Nadia Sciberras - Academia.edu (original) (raw)

Papers by Nadia Sciberras

Orthopaedic Proceedings, Feb 26, 2020

Orthopaedic Proceedings, Feb 21, 2018

In our department, currently there is variation in the number of xrays that patients receive foll... more In our department, currently there is variation in the number of xrays that patients receive following ORIF of distal radius fractures. This audit investigated the use of xrays following ORIF of distal radius fractures. Patients were identified from daily trauma lists. Patients who had a primary ORIF or ORIF following failed conservative management were included in the study. PACS was used to identify the number of post-operative xrays performed. These were correlated with clinic letters to see if there was any change in management following xray review. Between July and November 2013, 102 patients were admitted with distal radius fracture. Of these, 35 (mean age:51 years) had an ORIF. Four were not followed-up in Scotland. Of the remaining 31 patients, eleven had one post-operative xray, seventeen had two and three had three xrays. Of the patients who had one xray, seven had the xray in the first three weeks, the rest at six weeks. Patients who had two xrays had an xray at two and 6 weeks. Of the three patients who had three xrays, two had comminuted fractures that required further CT investigation, one for a suspicion of an intra-articular screw, the other for possibility of non-union. The third patient had no apparent reason for requiring three xrays. Thus of the 31 patients in the study, 29 did not require any further investigations. The results show a variation in the frequency of post-operative xrays after fixation of distal radius fractures. In most cases the management plan was unchanged after plain xrays were undertaken. This suggests that a protocol driven approach to follow-up after fixation of distal radius fractures could reduce the burden on fracture clinic and radiology departments. We propose that unless indicated by intra-operative findings or post-operative concerns, patients should have xrays at the two week review appointment.

Journal of Bone and Joint Surgery-british Volume, 2014

In our department, currently there is variation in the number of xrays that patients receive foll... more In our department, currently there is variation in the number of xrays that patients receive following ORIF of distal radius fractures. This audit investigated the use of xrays following ORIF of distal radius fractures. Patients were identified from daily trauma lists. Patients who had a primary ORIF or ORIF following failed conservative management were included in the study. PACS was used to identify the number of post-operative xrays performed. These were correlated with clinic letters to see if there was any change in management following xray review. Between July and November 2013, 102 patients were admitted with distal radius fracture. Of these, 35 (mean age:51 years) had an ORIF. Four were not followed-up in Scotland. Of the remaining 31 patients, eleven had one post-operative xray, seventeen had two and three had three xrays. Of the patients who had one xray, seven had the xray in the first three weeks, the rest at six weeks. Patients who had two xrays had an xray at two and ...

Current Orthopaedic Practice, Mar 1, 2013

Orthopaedic Proceedings, Feb 21, 2018

The Columbus® knee system was designed as a standard knee implant that allows high flexion withou... more The Columbus® knee system was designed as a standard knee implant that allows high flexion without the need for additional bone resection. The aim of this retrospective study was to investigate the correlation between the maximum flexion achieved at five years and the slope of the tibial component. The hypothesis was that increased slope would give increased flexion. The study design was a retrospective cohort study at a single centre. The inclusion criterion was having had a navigated cemented Columbus primary TKA implanted between March 2005 and December 2006 using the image free OrthoPilot® navigation system (Aesculap, Tuttlingen, Germany) in our institution. Follow-up had been carried out at review clinics by an independent arthroplasty team. Patient-related data had been recorded either in case notes, the departmental proprietary database or as radiographic images. In addition to demographics, five-year follow-up range of motion (ROM) was collected. All available radiographs on the national Picture Archiving and Communication System (Eastman Kodak Company, 10.1_SP1, 2006), whether taken at our institution or at the patient9s local hospital, were analysed by a trainee orthopaedic surgeon (NCS) who was independent of the patients9 care. Component position according to the Knee Society TKA scoring system was determined from the five-year review lateral x-ray. The tibial slope was calculated as 90° minus the angle of the tibial component so giving a posterior slope as a positive number and an anterior slope as a negative number. The correlation between maximum flexion angle and tibial slope was calculated. Further to this a subgroup of only CR prostheses and patients with BMI 35. A total of 219 knees in 205 patients were identified. 123 had five-year radiograph and maximum flexion measurement available. Cohort demographics were mean age 68(8.6), mean BMI 32.0(5.9) and mean maximum flexion at five years of 101°(11°). The tibial slope angle showed variation around the mean of 2°(2.8°). There was no correlation between tibial slope and maximum flexion for either that whole cohort (r=-0.051, p=0.572, Figure 1b) or the subgroup of CR and BMI 35, mean 101° (SD11.4°). This study did not find any correlation between the tibial slope and maximum flexion angle in 123 TKAs at five year follow up. Further studies with a more accurate measurement of tibial slope should be carried out to confirm whether a relationship exists in the clinical setting.

Few doctors answer their bleep by stating who they are. Answering the phone in a formal manner is... more Few doctors answer their bleep by stating who they are. Answering the phone in a formal manner is of utmost importance in the hospital setting especially by on-call teams who are normally referred patients by other specialties, general practitioners and in some cases by other hospitals. An audit to evaluate the internal hospital communication was completed. In the first part of this audit, junior doctors within the orthopaedic department at the RAH were bleeped. Doctors were expected to answer by initiating the conversation by stating (1) name, (2) department, (3) grade and (4) a greeting. A list of omissions was recorded. If the call went through switchboard, it was expected that the hospital name was stated. The second part of the audit extended to other specialties in the RAH as well as orthopaedic departments in hospitals within the Greater Glasgow and Clyde health board (NHS GGC). Forty-three bleeps were made to doctors of various grades over a period of two months. Nine bleeps (two from other hospitals) were not answered. Five doctors answered their bleep in full. Only twenty-one doctors stated their name whilst eleven stated their grade. In both instances the department was not necessarily stated. The results were similar between the different departments as well as between the seven hospitals offering an orthopaedic service within NHS GGC. Of the thirteen on-call doctors that were bleeped as an external call through switchboard, only one doctor stated the hospital name. This has implications since most hospitals within NHS GGC share a common switchboard. These results emphasise the need for a protocol within NHS GGC for a standard etiquette for intra and inter hospital communication to ensure that patient safety and confidentiality is safeguarded.

Simple nasal bone fractures are the third most common type of all fractures leading to numerous p... more Simple nasal bone fractures are the third most common type of all fractures leading to numerous patient visits at the Accident & Emergency department. Nasal fractures are commonly over-investigated in St Luke's hospital leading to a substantial financial burden on our health system. In this article we review the frequency of simple nasal fractures as well as the necessity or otherwise of nasal x-ray imaging in addition to the financial and health consequences that result from nasal x-ray imaging. These issues are also discussed from a legal perspective.

Arthroplasty today, Jun 1, 2017

Background: This randomized controlled trial validated a redesigned version of navigated total kn... more Background: This randomized controlled trial validated a redesigned version of navigated total knee arthroplasty software with a streamlined registration (Smart) against the previous version (Classic). The objectives were to determine if Smart software had the same accuracy of component positioning and whether registration and operative time were reduced. Methods: A total of 220 patients were recruited and had a navigated total knee arthroplasty performed. With the exception of the software, all patients had the same perioperative care. At 6-week follow-up with an independent arthroplasty service, all patients had a computerized tomography scan. This was assessed by an independent radiologist to measure the mechanical alignment of the components. Results: The mean postoperative mechanical femorotibial angles were equivalent between groups (mean difference À0.2 , 95% confidence interval À0.7 to 0.3 , P ¼ .407). Component positions were similar in both groups. Mean registration time was significantly shorter for the Smart group (2 minutes 30 seconds ± 54 seconds) than the Classic group (3 minutes 23 seconds ± 39 seconds), P < .001. The mean operative time was 72 ± 12 minutes in both groups (P ¼ .855). At 6-week follow-up, both groups had similar clinical outcomes with 96.5% of patients being satisfied or very satisfied. Conclusions: The study verified that a reduced registration time did not alter the accuracy of component placement. However, despite a shorter registration time, the overall surgical time was not reduced.

Journal of orthopaedics, Mar 1, 2020

BackgroundNavigated total knee arthroplasty (TKA) improves implant and limb alignment but outlier... more BackgroundNavigated total knee arthroplasty (TKA) improves implant and limb alignment but outliers continue to exist. This study aimed to determine the technical and surgical causes of outliers.MethodsThis retrospective cohort study included 208 patients who had undergone navigated TKA. Limb and implant alignment indices were measured on post-operative CT scans: mechanical femoro-tibial angle (MFTA); coronal femoral angle (CFA); coronal tibial angle (CTA); sagittal femoral angle (SFA); and sagittal tibial angle (STA). Values outside 0°±3° for MFTA and SFA, 90°±3° for CFA, CTA and STA were considered outliers. Intra-operative navigation data and CT scans were evaluated to categorize the causes of sagittal and coronal plane outliers into hip centre error; ankle centre error; heterogeneous tibial cement mantle; malalignment accepted by surgeon; suboptimal knee balance; and no obvious explanation.ResultsOf the 1040 measurements (five per TKA), the overall incidence of outliers was 10.4% (n = 108). Femoral component outliers (CFA + SFA, n = 51) were all attributable to hip centre error. Tibial component outliers (CTA + STA, n = 43) were attributable to ankle centre error (n = 6), heterogeneous cement mantle (n = 20), malalignment accepted by the surgeon (n = 6) and no obvious cause (n = 11). MFTA outliers were attributable to hip centre error (n = 4) or suboptimal knee balance (n = 10).ConclusionsSurgeon related errors can be minimized by a meticulous operative technique. These results indicate scope for additional technical improvement, especially in hip centre acquisition, which may further reduce the incidence of outliers.

Current Orthopaedic Practice, Nov 1, 2015

Background:The navigated Columbus® total knee arthroplasty (TKA) is a relatively new implant with... more Background:The navigated Columbus® total knee arthroplasty (TKA) is a relatively new implant with few published mid-term follow-up reports. This retrospective study assessed the clinical and radiographic outcomes of a consecutive series of these implants. Methods:One hundred and seventy-eight knees in 165 patients were identified. The patient cohort had a mean age of 69 (50-89) years. Follow-up of 105 knees (59%) was 60.6 (58-76) months. All complications and readmissions within the cohort were identified via the Scottish Information Services Division (NHS Scotland). Survival analysis was carried out for all 178 knees using Kaplan-Meier, with hospital and national records used to identify the last known date when the patient was alive and the prosthesis was still in place. Results:Four patients had a revision TKA (all cause revision rate 2.2%) giving a cumulative 5-year survival of 97.3% (95% CIs 92.9%, 99.9%) with revision for any cause as the endpoint. Only one patient required revision for aseptic loosening. The mean maximal active flexion was 100.3 (60-120) degrees, with a mean fixed flexion of 0.4 (0-5) degrees. Ninety-six percent of the patients were either satisfied or very satisfied with their operation. The mean Oxford knee score was 37 (5-48), the median Knee Society Score was 86 (51-99), and median Knee Society function score was 90 (5-100). Conclusions:The results of this study are comparable to those reported in the National Joint Registry and show that the implant is functioning well at 5 yr.

Current Orthopaedic Practice, 2014

Current Orthopaedic Practice, Nov 1, 2014

A ggressive digital papillary carcinoma (ADPACa), first described by Helwig in 1984 as a variant ... more A ggressive digital papillary carcinoma (ADPACa), first described by Helwig in 1984 as a variant of eccrine sweat gland carcinoma, is a rare malignant neoplasm occurring in the hands, feet, fingers, and toes. These tumors have a high local recurrence rate and a uniformly fatal metastatic potential. They typically occur in male patients between the fifth and seventh decades. We present a patient referred to the orthopaedic department with the diagnosis of a digital mucous cyst that proved to be an aggressive digital papillary carcinoma. Informed consent was obtained from the patient.

Orthopaedic Proceedings, Feb 21, 2018

Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significa... more Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significant surgical challenge. Such defects are associated with significant loss of host bone stock, which must be addressed in order to achieve stable implant fixation. A number of imaging techniques including CT scanning with 3D image reconstruction are available to assist the surgeon in the pre-operative planning of such procedures. We describe the use of a novel technique to assist the pre-operative planning of severe acetabular defects during revision hip arthroplasty. Patient and Methods – We present the use of this technique in the case of a 78 year old patient who presented 20 years from index procedure with severe hip pain and inability to weight bear due aseptic loosening of a previously revised total hip arthroplasty. A Paprosky 3B defect was noted with intra-pelvic migration of the acetabular component. Pre-operative investigations included: inflammatory markers, pelvic CT scan with 3D reconstruction, pelvic angiography and hip aspiration. Using DICOM images obtained from the CT scan, we used free open source software to carry out a 3D surface render of the bony pelvis. This was processed and converted to a suitable format for 3D printing. Using selective laser sintering, a physical 3D model of the pelvis, acetabular component and proximal femur were produced. Using this model the surgeon was able to gain an accurate representation of both the position of the intra-pelvic cup and more accurately assess the loss of bone stock. This novel technique is particularly useful in the pre-operative planning of such complex acetabular defects in order to determine if/which reconstruction technique is most likely to be successful. 3D printing is a relatively recent technology, which has numerous potential clinical applications. This is the first reported case of this technology being used to assess acetabular defects during revision hip arthroplasty. The use of this technology gives the surgeon a 3D model of the pelvis, quickly (7 days from CT) and at a tenth of the cost (£280) of producing such a model through the traditional commercial routes. The model allowed the surgeon to size potential implant, quantify the amount of bone graft required (if applicable) and to more accurately classify the loss of acetabular bone stock.

Orthopaedic Proceedings, Feb 21, 2018

Frail patients with neck of femur fracture, amongst other medical problems, are frequently fast-t... more Frail patients with neck of femur fracture, amongst other medical problems, are frequently fast-tracked to orthopaedic wards to meet government A&E waiting time targets. This is a second cycle of audit since 2008 examining the safety of fast-tracking following individual critical incidents. Data was collected prospectively between March and June 2011 by the first on-call orthopaedic doctor. 56 patients (12 male), average age 81.2y (50–97) were fast tracked. 52 were correctly referred as intra/extracapsular fracture, however 4 did not have a neck of femur fracture. 9 patients were transferred with no verbal referral to the receiving orthopaedic doctor. On arrival to the ward, 8 patients were found to have abnormal observations and acute medical problems requiring immediate review from the physicians. There were a total of 150 omissions from a total of 456 points from the fast track protocol. Vital observations of patients fast-tracked after 2100h were worse (MEWS range 0 to 11) when compared with those fast-tracked prior to 2100h (MEWS range 0 to 3). This occurs at a time when medical staff support is minimal. Fast-tracking is a common practice amongst many district-general and some teaching hospitals in Scotland. These data support concerns from orthopaedic surgeons highlighting a need for more complete initial assessment and management in A&E prior to transfer to the ward. Recent evidence suggests medical optimisation of the multiple acute and chronic medical comorbidities common amongst patients with neck of femur fracture is the main facilitator of early surgery which significantly reduces post-operative mortality.

Orthopaedic Proceedings, Feb 21, 2018

Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various pro... more Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various protocols exist for treating these infections, each with its own advocates. In this series we report the one to five year follow-up of infected TKA that were treated with a two-stage revision knee replacement at the Glasgow Royal Infirmary between December 2003 and March 2009. 48 patients were identified from the hospital database. 6 of these were excluded as they did not meet the stipulated infection criteria. Another patient was excluded as no notes were available thereby the infection status could not be determined. Another 8 patients were excluded as these only had a first stage. 33 patients (16 male) average age 67y (49–88) met the inclusion criteria. Mean BMI was of 31.62 (19–47) and 8 patients suffered from rheumatoid arthritis. At presentation, the median for the ESR, CRP and WCC were 70.5, 133 and 8.5 respectively. The infective organism was identified in 22 patients. Following the first stage, the patients were treated with antibiotics (initially intravenous followed by oral) for an average of 11.8 weeks (4–52 weeks). This procedure failed to eliminate the infection in 6 patients (18.18%) who had further re-admissions for infection of the affected prosthesis. The resultant success rate is of over 80% which is comparable to literature data (success rates of 41% to 96% quoted). For these patients, the average time to review was 25.13 months (12–67months). At review these patients had a mean extension of 2.17° (0–10°) and a mean flexion of 98.26 (70–120°). These patients were all satisfied with their outcome. Our results show a high successful rate of elimination of infection when a two-stage revision is used for infected knee prosthesis with over 80% of patients free of infection.

Journal of surgical case reports, Jun 1, 2010

Amputation is frequently required to treat wet gangrene secondary to peripheral vascular disease.... more Amputation is frequently required to treat wet gangrene secondary to peripheral vascular disease. Although different types of amputations have been reported, limited digital and ray amputation are the commonest amputations performed. The level of amputation will be determined by the distribution of lower limb disease but for every patient a balance between limb and functional preservation at lower levels versus better wound healing at higher levels should be sought. In this article we describe the novel osteo-myocutaneous flap, which we have used in our patient. We believe that this flap results in improved wound healing and although it results in loss of two digits, it does not impair function.

Osteoarthritis (OA) is a common chronic disorder with symptoms ranging from mild pain to complete... more Osteoarthritis (OA) is a common chronic disorder with symptoms ranging from mild pain to complete loss of function thereby severely influencing the patient's quality of life. Although most patients initially benefit from conservative measures, a large number will eventually require surgical intervention, most commonly in the form of a total knee arthroplasty (TKA). Over 90,000 TKAs are performed annually in the United Kingdom. TKA may be performed either using conventional instrumentation or with the aid of computers, also known as navigated TKA. One disadvantage of using navigation is the v

Journal of Bone and Joint Surgery, American Volume, May 1, 2013

A fifty-five-year old man attends a trauma follow-up clinic six weeks after undergoing primary re... more A fifty-five-year old man attends a trauma follow-up clinic six weeks after undergoing primary repair of a zone-II finger flexor tendon laceration. The patient has a history of substance abuse and has been noncompliant with postoperative treatment. He has not attended any postoperative outpatient or physiotherapy appointments, he removed his splint immediately on discharge, and he admits to moving the finger freely without restrictions, against advice. On examination it is evident that the patient has sustained a rupture of the tendon repair. Does the history of noncompliance with initial treatment affect decisions regarding the further management of this patient? The term compliance relates to the degree of constancy and accuracy with which an individual patient follows a prescribed treatment. Patient noncompliance is a common problem across all specialties and presents a major obstacle to safe, effective, and efficient health-care delivery. In this article, we discuss the risk factors for noncompliance, the difficult ethical and medico-legal dilemmas posed by this issue, and mechanisms for potential solutions to this common problem.

Bilateral femoral fractures related to bisphosphonates are rare. Evidence on how and when to fix ... more Bilateral femoral fractures related to bisphosphonates are rare. Evidence on how and when to fix them is lacking [1]. This case illustrates a successful treatment strategy of early definitive fixation after a short period of resuscitation. A brief review of bisphosphonate fractures in included. As the literature is sparse in relation to bilateral bisphosphonate fractures, in particular how and when to operate upon them, we have examined the evidence on higher energy bilateral femoral fractures to ascertain some guidance. Abstract

Journal of Bone and Joint Surgery-british Volume, 2013

Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various pro... more Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various protocols exist for treating these infections, each with its own advocates. In this series we report the one to five year follow-up of infected TKA that were treated with a two-stage revision knee replacement at the Glasgow Royal Infirmary between December 2003 and March 2009. 48 patients were identified from the hospital database. 6 of these were excluded as they did not meet the stipulated infection criteria. Another patient was excluded as no notes were available thereby the infection status could not be determined. Another 8 patients were excluded as these only had a first stage. 33 patients (16 male) average age 67y (49–88) met the inclusion criteria. Mean BMI was of 31.62 (19–47) and 8 patients suffered from rheumatoid arthritis. At presentation, the median for the ESR, CRP and WCC were 70.5, 133 and 8.5 respectively. The infective organism was identified in 22 patients. Following the...

Orthopaedic Proceedings, Feb 26, 2020

Orthopaedic Proceedings, Feb 21, 2018

In our department, currently there is variation in the number of xrays that patients receive foll... more In our department, currently there is variation in the number of xrays that patients receive following ORIF of distal radius fractures. This audit investigated the use of xrays following ORIF of distal radius fractures. Patients were identified from daily trauma lists. Patients who had a primary ORIF or ORIF following failed conservative management were included in the study. PACS was used to identify the number of post-operative xrays performed. These were correlated with clinic letters to see if there was any change in management following xray review. Between July and November 2013, 102 patients were admitted with distal radius fracture. Of these, 35 (mean age:51 years) had an ORIF. Four were not followed-up in Scotland. Of the remaining 31 patients, eleven had one post-operative xray, seventeen had two and three had three xrays. Of the patients who had one xray, seven had the xray in the first three weeks, the rest at six weeks. Patients who had two xrays had an xray at two and 6 weeks. Of the three patients who had three xrays, two had comminuted fractures that required further CT investigation, one for a suspicion of an intra-articular screw, the other for possibility of non-union. The third patient had no apparent reason for requiring three xrays. Thus of the 31 patients in the study, 29 did not require any further investigations. The results show a variation in the frequency of post-operative xrays after fixation of distal radius fractures. In most cases the management plan was unchanged after plain xrays were undertaken. This suggests that a protocol driven approach to follow-up after fixation of distal radius fractures could reduce the burden on fracture clinic and radiology departments. We propose that unless indicated by intra-operative findings or post-operative concerns, patients should have xrays at the two week review appointment.

Journal of Bone and Joint Surgery-british Volume, 2014

In our department, currently there is variation in the number of xrays that patients receive foll... more In our department, currently there is variation in the number of xrays that patients receive following ORIF of distal radius fractures. This audit investigated the use of xrays following ORIF of distal radius fractures. Patients were identified from daily trauma lists. Patients who had a primary ORIF or ORIF following failed conservative management were included in the study. PACS was used to identify the number of post-operative xrays performed. These were correlated with clinic letters to see if there was any change in management following xray review. Between July and November 2013, 102 patients were admitted with distal radius fracture. Of these, 35 (mean age:51 years) had an ORIF. Four were not followed-up in Scotland. Of the remaining 31 patients, eleven had one post-operative xray, seventeen had two and three had three xrays. Of the patients who had one xray, seven had the xray in the first three weeks, the rest at six weeks. Patients who had two xrays had an xray at two and ...

Current Orthopaedic Practice, Mar 1, 2013

Orthopaedic Proceedings, Feb 21, 2018

The Columbus® knee system was designed as a standard knee implant that allows high flexion withou... more The Columbus® knee system was designed as a standard knee implant that allows high flexion without the need for additional bone resection. The aim of this retrospective study was to investigate the correlation between the maximum flexion achieved at five years and the slope of the tibial component. The hypothesis was that increased slope would give increased flexion. The study design was a retrospective cohort study at a single centre. The inclusion criterion was having had a navigated cemented Columbus primary TKA implanted between March 2005 and December 2006 using the image free OrthoPilot® navigation system (Aesculap, Tuttlingen, Germany) in our institution. Follow-up had been carried out at review clinics by an independent arthroplasty team. Patient-related data had been recorded either in case notes, the departmental proprietary database or as radiographic images. In addition to demographics, five-year follow-up range of motion (ROM) was collected. All available radiographs on the national Picture Archiving and Communication System (Eastman Kodak Company, 10.1_SP1, 2006), whether taken at our institution or at the patient9s local hospital, were analysed by a trainee orthopaedic surgeon (NCS) who was independent of the patients9 care. Component position according to the Knee Society TKA scoring system was determined from the five-year review lateral x-ray. The tibial slope was calculated as 90° minus the angle of the tibial component so giving a posterior slope as a positive number and an anterior slope as a negative number. The correlation between maximum flexion angle and tibial slope was calculated. Further to this a subgroup of only CR prostheses and patients with BMI 35. A total of 219 knees in 205 patients were identified. 123 had five-year radiograph and maximum flexion measurement available. Cohort demographics were mean age 68(8.6), mean BMI 32.0(5.9) and mean maximum flexion at five years of 101°(11°). The tibial slope angle showed variation around the mean of 2°(2.8°). There was no correlation between tibial slope and maximum flexion for either that whole cohort (r=-0.051, p=0.572, Figure 1b) or the subgroup of CR and BMI 35, mean 101° (SD11.4°). This study did not find any correlation between the tibial slope and maximum flexion angle in 123 TKAs at five year follow up. Further studies with a more accurate measurement of tibial slope should be carried out to confirm whether a relationship exists in the clinical setting.

Few doctors answer their bleep by stating who they are. Answering the phone in a formal manner is... more Few doctors answer their bleep by stating who they are. Answering the phone in a formal manner is of utmost importance in the hospital setting especially by on-call teams who are normally referred patients by other specialties, general practitioners and in some cases by other hospitals. An audit to evaluate the internal hospital communication was completed. In the first part of this audit, junior doctors within the orthopaedic department at the RAH were bleeped. Doctors were expected to answer by initiating the conversation by stating (1) name, (2) department, (3) grade and (4) a greeting. A list of omissions was recorded. If the call went through switchboard, it was expected that the hospital name was stated. The second part of the audit extended to other specialties in the RAH as well as orthopaedic departments in hospitals within the Greater Glasgow and Clyde health board (NHS GGC). Forty-three bleeps were made to doctors of various grades over a period of two months. Nine bleeps (two from other hospitals) were not answered. Five doctors answered their bleep in full. Only twenty-one doctors stated their name whilst eleven stated their grade. In both instances the department was not necessarily stated. The results were similar between the different departments as well as between the seven hospitals offering an orthopaedic service within NHS GGC. Of the thirteen on-call doctors that were bleeped as an external call through switchboard, only one doctor stated the hospital name. This has implications since most hospitals within NHS GGC share a common switchboard. These results emphasise the need for a protocol within NHS GGC for a standard etiquette for intra and inter hospital communication to ensure that patient safety and confidentiality is safeguarded.

Simple nasal bone fractures are the third most common type of all fractures leading to numerous p... more Simple nasal bone fractures are the third most common type of all fractures leading to numerous patient visits at the Accident & Emergency department. Nasal fractures are commonly over-investigated in St Luke's hospital leading to a substantial financial burden on our health system. In this article we review the frequency of simple nasal fractures as well as the necessity or otherwise of nasal x-ray imaging in addition to the financial and health consequences that result from nasal x-ray imaging. These issues are also discussed from a legal perspective.

Arthroplasty today, Jun 1, 2017

Background: This randomized controlled trial validated a redesigned version of navigated total kn... more Background: This randomized controlled trial validated a redesigned version of navigated total knee arthroplasty software with a streamlined registration (Smart) against the previous version (Classic). The objectives were to determine if Smart software had the same accuracy of component positioning and whether registration and operative time were reduced. Methods: A total of 220 patients were recruited and had a navigated total knee arthroplasty performed. With the exception of the software, all patients had the same perioperative care. At 6-week follow-up with an independent arthroplasty service, all patients had a computerized tomography scan. This was assessed by an independent radiologist to measure the mechanical alignment of the components. Results: The mean postoperative mechanical femorotibial angles were equivalent between groups (mean difference À0.2 , 95% confidence interval À0.7 to 0.3 , P ¼ .407). Component positions were similar in both groups. Mean registration time was significantly shorter for the Smart group (2 minutes 30 seconds ± 54 seconds) than the Classic group (3 minutes 23 seconds ± 39 seconds), P < .001. The mean operative time was 72 ± 12 minutes in both groups (P ¼ .855). At 6-week follow-up, both groups had similar clinical outcomes with 96.5% of patients being satisfied or very satisfied. Conclusions: The study verified that a reduced registration time did not alter the accuracy of component placement. However, despite a shorter registration time, the overall surgical time was not reduced.

Journal of orthopaedics, Mar 1, 2020

BackgroundNavigated total knee arthroplasty (TKA) improves implant and limb alignment but outlier... more BackgroundNavigated total knee arthroplasty (TKA) improves implant and limb alignment but outliers continue to exist. This study aimed to determine the technical and surgical causes of outliers.MethodsThis retrospective cohort study included 208 patients who had undergone navigated TKA. Limb and implant alignment indices were measured on post-operative CT scans: mechanical femoro-tibial angle (MFTA); coronal femoral angle (CFA); coronal tibial angle (CTA); sagittal femoral angle (SFA); and sagittal tibial angle (STA). Values outside 0°±3° for MFTA and SFA, 90°±3° for CFA, CTA and STA were considered outliers. Intra-operative navigation data and CT scans were evaluated to categorize the causes of sagittal and coronal plane outliers into hip centre error; ankle centre error; heterogeneous tibial cement mantle; malalignment accepted by surgeon; suboptimal knee balance; and no obvious explanation.ResultsOf the 1040 measurements (five per TKA), the overall incidence of outliers was 10.4% (n = 108). Femoral component outliers (CFA + SFA, n = 51) were all attributable to hip centre error. Tibial component outliers (CTA + STA, n = 43) were attributable to ankle centre error (n = 6), heterogeneous cement mantle (n = 20), malalignment accepted by the surgeon (n = 6) and no obvious cause (n = 11). MFTA outliers were attributable to hip centre error (n = 4) or suboptimal knee balance (n = 10).ConclusionsSurgeon related errors can be minimized by a meticulous operative technique. These results indicate scope for additional technical improvement, especially in hip centre acquisition, which may further reduce the incidence of outliers.

Current Orthopaedic Practice, Nov 1, 2015

Background:The navigated Columbus® total knee arthroplasty (TKA) is a relatively new implant with... more Background:The navigated Columbus® total knee arthroplasty (TKA) is a relatively new implant with few published mid-term follow-up reports. This retrospective study assessed the clinical and radiographic outcomes of a consecutive series of these implants. Methods:One hundred and seventy-eight knees in 165 patients were identified. The patient cohort had a mean age of 69 (50-89) years. Follow-up of 105 knees (59%) was 60.6 (58-76) months. All complications and readmissions within the cohort were identified via the Scottish Information Services Division (NHS Scotland). Survival analysis was carried out for all 178 knees using Kaplan-Meier, with hospital and national records used to identify the last known date when the patient was alive and the prosthesis was still in place. Results:Four patients had a revision TKA (all cause revision rate 2.2%) giving a cumulative 5-year survival of 97.3% (95% CIs 92.9%, 99.9%) with revision for any cause as the endpoint. Only one patient required revision for aseptic loosening. The mean maximal active flexion was 100.3 (60-120) degrees, with a mean fixed flexion of 0.4 (0-5) degrees. Ninety-six percent of the patients were either satisfied or very satisfied with their operation. The mean Oxford knee score was 37 (5-48), the median Knee Society Score was 86 (51-99), and median Knee Society function score was 90 (5-100). Conclusions:The results of this study are comparable to those reported in the National Joint Registry and show that the implant is functioning well at 5 yr.

Current Orthopaedic Practice, 2014

Current Orthopaedic Practice, Nov 1, 2014

A ggressive digital papillary carcinoma (ADPACa), first described by Helwig in 1984 as a variant ... more A ggressive digital papillary carcinoma (ADPACa), first described by Helwig in 1984 as a variant of eccrine sweat gland carcinoma, is a rare malignant neoplasm occurring in the hands, feet, fingers, and toes. These tumors have a high local recurrence rate and a uniformly fatal metastatic potential. They typically occur in male patients between the fifth and seventh decades. We present a patient referred to the orthopaedic department with the diagnosis of a digital mucous cyst that proved to be an aggressive digital papillary carcinoma. Informed consent was obtained from the patient.

Orthopaedic Proceedings, Feb 21, 2018

Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significa... more Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significant surgical challenge. Such defects are associated with significant loss of host bone stock, which must be addressed in order to achieve stable implant fixation. A number of imaging techniques including CT scanning with 3D image reconstruction are available to assist the surgeon in the pre-operative planning of such procedures. We describe the use of a novel technique to assist the pre-operative planning of severe acetabular defects during revision hip arthroplasty. Patient and Methods – We present the use of this technique in the case of a 78 year old patient who presented 20 years from index procedure with severe hip pain and inability to weight bear due aseptic loosening of a previously revised total hip arthroplasty. A Paprosky 3B defect was noted with intra-pelvic migration of the acetabular component. Pre-operative investigations included: inflammatory markers, pelvic CT scan with 3D reconstruction, pelvic angiography and hip aspiration. Using DICOM images obtained from the CT scan, we used free open source software to carry out a 3D surface render of the bony pelvis. This was processed and converted to a suitable format for 3D printing. Using selective laser sintering, a physical 3D model of the pelvis, acetabular component and proximal femur were produced. Using this model the surgeon was able to gain an accurate representation of both the position of the intra-pelvic cup and more accurately assess the loss of bone stock. This novel technique is particularly useful in the pre-operative planning of such complex acetabular defects in order to determine if/which reconstruction technique is most likely to be successful. 3D printing is a relatively recent technology, which has numerous potential clinical applications. This is the first reported case of this technology being used to assess acetabular defects during revision hip arthroplasty. The use of this technology gives the surgeon a 3D model of the pelvis, quickly (7 days from CT) and at a tenth of the cost (£280) of producing such a model through the traditional commercial routes. The model allowed the surgeon to size potential implant, quantify the amount of bone graft required (if applicable) and to more accurately classify the loss of acetabular bone stock.

Orthopaedic Proceedings, Feb 21, 2018

Frail patients with neck of femur fracture, amongst other medical problems, are frequently fast-t... more Frail patients with neck of femur fracture, amongst other medical problems, are frequently fast-tracked to orthopaedic wards to meet government A&E waiting time targets. This is a second cycle of audit since 2008 examining the safety of fast-tracking following individual critical incidents. Data was collected prospectively between March and June 2011 by the first on-call orthopaedic doctor. 56 patients (12 male), average age 81.2y (50–97) were fast tracked. 52 were correctly referred as intra/extracapsular fracture, however 4 did not have a neck of femur fracture. 9 patients were transferred with no verbal referral to the receiving orthopaedic doctor. On arrival to the ward, 8 patients were found to have abnormal observations and acute medical problems requiring immediate review from the physicians. There were a total of 150 omissions from a total of 456 points from the fast track protocol. Vital observations of patients fast-tracked after 2100h were worse (MEWS range 0 to 11) when compared with those fast-tracked prior to 2100h (MEWS range 0 to 3). This occurs at a time when medical staff support is minimal. Fast-tracking is a common practice amongst many district-general and some teaching hospitals in Scotland. These data support concerns from orthopaedic surgeons highlighting a need for more complete initial assessment and management in A&E prior to transfer to the ward. Recent evidence suggests medical optimisation of the multiple acute and chronic medical comorbidities common amongst patients with neck of femur fracture is the main facilitator of early surgery which significantly reduces post-operative mortality.

Orthopaedic Proceedings, Feb 21, 2018

Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various pro... more Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various protocols exist for treating these infections, each with its own advocates. In this series we report the one to five year follow-up of infected TKA that were treated with a two-stage revision knee replacement at the Glasgow Royal Infirmary between December 2003 and March 2009. 48 patients were identified from the hospital database. 6 of these were excluded as they did not meet the stipulated infection criteria. Another patient was excluded as no notes were available thereby the infection status could not be determined. Another 8 patients were excluded as these only had a first stage. 33 patients (16 male) average age 67y (49–88) met the inclusion criteria. Mean BMI was of 31.62 (19–47) and 8 patients suffered from rheumatoid arthritis. At presentation, the median for the ESR, CRP and WCC were 70.5, 133 and 8.5 respectively. The infective organism was identified in 22 patients. Following the first stage, the patients were treated with antibiotics (initially intravenous followed by oral) for an average of 11.8 weeks (4–52 weeks). This procedure failed to eliminate the infection in 6 patients (18.18%) who had further re-admissions for infection of the affected prosthesis. The resultant success rate is of over 80% which is comparable to literature data (success rates of 41% to 96% quoted). For these patients, the average time to review was 25.13 months (12–67months). At review these patients had a mean extension of 2.17° (0–10°) and a mean flexion of 98.26 (70–120°). These patients were all satisfied with their outcome. Our results show a high successful rate of elimination of infection when a two-stage revision is used for infected knee prosthesis with over 80% of patients free of infection.

Journal of surgical case reports, Jun 1, 2010

Amputation is frequently required to treat wet gangrene secondary to peripheral vascular disease.... more Amputation is frequently required to treat wet gangrene secondary to peripheral vascular disease. Although different types of amputations have been reported, limited digital and ray amputation are the commonest amputations performed. The level of amputation will be determined by the distribution of lower limb disease but for every patient a balance between limb and functional preservation at lower levels versus better wound healing at higher levels should be sought. In this article we describe the novel osteo-myocutaneous flap, which we have used in our patient. We believe that this flap results in improved wound healing and although it results in loss of two digits, it does not impair function.

Osteoarthritis (OA) is a common chronic disorder with symptoms ranging from mild pain to complete... more Osteoarthritis (OA) is a common chronic disorder with symptoms ranging from mild pain to complete loss of function thereby severely influencing the patient's quality of life. Although most patients initially benefit from conservative measures, a large number will eventually require surgical intervention, most commonly in the form of a total knee arthroplasty (TKA). Over 90,000 TKAs are performed annually in the United Kingdom. TKA may be performed either using conventional instrumentation or with the aid of computers, also known as navigated TKA. One disadvantage of using navigation is the v

Journal of Bone and Joint Surgery, American Volume, May 1, 2013

A fifty-five-year old man attends a trauma follow-up clinic six weeks after undergoing primary re... more A fifty-five-year old man attends a trauma follow-up clinic six weeks after undergoing primary repair of a zone-II finger flexor tendon laceration. The patient has a history of substance abuse and has been noncompliant with postoperative treatment. He has not attended any postoperative outpatient or physiotherapy appointments, he removed his splint immediately on discharge, and he admits to moving the finger freely without restrictions, against advice. On examination it is evident that the patient has sustained a rupture of the tendon repair. Does the history of noncompliance with initial treatment affect decisions regarding the further management of this patient? The term compliance relates to the degree of constancy and accuracy with which an individual patient follows a prescribed treatment. Patient noncompliance is a common problem across all specialties and presents a major obstacle to safe, effective, and efficient health-care delivery. In this article, we discuss the risk factors for noncompliance, the difficult ethical and medico-legal dilemmas posed by this issue, and mechanisms for potential solutions to this common problem.

Bilateral femoral fractures related to bisphosphonates are rare. Evidence on how and when to fix ... more Bilateral femoral fractures related to bisphosphonates are rare. Evidence on how and when to fix them is lacking [1]. This case illustrates a successful treatment strategy of early definitive fixation after a short period of resuscitation. A brief review of bisphosphonate fractures in included. As the literature is sparse in relation to bilateral bisphosphonate fractures, in particular how and when to operate upon them, we have examined the evidence on higher energy bilateral femoral fractures to ascertain some guidance. Abstract

Journal of Bone and Joint Surgery-british Volume, 2013

Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various pro... more Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various protocols exist for treating these infections, each with its own advocates. In this series we report the one to five year follow-up of infected TKA that were treated with a two-stage revision knee replacement at the Glasgow Royal Infirmary between December 2003 and March 2009. 48 patients were identified from the hospital database. 6 of these were excluded as they did not meet the stipulated infection criteria. Another patient was excluded as no notes were available thereby the infection status could not be determined. Another 8 patients were excluded as these only had a first stage. 33 patients (16 male) average age 67y (49–88) met the inclusion criteria. Mean BMI was of 31.62 (19–47) and 8 patients suffered from rheumatoid arthritis. At presentation, the median for the ESR, CRP and WCC were 70.5, 133 and 8.5 respectively. The infective organism was identified in 22 patients. Following the...