TORC 2024 Abstracts
Foundation Doctors Podium Abstracts
Does Accurate Tip-Apex distance actually matter? Evaluating failure of fixation of hip fractures in a single major trauma centre
A Tan, D Trussler, C Donoghue, D Nicoll
Background: The importance of tip-apex distance (TAD) is well known to the Orthopaedic trainee. But, is it actually the most important feature for preventing failure? Inaccurate screw placement is often seen but does not necessarily equate with subsequent failure of fixation. Achieving accurate fracture reduction is felt to be key to success in these multi-morbid patients, for whom the cost of revision surgery is significant.
Aim: To determine whether accurate TAD or fracture reduction was associated with a lower rate of failure, and whether inaccurate screw placement led to a higher rate of failure.
Methods: Retrospective database study analysing the outcomes of hip fracture fixation patients in a single trauma centre. We analysed all hip fracture fixation patients and their fracture morphology over 3 months. We analysed implant choice and calculated tip-apex distance and whether it was within 25mm (Gold Standard). We also assessed fracture reduction and accuracy of screw position on orthogonal radiographs. A follow-up period of 24 months assessed for failure and revision procedures.
Results: 69 patients underwent surgical fixation for intertrochanteric or subtrochanteric femoral fractures during the study period, inclusive of 44 (64%) dynamic hip screw (DHS) and 25 (36%) intramedullary nailing (IMN) procedures. Average tip-apex distance recorded was 18.61mm (IQR 15.2mm-20.9mm), with 63 (91.30%) fixations satisfying the gold standard criteria. 2 (2.90%) fixations failed. TAD>25mm (C2= 4.43, p= 0.036) was associated with a greater risk of failure. However, neither fracture malreduction (C2= 0.41, p= 0.52) or AP screw position (C2 = 3.86, p= 0.16) were associated with a higher risk of failure.
Discussion: Our results demonstrate a strong adherence to TAD standards within our department. Findings of a significantly greater failure rate with TAD> 25mm is consistent with those of Baumgaertner. Surprisingly, fracture reduction was not found to be a significant determinant of fixation success.
NHS Tayside; Management of Patients with Suspected Primary or Metastatic Bone Disease – Are We Adhering to BOAST Guidelines?
Dr M. Hunter, Dr A. Harmer, Miss K. Hoban, Dr M. Jawad
Intro / Background: One in two people will develop malignancy in their lifetime;(1) of these patients,~4.8% will develop Metastatic Bone Disease (MBD) within 1-year of diagnosis.[2] Early identification and management can reduce mortality and morbidity of MBD.[2,3] Patients presenting with suspected MBD should be managed according to the ‘BOAST guidelines for MBD’[4] which contain 16 Standards of Practice (SOPs).
Aims: To assess NHS Tayside adherence to 16 SOPs within the BOAST guidelines. Pre- and post-audit cycles were completed following implementation of a poster.
Methods: A closed loop audit, including all adult patients admitted to the orthopaedic department between 01/11/22-31/12/22 (Cycle 1) and 01/07/24-04/10/24 (Cycle 2). A poster outlining BOAST guidelines and MBD management was displayed and circulated via email between cycles. We compared adherence to identify changes in practice. Patients were identified from trauma lists; those with a history of malignancy or documented prodromal symptoms of cancer were included. Data was extracted from E-Trauma, EKORA, ICE, PACS, and Clinical Portal.
Results: N[1]=70 patients were audited for Cycle 1(mean age 77) and N[2]=35 patients for Cycle 2 (mean age 72). Adherence was poor in both cycles. 5 SOPs were improved after intervention. There was 100% compliance with documentation of neoadjuvant therapy use (Cycle 1:1.4%/ Cycle 2:100%) and use of venous thromboembolism prophylaxis (71%/100%). Other improvements included biopsy of suspected primary bone tumours (1.4%/11%) and use of appropriate investigations– blood tests (24%/29%), staging CT-CAP (0%/45%), and orthogonal imaging (100%/97%). 4 SOPs had poorer adherence in the second cycle.These included timely referral to sarcoma MDT (2.8%/0%), documented prodromal symptoms (100%/49%), orthopaedic follow-up (41%/31%), and family involvement in decision making (45%/17%).
Discussion / Conclusion: This audit is useful in understanding local awareness and adherence to BOAST guidelines. Despite intervention, adherence has not significantly improved across SOPs. This data suggests that future re-education on MBD may be beneficial to improve care for affected patients.