The Surgeon - Articles in Press

Acute fractures of the scaphoid bone: Systematic review and meta-analysis - Corrected Proof

S. Alshryda, A. Shah, S. Odak, J. Al-Shryda, B. Ilango, S.R. Murali — 2012-05-17

Abstract: Background: The scaphoid fractures account for 50%–80% of all carpal bone fractures in young individuals. Non-union of the fracture occurs in approximately 5%–10% of undisplaced scaphoid fractures. Current management varies significantly among different places and surgeons.Objectives: The purpose of this review is to investigate the evidence of the effectiveness and safety of various treatments of acute scaphoid fractures.Methodology: Systematic review and metanalysis of all the randomised and quasi-randomised trials comparing different treatments of acute scaphoid fractures.Results: Thirteen RCTs (Published 18 times) have met our inclusion criteria. The followings have been investigated:1. Colles cast versus scaphoid cast.2. Above elbow versus below elbow scaphoid cast.3. Colles cast with the wrist in flexion versus Colles cast with the wrist in extension.5. Operative versus non-operative treatment.6. Union rate versus time to union.Conclusion: Scaphoid fracture can be treated by Colles cast for up to 12 weeks. The wrist should not be in flexion. There is no advantage of an above elbow cast over a below elbow cast. Operative treatment for scaphoid does not provide a higher union rate in undisplaced fractures, but may do in displaced fracture. Open approach seems to be superior to percutaneous fixation.

Commemorating Lord Lister, one hundred years on - Corrected Proof

David Tolley — 2012-05-03

The Lister Centenary celebration held on 9 and 10 February 2012 was an eclectic mix of plenary lectures by a glittering array of internationally renowned surgeons and an impressive spread of short papers and poster presentations by young surgeons who competed for the Lister Centenary Medal, which acknowledged the watershed effect of Lister's work on surgery in the nineteenth century.

Gut-origin sepsis: Evolution of a concept - Corrected Proof

Edwin A. Deitch — 2012-04-25

Abstract: The concept of bacterial translocation and gut-origin sepsis as a cause of systemic infectious complications and the multiple organ dysfunction syndrome (MODS) in surgical and ICU patients has emerged over the last several decades, although the exact clinical relevance of these phenomenon continue to be debated. Thus, the goal of this review will be to trace the evolution of gut-origin sepsis and gut-induced MODS and put these disorders and observations into clinical perspective. Additionally, the mechanisms leading to gut-derived complications will be explored as well as therapeutic options to limit or prevent these complications. From this work, several major conclusions emerge. First, that bacterial translocation occurs clinically and is responsible for increased infectious complications in patients undergoing major abdominal surgery. However, the phenomenon of bacterial translocation is not sufficient to explain the development of MODS in ICU patients. Instead, the development of MODS in these high-risk patients is likely due to gut injury and the systemic spread of non-microbial, tissue-injurious factors that reach the systemic circulation via the intestinal lymphatics. These observations have resulted in the gut-lymph hypothesis of MODS.

Diagnosis and management of olecranon bursitis - Corrected Proof

2012-04-16

Abstract: We aim to review the current knowledge on diagnosis, clinical features and main management modalities of olecranon bursitis. We underline that the first treatment line is conservative, including ice, rest, anti-inflammatory and analgesic drugs and, occasionally, bursal fluid aspiration. In unresponsive patients, although open excisional procedures allow to completely remove the pathological bursal tissue, arthroscopy is increasingly being considered as a suitable new modality of management. These minimally invasive procedures, although not free from complications, avoid the wound problems often occurring following open excision.

Anterior cruciate ligament tears in children - Corrected Proof

Nicola Maffulli, Angelo Del Buono — 2012-04-11

Abstract: Anterior cruciate ligament (ACL) injuries have become common in children and adolescents who practice competitive sports, accounting for 0.5–3% of all ACL injuries. Magnetic resonance imaging (MRI) is useful for diagnosis and treatment planning, but is no better than clinical examination, especially when the MRI is interpreted by less experienced health care professionals. Management of ACL deficiency in children is still controversial, but the present trend is towards early reconstruction, because repeated instability episodes may lead to secondary lesions of the knee, and induce meniscal tears and early degenerative alterations of the joint. Postoperatively, complications are rare, and most of the documented growth complications are secondary to avoidable technical errors such as placement of a fixation device across a growth plate. We recommend to reconstruct the ACL paying attention to avoid irreversible damage to the epiphyseal growth plates of the lower femur and upper tibia.

Review of nomenclature in colonic surgery – Proposal of a standardised nomenclature based on mesocolic anatomy - Corrected Proof

K. Culligan, F.H. Remzi, M. Soop, J.C. Coffey — 2012-03-29

Abstract: The standardisation of the surgical management of rectal cancer has been facilitated by adoption of an anatomic surgical nomenclature. Thus, “total mesorectal excision” substituted “anterior resection” or “proctosigmoidectomy” and implies resection of both rectum and mesorectum. Similar trends towards standardisation of colonic surgery are ongoing, yet there remains a heterogeneity of terminology utilised (eg, “right hemicolectomy”, “ileocolic resection”, and “total mesocolic excision”). Recent descriptions of mesocolic anatomy provide an opportunity to standardise colonic resection according to a more precise and informative anatomic nomenclature. This article aims to firstly emphasise the central importance of the mesocolon and from this propose a related nomenclature for resectional colonic surgery. Introduction of a standardised nomenclature for colonic resection is a necessary step towards standardisation of colonic surgery in general.

The isolated lateral malleolar fracture: Where are we and how did we get here? - Corrected Proof

George Smith — 2012-03-29

Abstract: Despite the isolated lateral malleolar ankle fracture being one of the most common injuries treated by orthopaedic surgeons it remains an injury that is widely misunderstood. Treatment protocols are compounded by the contemporary literature being divided on its optimal management. This review takes the reader through a process of how the historical literature on this subject has been formed, it critiques the main responsible papers and leads one to question the current dogma attached to both this injury and to current research in general.

Is there a requirement for axillary lymph node dissection following identification of micro-metastasis or isolated tumour cells at sentinel node biopsy for breast cancer? - Corrected Proof

D.P. Joyce, J.G. Solon, R.S. Prichard, C. Power, A.D.K. Hill — 2012-03-02

Abstract: Introduction: Recent decades have seen a significant shift towards conservative management of the axilla. Increasingly, immunohistochemical analysis of sentinel nodes leads to the detection of small tumour deposits, the significance of which remains uncertain. The aims of this study are to examine patients whose sentinel lymph nodes are positive for macro-metastasis, micro-metastasis or isolated tumour cells (ITCs) and to determine the rate of further nodal disease after axillary lymph node dissection (ALND).Methods: A retrospective analysis of all patients undergoing a sentinel lymph node biopsy (SLNB) between January 2007 and December 2010 in a tertiary referral breast unit was performed. Patients who underwent an axillary lymph node dissection for macro-metastasis, micro-metastasis or ITCs were identified. Demographics, histological data and the rate of further axillary disease were examined.Results: In total, 664 breast cancer patients attended the symptomatic breast unit during the study period, 360 of whom underwent a SLNB. Seventy patients had a SLNB positive for macro-metastasis. All of these patients underwent ALND. A positive SLNB with either micro-metastasis or ITCs was identified in 58 patients. Only 41 of the 58 patients went on to have an ALND, due primarily to variations in surgeons' preferences. Nineteen patients with micro-metastasis underwent an ALND. Four patients had further axillary disease (21%). Twenty-two patients had ITCs identified, of whom only one had further disease (4.5%). No statistically significant difference was found between the two groups in terms of tumour size, grade, lymphovascular invasion or oestrogen receptor status.Conclusion: ALND should be considered in patients with micro-metastasis at SLNB. It should rarely be employed in the setting of SLNB positive for ITCs.

Assessing the sustainability of improved surgical infection prevention practices - Corrected Proof

2012-02-20

Up to 60% of surgical site infections (SSI) are believed to be preventable through strict adherence to best practice guidelines in surgical infection prevention. Surgical patients are also particularly at risk of catheter-related bloodstream infection (CRBSI), which accounts for 7% of all healthcare-associated infection (HCAI). We have previously reported the implementation and evaluation of an effective infection prevention programme, developed by surgeons targeting surgical practice. We subsequently sought to determine if improvements noted were sustained after completion of the initial programme of educational interventions.

Polyps arising in a colonic interposition graft: Instigation of endoscopic graft surveillance may be required - Corrected Proof

L. Ramage, A.R. Davies, J. Deguara, R.C. Mason — 2012-02-17

The development of polyps and colonic carcinomas within colonic interposition grafts used in the treatment of oesophageal cancer, is a rare event. Development of a carcinoma within a graft may be insidious, and potentially disastrous in terms of outcome if not detected rapidly in this complex patient population. We report two such patients, emphasising the need for instigation of surveillance of both the graft and the native colon.

Percutaneous repair of acute ruptures of the tendo Achillis - Corrected Proof

Stephane Guillo, Angelo Del Buono, Marion Dias, Vincenzo Denaro, Nicola Maffulli — 2012-02-16

Abstract: Minimally invasive repair of acute traumatic ruptures of the tendo Achillis may produce lower complications compared to open repair. Twenty-three active patients underwent percutaneous repair of an acute rupture of the tendo Achillis. Post-operatively, the ATRS score was administered to assess the functional status. The maximum calf circumference, isometric plantar flexion strength of the gastrocsoleus muscle complex, ankle dorsiflexion, and return to sport activity were assessed in all patients at an average post-operative follow-up of 25.7 months. At the last follow-up, the mean Achilles tendon total rupture score (ATRS) score was 84 (range: 53–99). Ankle dorsiflexion and maximum calf circumference on the operated limb were not significantly different compared to the uninjured side. The isometric strength on the operated limb was significantly lower (P=0.04) compared to the contralateral side. Of the 21 (90%) patients participating in sports activities, 16 (80%) had returned to their pre-operative sport, 2 changed to lower activity, and 1 increased his performance. This percutaneous technique provides satisfactory outcome in terms of strength and return to pre-operative level of sport activity.

A clinical and radiological assessment of incisional hernias following closure of temporary stomas - Corrected Proof

2012-01-30

Abstract: Aims: The rate of incisional hernia at stoma closure sites is unclear. This study aimed to describe this rate in patients with closed stomas who had definitive post-operative imaging of their abdominal wall.Methods: A retrospective review of patients who had undergone stoma reversal and had a CT or MRI scan of the abdomen ≥2 months following reversal was performed. A radiologist, blinded to the original radiological report and clinical results, reviewed all scans for abdominal wall herniation. This was correlated to documented clinical findings.Results: Fifty-nine patients were included: 49 loop ileostomy and 10 end colostomy reversals. CT scans were performed for 57 patients and MRI for two. The median time from closure to imaging was 10 months (range 3–32 months). The combined clinical and radiological hernia rate was 34% (20/59). Imaging alone produced a rate of 31% (18/59). The clinical rate of hernia detection was 14% (8/59). Using the rate of clinical herniation as the detection standard, imaging had a low positive predictive value (33%, 6/18) but a high negative predictive value (95%, 39/41). Four patients required surgical repair of their stoma site hernia (20%, 4/20).Conclusions: One in three patients undergoing stoma closure developed an incisional hernia. One in five of those with a hernia underwent surgical repair. Definitive imaging may provide an early surrogate marker for late clinically relevant hernias. Consideration of methods to prevent stoma closure site hernias should be considered.

Clinical and histopathological factors affecting failed sentinel node localization in axillary staging for breast cancer - Corrected Proof

2012-01-27

Abstract: Background: Sentinel lymph node biopsy (SLNB) has become the standard of care in axillary staging of clinically node-negative breast cancer patients.Aims: To analyze reasons for failure of SLN localization by means of a multivariate analysis of clinical and histopathological factors.Methods: We performed a review of 164 consecutive breast cancer patients who underwent SLNB. A superficial injection technique was used.Results: 9/164 patients failed to show nodes. In 7/9 patients no evidence of radioactivity or blue dye was observed. Age and nodal status were the only statistically significant factors (p < 0.05). For every unit increase in age there was a 9% reduced chance of failed SLN localization. Patients with negative nodal status have 90% reduced risk of failed sentinel node localization than patients with macro or extra capsular nodal invasion.Discussion: The results suggest that altered lymphatic dynamics secondary to tumour burden may play a role in failed sentinel node localization. We showed that in all failed localizations the radiocolloid persisted around the injection site, showing limited local diffusion only. While clinical and histopathological data may provide some clues as to why sentinel node localization fails, we further hypothesize that integrity of peri-areolar lymphatics is important for successful localization.By means of a multivariate analysis of clinical, biochemical and histopathological parameters, we review reasons for failure of localization of sentinel nodes in axillary staging for breast cancer and compare it with recent reports in the literature.

Resection of focally progressive gastrointestinal stromal tumours resistant to imatinib therapy - Corrected Proof

G.H. Tse, E.H.C. Wong, P.J. O’Dwyer — 2011-11-28

Abstract: Aims: To analyse the outcome of patients with gastrointestinal stromal tumour (GIST) who receive imatinib therapy and undergo subsequent resection of focally progressive disease.Methods: We reviewed the records of all cases of GIST discussed at the West of Scotland Sarcoma regional multi-disciplinary team meeting between January 2002 and December 2009 inclusive. We analysed all patients who had undergone surgery for progressive disease on imatinib therapy. Focally progressive disease was diagnosed on computated tomography (CT) and positron-emission tomography-CT and was defined by a GIST lesion initially responsive to imatinib therapy but then underwent growth with evidence of metabolic activity. All procedures were undertaken in a university teaching hospital by a single surgeon.Results: Nine patients were identified who underwent ten resections of focally progressive GIST. Six had previously undergone resection of their primary tumour while three had presented with un-resectable disease. Nine operations were for resection of a solitary progression while one operation was for three foci of progression. Five patients underwent liver resection which was confined to the segments were there was focal progression of GIST; of these one patient had multiple liver metastases and portal hypertension with a mass at the porta hepatis.The absolute survival for patients after resection was 18.4±13.7 months (mean±standard deviation), with progression free survival of 14.1±13.5 months equating to 56% at 1-year. Four patients had been switched from imatinib to sunitinib, for further multi-focal progression.Conclusions: Surgical resection of focally progressive GIST may prolong survival and a second or third resection is a feasible option in selected patients.

The use of weekly departmental review of all orthopaedic intra-operative radiographs in order to improve quality, due to standardized peer expectations and the “Hawthorne effect” - Corrected Proof

2011-11-28

Abstract: Introduction: Clinical governance highlights risk management, clinical effectiveness and use of evidence based practice as key elements in the provision of a quality service. A change in the method of quality control in our orthopaedic trauma unit allowed us the opportunity to study if the quality of operative outcomes had changed as a result. The Hawthorne effect refers to phenomenon whereby employees work quality improves by virtue of their awareness that their labour is being assessed.Methods: A new outcome appraisal forum was introduced in our department in 2009. This forum involved a weekly whole department review of all the previous week’s intraoperative radiographs. We used the tip apex distance (TAD) of the dynamic hip screw (DHS) procedures in hip fracture patients as a surrogate marker, of any objective change in the quality and consistency of intra-operative radiographs, in the year prior to and after the introduction of this review system.Results: We found that the mean TAD and the number of TAD measurements over 25 mm decreased significantly in the year after the new quality control mechanism was introduced.Conclusion: We would recommend the use of a weekly quality control meeting scrutinizing every intraoperative radiograph as a simple, cost effective method of incorporating many aspects of clinical governance, as well as fostering a culture of quality.

Hip artroplasty: A transient reason not to be pregnant - Corrected Proof

Nicola Maffulli, Angelo Del Buono, Vincenzo Denaro — 2011-11-21

Abstract: Metal implants corrode and release metal ions, cobalt and chromium, which, in turn, may cause systemic toxicity, mostly in the first few months from implantation of metal-on-metal hip arthroplasty. At the time of delivery, the placenta reduces the passage of cobalt and chromium ions released from metal-on-metal prosthesis. From a biomechanical view point, hip replacement should not be considered a contraindication for pregnancy or for spontaneous delivery, and does not seem to have any negative effects in terms of risk of dislocation, loosening, fracture, or revision surgery, neither negative effects on clinical and functional outcomes. The long-term biological consequences of exposure to Co–Cr particles and ions remain largely unknown.

Changing practices in the surgical management of hyperparathyroidism – A 10-year review - Corrected Proof

T. McVeigh, A.J. Lowery, D.S. Quill, M.J. Kerin — 2011-11-21

Abstract: Aim: Parathyroid surgery has undergone a paradigm shift over the last decade, with a move from traditional bilateral neck exploration to minimally invasive parathyroidectomy (MIP), and increasing reliance on pre- and intra-operative localization of overactive glands. We aimed to assess changing surgical practices and their impact on the management of parathyroid disease in a tertiary referral centre in the West of Ireland.Methods: A retrospective cohort analysis of those patients undergoing a surgical intervention for parathyroid disease in the period between 1999 and 2009 in our centre was carried out. Data was analysed using PASW (v18) software.Results: 248 procedures were performed, increasing from an annual rate of 6 in 1999 to 45 in 2009. 129 procedures were completed by minimally invasive means, following the introduction of MIP in 2003. Single-gland disease accounted for 87% of cases (n = 216) with carcinomas in 2 patients (0.8%). Pre-operative localization had disappointing diagnostic value, with high false negative rates for both ultrasound (37.3%) and Sestamibi Scanning (35.81%). Intra-operative adjuncts were more helpful, with intra-operative Parathyroid hormone monitoring facilitating curative resection of adenomas in 94.03% at 10 min. Median length of post-operative stay has significantly decreased from 6 days in 1999 to 1 night only in 2009 (p < 0.01, ANOVA). Those patients undergoing MIP had shorter stay than the open group (1.71 days -v-4.73, p = 0.003,t-test).Conclusion: The practice in our centre has shifted to a less invasive approach. Increased utilisation of intra-operative adjuncts has facilitated this change, and resulted in favourable changes in length of stay, extent of dissection, and number of patients treated.

Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE) - Corrected Proof

R.S.J. Dalton, N.J. Smart, T.J. Edwards, I. Chandler, I.R. Daniels — 2011-11-16

Abstract: Background: Many studies report that low rectal cancer treated with abdomino-perineal excision (APE) have higher rates of CRM involvement with associated local recurrence and worse survival when compared to low anterior resection. We present a single surgeon’s short-term outcomes using the prone perineal extra-levator (elAPE) approach.Methods: Thirty-one patients between 2006 and 2010 underwent elAPE with curative intent. Data was collected prospectively recording patient tumour characteristics and histological outcome. Outcome measures included circumferential resection margins, recurrence rates, 30-day morbidity and mortality.Results: Mean distance of tumour from anal verge was 3.63 ± SD 1.52 cm. 14 patients had pre-operative chemo-radiotherapy. The involved circumferential resection margin rate was 3.2%. Median follow-up was 20 (0–45) months, with overall mortality of 13.3% and 30 day mortality of 6.6%.Conclusions: The prone position elAPE has a low circumferential resection margin involved rate and, through improved vision, reduces the risk of inadvertent tumour or specimen perforation.

Corrected Proof

Paul Banaszkiewicz — 2011-11-14

This is a new edition to the Oxford handbook series. Written by specialists in orthopaedics from Oxford, Bristol and Stanmore, the book provides a basic introduction to orthopaedics for junior doctors, medical students and allied health professionals. It is pocket sized, concise, and written.

Wet or dry bandages for plaster back-slabs? - Corrected Proof

Santosh Baliga, D. Finlayson — 2011-11-14

Abstract: Cotton crêpe and stretch bandages are commonly used in back-slabs and casts in orthopaedic practice. In theory they allow swelling to occur after injury while splinting the fracture.The application of a wet bandage prevents the Plaster-of-Paris (POP) setting too rapidly, giving time to apply a mould or attain correct limb position. However, we hypothesised that a wet bandage contracts upon drying and may cause constriction of the splint.This study aimed at determining whether there was any significant change in length of commonly used bandages when wet as well as any further change when left to dry again. Two types of bandage were evaluated.250 mm strips of bandage were dipped into water, gently squeezed and laid flat on a bench. The bandage was then immediately measured in length. The strips were then left to dry and re-measured.This experimental study shows that both cotton crepe and cling significantly shrink by around 7% when wet. This phenomenon has the potential to significantly increase the pressure exerted on the limb by a back-slab. We speculate that the application of wet bandages is why some back-slabs may need released. It is therefore recommended that bandages should be applied only in the dry form.

Malignant otitis externa: An Australian case series - Corrected Proof

Ronald Chin, Phoebe Roche, Elizabeth Sigston, Neil Valance — 2011-10-28

Abstract: Objectives: To establish a clinicopathological profile of malignant otitis externa (MOE) in an Australian tertiary referral institution.Study Design: Retrospective cohort outcomes study.Methods: 24 patients were identified with MOE between January 1998 and July 2007. Patients were classified into Radiological Grades I–IV. Laboratory investigations Including C–reactive protein (CRP), white cell count (WCC), glycosylated haemoglobin (HBA1c) and average glucose level over admission were recorded.Results: Radiological Grade was significantly associated with duration of therapy (rank correlation 0.57, p = 0.004). CRP was a useful indicator confirming disease resolution. Diabetics with MOE had elevated average blood sugar levels during their Hospital admission (p < 0.001) and had poor overall glycaemic control represented by Elevated HBA1c scores (p < 0.001).Conclusions: Malignant otitis externa is a rare disease, which is best managed in a multidisciplinary team setting. This practical grading system can be used to predict the duration of therapy at time of diagnosis, which enables the efficient utilisation of Hospital resources. Poorly controlled diabetics are more susceptible to developing.MOE than diabetics with satisfactory glycaemic control and may represent a subgroup of more brittle diabetics. CRP combined with appropriate clinical and radiological investigations is useful in assessing disease resolution.

Approaches to the hip for Total Hip Arthroplasty (THA) - Corrected Proof

I.H. Abdulkareem — 2011-10-13

Edmunds and Boscainos made comparison between the anterolateral and posterior approaches to Total Hip Arthroplasty (THA), using Harris hip scores and Trendelenburg’s test by looking at pre-operative results and comparing them to post-operative results. They also mentioned that the two most commonly used and described approaches to Total Hip Arthroplasty (THA) are the anterolateral and the posterior approach. They failed to look at the different variations of the anterolateral approach.

A review of major trauma admissions to a tertiary adult referral hospital over a ten year period: Fewer patients, similar survival - Corrected Proof

J.G. Solon, P. Houlihan, D.F. O’Brien, S. Connolly, D. O’Toole, D.A. McNamara — 2011-10-10

Abstract: Background: Trauma is an important cause for presentation to the emergency department, representing a significant number of emergency surgical admissions. Societal changes result in alterations in the epidemiology of trauma.Objectives: This study aimed to review patients admitted to a tertiary referral hospital as a result of traumatic injuries, assessing for changes in admission epidemiology.Methods: Trauma admissions over two year-long periods a decade apart were reviewed. The Trauma Audit and Research Network (TARN) audit system identified admissions and transfers between June 2006 and May 2007. The Hospital In-Patient Enquiry (HIPE) system identified those fulfilling TARN criteria a decade earlier. Comparative analysis was performed on the dataset.Results: There were 367 trauma admissions between June 2006 and May 2007: 88 road traffic accidents (RTAs), 201 falls and 77 other injuries, with 627 admissions a decade earlier: 286 RTAs, 247 falls and 94 others. Males comprised 72% and 69% of RTA admissions in both periods respectively. Firearm-related injuries increased significantly (p = 0.015). Neurosurgical transfers decreased from 256 to 150 with a slight increase in unadjusted overall mortality from 8.5% to 10.9%. Admissions of patients aged less than 19 reduced from 150 to 59 (p = 0.0031) with a similar trend in those aged between 20 and 29 years from 149 to 78.Conclusion: Admissions resulting from RTAs and of patients aged under 30 reduced significantly, however, young males remain the most affected sub-group. Firearm injuries increased significantly, a worrying trend in view of the severity of injury sustained by these victims.

A comparison of the teamwork attitudes and knowledge of Irish surgeons and U.S Naval aviators - Corrected Proof

Paul O’Connor, Stephen Ryan, Ivan Keogh — 2011-10-05

Abstract: Poor teamwork skills are contributors to poor performance and mishaps in high risk work settings, including the operating theatre. A questionnaire was used to assess the attitudes towards, and knowledge of, Irish surgeons (n = 72) towards the human factors that contribute to mishaps and poor teamwork in high risk environments. The responses were compared to those obtained from U.S. Naval aviators (n = 552 for the attitude questions, and n = 172 for the knowledge test). U.S. Naval aviators were found to be significantly more knowledgeable, and held attitudes that were significantly more positive towards effective teamworking than the surgeons. Moreover, 78.9% of Senior House Officers and Registrars stated that junior personnel were frequently afraid to speak-up (compared with 31.3% of Consultants). Only 7.3% of surgeons stated that an adequate pre-operative brief team brief was frequently conducted, and only 15% stated that an adequate post-operative team brief was frequently conducted. It is suggested that the human factors training currently provided to surgeons in Ireland is a positive first step. However, there is a need to stress the importance of assertiveness in juniors, listening in seniors, and more reinforcement of good teamworking behaviours in the operating theatre.

Expert practical operative skills teaching in Trauma and Orthopaedics at a nominal cost - Corrected Proof

J Davies, R Pilling, R Dimri, G Chakrabarty — 2011-09-23

Abstract: Background and purpose: The AO Foundation Operative Fracture Management course is the gold standard in training courses currently available for trainees at ST3 level. We have devised a low cost operative skills course comprising instructional lectures, demonstrations and practical dry bone workshops. To assess the quality of teaching, candidates’ feedback was analysed in two cohorts for the running of the course over two consecutive years: 2008 and 2009.Methods: Trainees were given short instructional lectures by consultant surgeons followed by workshops, with a trainer to candidate ratio of 1:4. A trauma inventory was provided by Stryker Trauma UK, ensuring a nominal fee for each candidate (£50). Feedback was anonymously collected according to a Likert scale and analysed using non-parametric methods appropriate for ranked data.Main findings: Twenty one of 22 (95%) candidates gave feedback in 2008 and 18 out of 18 candidates (100%) in 2009. The teaching provided was highly rated consistently for both years, apart from an informal session on theatre tips and tricks in 2008. This was not repeated in 2009 to allow more practical time. Only one session, an intramedullary nailing lecture, had a significant difference in scores between the 2 years (p = 0.044) because of improved scores in 2009.Conclusions: Due to changes in training, trainees have reduced exposure in theatre and this has implications for the early stages of acquiring practical operative skills. As an adjunct to the AO course, practical skills teaching by consultants in the format of a low cost skills workshop outside of a theatre environment can be achieved with support from a trauma implant supplier.

Laparoscopic adrenalectomy: Auditing the 10 year experience of a single centre - Corrected Proof

2011-09-19

Abstract: Background: Laparoscopic adrenalectomy (LA) is the gold standard for benign adrenal resection, and has been performed at our centre since 2000. We present a retrospective audit of our ten-year experience, and discuss the learning curve.Methods: Creating a retrospective database, clinical and outcome data were collected for all resections performed over a ten-year period (2000–2010). Patients were chronologically divided into an ‘early’ (first 40 cases) and ‘late’ (subsequent cases) group to provide an insight into the learning curve.Results: Over this period, 134 laparoscopic resections were performed, predominantly for benign adenomas (80.3%), with 48% of patients having primary hyperaldosteronism. There was almost equal sex distribution and mean age was 50.2 years, with a median BMI of 28.2. The mean operating time for left and right procedures were 127 and 124 min respectively, with 56.7% of resections being left sided. Our rate of conversion to open was 3.9%. Median length of stay was 4 days post-operatively. There was no mortality and 8.7% patients experienced a surgical complication. Analysis of the grouped data demonstrated a statistically significant reduction in open conversion rate (p = 0.017) and operative time (p = 0.011) in the ‘late’ group. Among the two groups there was no statistically significant difference in the length of stay and surgical complication rate. All results were comparable to published series in the literature.Conclusion: LA has proven to be a safe procedure with a low complication rate at our centre. Our data provide evidence that operative time and conversion rate improves with experience.

Endoscopic screening for colorectal cancer? - Corrected Proof

R.J.C. Steele — 2011-09-15

Until recently, all the evidence around the efficacy of screening for colorectal cancer has been based on faecal occult blood testing (FOBT). As a result, in the United Kingdom, Ireland and in many other countries throughout the world, FOBT screening is in place or in the process of being rolled out. However, recent evidence has emerged which has made the screening community think again. A multi-centre randomised trial of once only flexible sigmoidoscopy between the ages of 55 and 65 years has recently been reported and the results are impressive. Not only is there a reduction in mortality from colorectal cancer, there is also a reduction in incidence which is maintained for up to 12 years after the examination. Interestingly, although the trial mandated colonoscopy for everyone with a significant polyp or cancer found at flexible sigmoidoscopy, the intervention had no effect on incidence of right-sided cancer. However, having a flexible sigmoidoscopy almost abolished the risk of developing a left-sided cancer owing to the removal of adenomatous polyps.

When should we operate on elderly patients with a hip fracture? It’s about time! - Corrected Proof

Sukhmeet S. Panesar, Nicole Simunovic, Mohit Bhandari — 2011-09-15

Abstract: Demographic predictions indicate the annual incidence of hip fractures will rise to 100,000 per annum in 2020. The annual costs to the NHS are approximately two billion pounds. Despite significant advances in the operating technique and management of these fractures, controversies still exist. One such matter for debate is the ideal timing for hip fracture surgery. There are arguments for and against early stabilization, yet all this evidence comes from observational studies. We present data from an often overlooked source, the largest patient safety reporting system in the world housed at the National Patient Safety Agency. Since 2003, 4325/4521 (96%) patients suffered some harm due to their operation being delayed. The issue of the ideal timing for hip surgery warrants an answer. This could be in the form of a controlled trial. A randomized trial comparing early surgery versus standard of care (site dependent) in hip fracture repair may provide some future guidance. In the meantime, current evidence suggests that we should stratify the elderly according to their medical morbidities; both new and old; optimize patient’s who develop hypovolemia, accelerated hypertension, untreated infection, symptomatic arrhythmia or cardiopulmonary dysfunction; and attempt to bring patient’s suffering from chronic diseases as close to their baseline level of functioning as normal. Hip fracture repair should then occur as soon as possible.

Painful swollen limb caused by pelvic granuloma in a patient with total hip replacement - Corrected Proof

2011-09-15

A 78-year-old lady presented with swollen ipsilateral lower limb more than a decade following an un-cemented right total hip replacement (THR). Her symptoms were treated medically; in sequence, for lymphoedema, cellulitis, and trochanteric bursitis, with little benefit. A venous Doppler scan ruled out deep venous thrombosis, and a plain radiograph of pelvis demonstrated evidence of polyethylene liner wear in the THR prosthesis (). Later, a mass became palpable in the right groin/iliac fossa, suspicious of bowel cancer. It was associated with onset of pain in the swollen limb. A CT scan revealed a large soft tissue density lesion in right iliacus muscle, measuring 8.3 × 6.0 cm, and displacing right pelvic vessels medially (a and b). The case was discussed in a sarcoma multidisciplinary team meeting, and after an MRI scan, malignancy was ruled out. The mass was considered benign and the patient was referred to Orthopaedics.

Importance of strict patient selection criteria for combined carotid endarterectomy and coronary artery bypass grafting - Corrected Proof

2011-09-15

Abstract: Background: Management of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria.Methods: From 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43–88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis.Results: Thirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies.Conclusion: Combined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery.

The United Kingdom and Ireland Trauma & Orthopaedic eLogbook—An evidence base for enhancing training - Corrected Proof

2011-09-15

Abstract: The United Kingdom and Ireland Trauma and Orthopaedic (T&O) eLogbook was originally conceived over ten years ago in order to provide individual surgeon support and allow national analysis of surgical training experience. Since 2003 every trainee in T&O has been required to submit data recording their operative experience throughout the six years of higher specialist training. We describe how orthopaedic surgeons are using the evidence from the eLogbook to improve training, set operative standards and support consultant (post-specialist registration) revalidation.

Minimally invasive video-assisted parathyroidectomy is a safe procedure to treat primary hyperparathyroidism - Corrected Proof

V Garimella, S Yeluri, A Alabi, AK Samy — 2011-09-15

Abstract: Introduction: Cervical exploration to identify the four parathyroid glands was considered to be the gold standard for management of primary hyperparathyroidism. In recent years, advances in preoperative localizing techniques have led to the use of more targeted, minimally invasive procedures to remove parathyroid glands. We present our series of patients who underwent Minimally Invasive Video-Assisted Parathyroidectomy (MIVAP) procedures and our results in treating primary hyperparathyroidism.Methods: Patients who underwent video-assisted parathyroidectomy were identified from a prospectively maintained database. Clinico-pathological data including indications for surgery, complications, conversion to open procedure and success of surgery were obtained from clinical notes.Results: A total of 56 patients underwent MIVAP between 2002 and 2010 at a district general hospital setup. The clinical indication was diagnosed primary hyperparathyroidism. Preoperative localization was attempted in all patients by sestamibi and high resolution ultrasound scans. The median age of patients was 65 years (32–82) and the median operating time was 78 min (20–168). Conversion to open procedure was done in 8/56 (14%) cases. The reason for conversion was failed exploration in 5 patients, inability to retrieve a very large friable adenoma in one patient, lipo-adenoma in one patient and very small parathyroid adenoma in one patient. Postoperative complications happened in one patient (2%) who developed postoperative sepsis resulting in temporary recurrent laryngeal nerve (RLN) palsy. All but 5 patients became normo-calcaemic following surgery.Conclusion: MIVAP is a safe and effective procedure for treating patients with primary hyperparathyroidism. It also allows classical 4 gland exploration, whenever necessary.

An alternative method for predicting size of femoral component of Oxford partial knee replacement - Corrected Proof

S. Sawalha, C. Pasapula, N. Coleman — 2011-09-15

Abstract: Background: No direct intra-operative measurement to determine the ideal size of the femoral component of Oxford unicompartmental knee replacement (UKR) is currently present. The aim of this study is to assess the accuracy of patients’ shoe size as a predictor of femoral component size.Methods: A retrospective study was conducted to identify the correlation between patients’ shoe size (British system) and the femoral component size. After excluding patients who died (n = 2) and patients in whom the implanted femoral component size was inaccurate (n = 13), the remaining cases (93 UKR in 88 patients) formed the study sample. Postoperative radiographs were reviewed to determine femoral component fit.Results: We found positive correlation between shoe size and femoral component size. In females; a shoe size from 2.5 to 6 predicted a small femoral component and shoe size from 6.5 to 8.0 predicted a medium femoral component. In males, a shoe size from 6 to 9.5 predicted a medium femoral component and a shoe size from 10 to 13 predicted a large femoral component. This relation predicted the femoral component size accurately in 80% of cases. A subgroup analysis, after excluding patients who changed their shoe size during adulthood after foot surgery or pathology (n = 20), showed an accuracy rate of 81%.Conclusion: Shoe size is a simple method that predicts femoral component size more accurately than other methods currently used such as templating, tibial component size and height based on gender.Highlights: ► We assess if patients’ shoe size predicts femoral component size of Oxford knee replacement (UKR). ► Positive correlation was found in 93 Oxford UKR cases studied. ► Shoe size predicted the femoral component size accurately in 80% of cases. ► Changing shoe size during adulthood did not affect the accuracy rate.

The value of whole colonic imaging - Corrected Proof

M. Chaudery, D. Edwards — 2011-09-15

Sir, We are grateful to have the opportunity to respond to the article by Bhangu et al stating that flexible sigmoidoscopy (FS) would have missed 15% of proximal colorectal cancers (CRC) in patients presenting with symptoms alone. We would recommend that the majority of patients referred under the 2 week wait (2WW) criteria should receive whole colonic imaging (WCI). Our preference would be colonoscopy as we believe that this is the most effective way of reaching a diagnosis without missing proximal pathology.

Laparoscopic vs. open liver resection for malignant liver disease. A systematic review - Corrected Proof

Ahsan Rao, Ghaus Rao, Irfan Ahmed — 2011-09-15

Abstract: Introduction: Since the introduction of minimally invasive techniques, there is little agreement about use of laparoscopic surgery for malignant liver lesions as compared to open resection. We aim to analyse all available data comparing both these groups.Methods: All the studies that compared laparoscopic and open liver resections for malignant lesions were searched on various databases. Data were collected and analysed in Review Manager RevMan (version 5.0).Results: There were total of 10 studies (n = 700) that compared laparoscopic (296/700) and open (404/700) hepatic resections for malignant lesions. Laparoscopic group was associated with reduced number of patients requiring blood transfusion [Odds ratio 0.35 CI 0.20, 0.60 P<0.001 HG 0.85], decreased number of positive resection margin [Odds ratio 0.34 CI 0.16, P0.006 HG 0.73] and decrease in overall complication rate [Odds ratio 0.43, CI 0.26, 0.73 P0.002 HG 0.22]. Laparoscopic group was associated with less operative blood loss [WMD 162.6 ml CI −261.79, 73.45 P<0.001] and reduced hospital stay [WMD 4.28 days CI −6.33, −2.23 P<0.001]; however, there was significant heterogeneity [HG <0.001] between the studies for these parameters.Conclusion: The laparoscopic group was associated with reduce overall complication rate, positive resection margins and number of patients requiring blood transfusion. There is still need for level I and II data to compare laparoscopic versus open hepatic resection in malignant lesions.

Surgical techniques: Use of arthroscopic “Alligator” forceps for the removal of excess cement in unicompartmental knee arthroplasty - Corrected Proof

Paul D. Sturch, Daniel Marsland, Ian W. Barlow — 2011-09-15

During minimally invasive cemented unicompartmental knee arthroplasty (UKA), the removal of excess cement from the posterior aspect of the joint following insertion of the prosthesis may be technically difficult due to limited surgical exposure (). Retained cement following UKA is a well recognised complication which may require further surgery as a consequence of loose body formation or impingement. The use of the arthroscopic Alligator grasping forceps (Acufex, UK) () facilitates easy access and retrieval of cement following component insertion (). The senior author has used this simple technique successfully in 200 UKAs.