection, Orthopaedics, Open surgery