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Lateral compression type I injuries of the pelvic ring: Are they mechanically stable?
Injury, Int. J. Care Injured 40 (2009) 1129–1130
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Abstracts from the 2009 Meeting of the British Trauma Society The following abstracts, presented during the 2009 Annual Meeting of the British Trauma Society, were the winners of the Injury Journal Awards. The authors of the three abstracts were: K.M. Willett*1, B. Gray1, S. Lamb1, A. Handa1, S. Lamb1, R. Handley2 (1University of Oxford, UK; 2Oxford Radcliffe Hospital, UK) N.K. Kanakaris*, C. Tzioupis, V.S. Nikolaou, P.V. Giannoudis (Leeds General Infirmary, UK) N.S. Harshavardhana2, A. Sahu*3, S. Maret4, A. Sangar1, P. Jairaj1, S.W. Richards1 (1Poole General Hospital NHS Trust, UK; 2Nottingham University Hospitals NHS Trust, UK; 3Stepping Hill Hospital, UK; 4Southampton University Hospitals NHS Trust, UK) The remainder of the abstracts presented at the British Trauma Society meeting are published in the open access online journal ‘‘Injury Extra’’ http://www.elsevier.com/locate/inext
Ninety-four percent of participants had normal ABPI’s (>1.0). There was no difference between patients with or without an impaired ABPI (<0.7 mmHg) and wound problems (p = 0.20). There was no difference in patent perforators between the injured and uninjured (p = 0.39). Conclusions: Occult vascular insufficiency is present but at low incidence. ABPI and Duplex-US are insensitive for predicting infection or delayed healing. The ankle fracture injury does not disrupt the local perforators. TcPO2 is sensitive and specific for predicting skin problems. Impairment of skin oxygenation is transient. Current TcPO2 technology however is impractical as a clinical tool. Keywords: Vascularity; Ankle fracture; Older people; Wound complications doi: 10.1016/j.injury.2009.06.014
1st Prize [2A.5] The presence and pattern of vascular insufficiency in the older patient suffering an unstable ankle fracture: The relationship to skin and wound complications K.M. Willett1,*, B. Gray1, S. Lamb1, A. Handa1, S. Lamb1, R. Handley2 1 2
University of Oxford, UK Oxford Radcliffe Hospital, UK
Hypothesis: Impaired vascularity of the skin in elderly ankle fracture patients causes the skin and wound complications. Materials and methods: This is part of a RCT comparing ORIF and close contact casting (CCC) for isolated unstable ankle fractures in patients >60 years. Assessments over 6 months: (i) transcutaneous O2 saturation (TcPO2) of medial and lateral ankle skin, (ii) AnkleBrachial Pressure Index (ABPI), (iii) 3-vessel arterial duplex scan, (iv) distal calf perforator artery patency. The uninjured limb was the control. Results: Eighty-nine patients eligible; 59 participated (76% female). Thirty randomised to ORIF; 29 to CCC. Each had one death and one withdrawal. Vascular data available on 55. Two patients had delays in wound healing (>25% for >6 weeks). Two further developed wound infections. No skin breakdowns in CCC group. There was a reduced TcPO2 on day 3 in the injured limb. The TcPO2 rose at 6 weeks compared to day 3 (medial 58 mmHg; lateral 53 mmHg, p = 0.002) in the injured leg. At 6 months the TcPO2 measurements were not different to uninjured leg. A critical TcPO2 (<20 mmHg) found in four, correlated with skin problems (p = 0.003). Two of these had the only major delays in wound healing and one of the two wound infections. 0020–1383/$ – see front matter
2nd Prize [7A.3] Lateral compression type I injuries of the pelvic ring: Are they mechanically stable? N.K. Kanakaris*, C. Tzioupis, V.S. Nikolaou, P.V. Giannoudis Leeds General Infirmary, UK Aim: To investigate whether lateral compression type I injuries of the pelvic ring are inheritably mechanically stable. Patients and methods: Between January 2005 to January 2007 all consecutive admissions of a tertiary referral center for pelvic ring reconstruction with a LCI injury pattern were eligible for inclusion. Exclusion criteria were other patterns of pelvic ring injuries. All patients underwent radiological assessment including AP pelvis, inlet/outlet views and CT. Patient demographics, mechanism of injury, other associated injuries, ISS, length of hospitalisation, type of operation, mode of mobilization, preoperative and postoperative visual analogue score pain VAS and follow-up until fracture union were prospectively documented. Mechanical stability of the pelvic ring was assessed in the operating theatre under general anaesthesia. Instability was defined as displacement >2 cm of the anterior or posterior elements. The minimum follow-up was 12 months. Results: Out of 210 patients admitted with pelvic fractures, 40 fulfilled the inclusion criteria (LCI type). There were 23 female 17 male and with a mean age of 33.5 (range 18–68). The mean ISS was 10 (range 9–19). 23 patients (group 1) were found to have more than 2 cm rotational displacement during EUA and were stabilised with SI screws posteriorly and a combination of retropubic screws,
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Abstracts / Injury, Int. J. Care Injured 40 (2009) 1129–1130
external fixator or plating anteriorly. Seventeen patients (group 2) exhibited minimal displacement less than 5 mm and were not stabilised. Rotational instability >2 cm was characterised by complete fracture of the sacrum posteriorly. Stabilisation of the pelvic ring in group I was associated with a significant reduction of the VAS within 72 h from surgery, early ambulation and discharge from the hospital. Conclusion: This study supports the view that not all LCI fracture patterns are mechanically stable. Examination under anaesthesia of the pelvic ring can assist the clinician in the decision-making progress. Keywords: Lateral compression; Pelvic fractures; Clinical; Case–control series doi: 10.1016/j.injury.2009.06.015 3rd Prize [4A.2] Payment by results (PbR) in orthopaedic trauma: Where are we losing? N.S. Harshavardhana2, A. Sahu3,*, S. Maret4, A. Sangar1, P. Jairaj1, S.W. Richards1 1
Poole General Hospital NHS Trust, UK Nottingham University Hospitals NHS Trust, UK 3 Stepping Hill Hospital, UK 4 Southampton University Hospitals NHS Trust, UK 2
Background: Clinical coding has attracted significant interest recently as it has become synonymous with reimbursement. We hereby present the results of first and largest study in the UK involving 547 orthopaedic trauma cases wherein a meticulous indepth analysis was performed. Study design: Completed audit cycle.
Objectives: To review the existing coding for orthopaedic trauma, to ascertain accuracy of procedural codes and to identify limitations, implement changes, re-evaluate and close the audit loop. Methods: All orthopaedic trauma surgeries (244 cases) performed over 1 month (March 2006) were comprehensively analysed. The primary procedural accuracy of OPCS4.2, its limitations and loss of revenue due to missing codes (six patients) were determined. Changes were implemented to streamline/optimise financial reimbursement and improve data quality/accuracy by education/training. Electronic discharge summaries were implemented to enhance efficiency. The audit loop was subsequently closed to evaluate implementation of these changes by re-auditing all trauma surgeries performed in the same month the following year, i.e. March 2007 (303 cases) against OPCS4.3 codes. Results: The primary procedural accuracy was 95.38% (11/238 coding errors) and omissions in six patients resulted in net loss of revenue of £13,700 for March 2006. Following the closure of audit loop in March 2007 after implementation of changes, the primary procedural accuracy was 98.95% (3/286 coding errors) and cumulative loss of revenue due to omissions in 17 patients was £46,750. Discussion: Despite improvement in coding accuracy to 99% on closure of audit loop, there were increased financial losses for trauma directorate. An in-depth analysis is being performed to identify lacunae (training/staffing issues) as the trauma workload rose by 25% in a year. Conclusion: Accurate and ethical coding is challenging having impact on data quality, audit and research in addition to reimbursement. Literature emphasises on legible documentation, liaison between coders and clinicians and education/training of healthcare professionals. Keywords: Clinical coding; Payment by results (PbR); OPCS codes; Data quality doi: 10.1016/j.injury.2009.06.016
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Abstracts from the 2009 Meeting of the British Trauma Society The following abstracts, presented during the 2009 Annual Meeting of the British Trauma Society, were the winners of the Injury Journal Awards. The authors of the three abstracts were: K.M. Willett*1, B. Gray1, S. Lamb1, A. Handa1, S. Lamb1, R. Handley2 (1University of Oxford, UK; 2Oxford Radcliffe Hospital, UK) N.K. Kanakaris*, C. Tzioupis, V.S. Nikolaou, P.V. Giannoudis (Leeds General Infirmary, UK) N.S. Harshavardhana2, A. Sahu*3, S. Maret4, A. Sangar1, P. Jairaj1, S.W. Richards1 (1Poole General Hospital NHS Trust, UK; 2Nottingham University Hospitals NHS Trust, UK; 3Stepping Hill Hospital, UK; 4Southampton University Hospitals NHS Trust, UK) The remainder of the abstracts presented at the British Trauma Society meeting are published in the open access online journal ‘‘Injury Extra’’ http://www.elsevier.com/locate/inext
Ninety-four percent of participants had normal ABPI’s (>1.0). There was no difference between patients with or without an impaired ABPI (<0.7 mmHg) and wound problems (p = 0.20). There was no difference in patent perforators between the injured and uninjured (p = 0.39). Conclusions: Occult vascular insufficiency is present but at low incidence. ABPI and Duplex-US are insensitive for predicting infection or delayed healing. The ankle fracture injury does not disrupt the local perforators. TcPO2 is sensitive and specific for predicting skin problems. Impairment of skin oxygenation is transient. Current TcPO2 technology however is impractical as a clinical tool. Keywords: Vascularity; Ankle fracture; Older people; Wound complications doi: 10.1016/j.injury.2009.06.014
1st Prize [2A.5] The presence and pattern of vascular insufficiency in the older patient suffering an unstable ankle fracture: The relationship to skin and wound complications K.M. Willett1,*, B. Gray1, S. Lamb1, A. Handa1, S. Lamb1, R. Handley2 1 2
University of Oxford, UK Oxford Radcliffe Hospital, UK
Hypothesis: Impaired vascularity of the skin in elderly ankle fracture patients causes the skin and wound complications. Materials and methods: This is part of a RCT comparing ORIF and close contact casting (CCC) for isolated unstable ankle fractures in patients >60 years. Assessments over 6 months: (i) transcutaneous O2 saturation (TcPO2) of medial and lateral ankle skin, (ii) AnkleBrachial Pressure Index (ABPI), (iii) 3-vessel arterial duplex scan, (iv) distal calf perforator artery patency. The uninjured limb was the control. Results: Eighty-nine patients eligible; 59 participated (76% female). Thirty randomised to ORIF; 29 to CCC. Each had one death and one withdrawal. Vascular data available on 55. Two patients had delays in wound healing (>25% for >6 weeks). Two further developed wound infections. No skin breakdowns in CCC group. There was a reduced TcPO2 on day 3 in the injured limb. The TcPO2 rose at 6 weeks compared to day 3 (medial 58 mmHg; lateral 53 mmHg, p = 0.002) in the injured leg. At 6 months the TcPO2 measurements were not different to uninjured leg. A critical TcPO2 (<20 mmHg) found in four, correlated with skin problems (p = 0.003). Two of these had the only major delays in wound healing and one of the two wound infections. 0020–1383/$ – see front matter
2nd Prize [7A.3] Lateral compression type I injuries of the pelvic ring: Are they mechanically stable? N.K. Kanakaris*, C. Tzioupis, V.S. Nikolaou, P.V. Giannoudis Leeds General Infirmary, UK Aim: To investigate whether lateral compression type I injuries of the pelvic ring are inheritably mechanically stable. Patients and methods: Between January 2005 to January 2007 all consecutive admissions of a tertiary referral center for pelvic ring reconstruction with a LCI injury pattern were eligible for inclusion. Exclusion criteria were other patterns of pelvic ring injuries. All patients underwent radiological assessment including AP pelvis, inlet/outlet views and CT. Patient demographics, mechanism of injury, other associated injuries, ISS, length of hospitalisation, type of operation, mode of mobilization, preoperative and postoperative visual analogue score pain VAS and follow-up until fracture union were prospectively documented. Mechanical stability of the pelvic ring was assessed in the operating theatre under general anaesthesia. Instability was defined as displacement >2 cm of the anterior or posterior elements. The minimum follow-up was 12 months. Results: Out of 210 patients admitted with pelvic fractures, 40 fulfilled the inclusion criteria (LCI type). There were 23 female 17 male and with a mean age of 33.5 (range 18–68). The mean ISS was 10 (range 9–19). 23 patients (group 1) were found to have more than 2 cm rotational displacement during EUA and were stabilised with SI screws posteriorly and a combination of retropubic screws,
1130
Abstracts / Injury, Int. J. Care Injured 40 (2009) 1129–1130
external fixator or plating anteriorly. Seventeen patients (group 2) exhibited minimal displacement less than 5 mm and were not stabilised. Rotational instability >2 cm was characterised by complete fracture of the sacrum posteriorly. Stabilisation of the pelvic ring in group I was associated with a significant reduction of the VAS within 72 h from surgery, early ambulation and discharge from the hospital. Conclusion: This study supports the view that not all LCI fracture patterns are mechanically stable. Examination under anaesthesia of the pelvic ring can assist the clinician in the decision-making progress. Keywords: Lateral compression; Pelvic fractures; Clinical; Case–control series doi: 10.1016/j.injury.2009.06.015 3rd Prize [4A.2] Payment by results (PbR) in orthopaedic trauma: Where are we losing? N.S. Harshavardhana2, A. Sahu3,*, S. Maret4, A. Sangar1, P. Jairaj1, S.W. Richards1 1
Poole General Hospital NHS Trust, UK Nottingham University Hospitals NHS Trust, UK 3 Stepping Hill Hospital, UK 4 Southampton University Hospitals NHS Trust, UK 2
Background: Clinical coding has attracted significant interest recently as it has become synonymous with reimbursement. We hereby present the results of first and largest study in the UK involving 547 orthopaedic trauma cases wherein a meticulous indepth analysis was performed. Study design: Completed audit cycle.
Objectives: To review the existing coding for orthopaedic trauma, to ascertain accuracy of procedural codes and to identify limitations, implement changes, re-evaluate and close the audit loop. Methods: All orthopaedic trauma surgeries (244 cases) performed over 1 month (March 2006) were comprehensively analysed. The primary procedural accuracy of OPCS4.2, its limitations and loss of revenue due to missing codes (six patients) were determined. Changes were implemented to streamline/optimise financial reimbursement and improve data quality/accuracy by education/training. Electronic discharge summaries were implemented to enhance efficiency. The audit loop was subsequently closed to evaluate implementation of these changes by re-auditing all trauma surgeries performed in the same month the following year, i.e. March 2007 (303 cases) against OPCS4.3 codes. Results: The primary procedural accuracy was 95.38% (11/238 coding errors) and omissions in six patients resulted in net loss of revenue of £13,700 for March 2006. Following the closure of audit loop in March 2007 after implementation of changes, the primary procedural accuracy was 98.95% (3/286 coding errors) and cumulative loss of revenue due to omissions in 17 patients was £46,750. Discussion: Despite improvement in coding accuracy to 99% on closure of audit loop, there were increased financial losses for trauma directorate. An in-depth analysis is being performed to identify lacunae (training/staffing issues) as the trauma workload rose by 25% in a year. Conclusion: Accurate and ethical coding is challenging having impact on data quality, audit and research in addition to reimbursement. Literature emphasises on legible documentation, liaison between coders and clinicians and education/training of healthcare professionals. Keywords: Clinical coding; Payment by results (PbR); OPCS codes; Data quality doi: 10.1016/j.injury.2009.06.016