British Orthopaedic Association Research Articles

Variation of Practice in Prophylactic Protocol to Reduce Prosthetic Joint Infection in Primary Hip and Knee Arthroplasty: A National Survey in the United Kingdom.

Prosthetic joint infection (PJI) has an enormous physiological and psychological burden on patients. Surgeons rightly wish to minimise this risk. It has been shown that a standardised, evidence-based approach to perioperative care leads to better patient outcomes. A review of current practice was conducted using a cross-sectional survey among surgeons at multiple centers nationwide. An 11-question electronic survey was circulated to hip and knee arthroplasty consultants nationally via the BOA (British Orthopaedic Association) e-newsletter. The respondents included 56 consultants working across 19 different trusts. Thirty-four (60.7%) screen patients for asymptomatic bacteriuria (ASB) preoperatively, with 19 (55.9%) would treating with antibiotics. Fifty-six (100%) screen for methicillin-resistant Staphylococcus aureus and treat if positive. Only 15 (26.8%) screen for methicillin-sensitive S. aureus (MSSA) or empirically eradicate. Zero (0%) routinely catheterise patients perioperatively. Forty-one (73.2%) would give intramuscular or intravenous gentamicin for a perioperative catheterisation. All surgeons use laminar flow theatres. Twenty-six (46.4%) use only an impervious gown, 6 (10.7%) exhaust pipes, and 24 (42.3%) surgical helmet system. Five different antimicrobial prophylaxis regimens are used 9 (16.1%) cefuroxime, 2 (3.6%) flucloxacillin, 19 (33.9%) flucloxacillin and gentamicin, 10 (17.9%) teicoplanin, 16 (28.6%) teicoplanin and gentamicin. Twenty-two (39.3%) routinely give further doses. ASB screening, treatment and intramuscular gentamicin for perioperative catheterisation is routinely practiced despite no supporting evidence base. MSSA screening and treatment is underutilised. Multiple antibiotic regimens exist despite little variation in organisms in PJI. Practice varies between surgeons and centers, we should all be practicing evidence-based medicine.

The 2023 Austrian-Swiss-German Fellowship.

The Austrian-Swiss-German Fellowship was set up in 1978 to facilitate a program through which surgeons from the German-speaking countries of Austria, Switzerland, and Germany could visit the United Kingdom, Canada, and the United States of America. In 2023, surgeons Brian Mullis and Satish Kutty, representing the American Orthopaedic Association and the British Orthopaedic Association, respectively, visited centers in Austria, Switzerland, and Germany over the course of 4 weeks. This article describes their journey and experiences.

A Clinical Audit of Orthopaedic Clinical Documentation of Acute Ankle Fractures: A Quality Improvement Project.

Background Orthopaedic ankle fractures are common injuries that require careful assessment, management, and documentation to ensure optimal patient outcomes. Proper documentation plays a critical role in facilitating communication among healthcare professionals, ensuring accurate diagnosis, treatment planning, and monitoring patient progress. Moreover, it is essential for medico-legal purposes and quality improvement initiatives. This article presents a comprehensive clinical audit aimed at evaluating the quality of orthopaedic ankle fracture documentation within a healthcare setting. The aim of this project was to assess the quality and accuracy of ankle fracture documentation within a single centreagainst the audit standards set by the British Orthopaedic Association (BOA) and the National Institute for Health and Care Excellence (NICE). Methods The study was a closed-loop audit utilising both retrospective and prospective analysis of ankle fracture clerking documentation performed by members of the trauma and orthopaedics team. Two audit cycles were completed in total; the first cycle was carried out in January 2020 where data were collected retrospectively from all orthopaedic admissions of ankle fractures. This was then re-audited against the BOA and NICE guidelines and presented to the local clinical governance meeting. A targeted educational intervention was then implemented with the goal of educating and reinforcing to key team members the documentation standards and the importance of accurate clerking documentation. The second cycle was carried out during July 2020 prospectively. All data were collected and collated with a total of nine data parameters analysed. Patients were included if they were skeletally mature and presented with closed malleolar and syndesmotic ankle injuries. Excluded patients were those who presented with open fractures, pilon fractures, and/or were skeletally immature. Data were then re-presented at the clinical governance meeting. Results A total of 23 patients were identified in the initial audit cycle and 22 patients in re-audit. On admission, it was found that 86% of patients presenting with ankle fractures had adequate documentation of their injury mechanism, which subsequently improved to 100% following the intervention. Similarly, there was a 71% improvement in precise documentation of clinical findings of ankle fractures. There was a marked improvement in the consistency of examination findings as well, with over 30% improvement in the rate of documentation for sensation status, skin integrity, circulation, and motor function. Results also revealed a 71% improvement in the documentation rates of vascular examinations where a Doppler ultrasound was used or pulses named in the documentation. Conclusion Through a targeted educational scheme focussing on the proposed documentation guidelines, we noted a significant improvement in documentation standards and accuracy of ankle fractures in the trauma and orthopaedic department. With ongoing educational input and reinforcement, team members can be supported to maintain a high level of documentation that meets all available standards, which will ultimately lead to improved patient care.

Can a Fully Electronic Patient Record-Based Virtual Fracture Clinic Increase Compliance With British Orthopaedic Association Guidelines for the Assessment of Acute Orthopaedic Trauma Patients?

Introduction There is clear guidance for the follow-up of acute orthopaedic trauma patients within 72 hours of presentation as per British Orthopaedic Association (BOA) guidelines. The virtual fracture clinic (VFC) model has been adopted nationwide to increase compliance with these guidelines. Traditionally our VFC was paper-based, but recently it has been made completely electronic with the introduction of Hive which is a comprehensive electronic patient record (EPR). The aim of this audit was to assess the effectiveness of the Hive VFC and to see the impact it has on improving the patient experience. Methods Data was collected retrospectively by looking at referrals to the Hive VFC across a seven-month period from its date of introduction. No patients were excluded and data was collected for 2,158 patients. Patient demographics, referral details, and outcomes were recorded on a Microsoft Excel version 16.0 for Windows spreadsheet (Microsoft Corporation, Washington, United States). Data was analysed using Microsoft Excel. Results Data was collected for 2,158 patients between September 9, 2022, and March 31,2023, in the Hive VFC. The largest proportion of injuries was found in the foot and ankle region with 32% of referrals (n=688), followed by hand and wrist with 30% (n=651), upper limb with 28% (n=595), and lower limb with 7% (n=142). There was a 50.4% (n=125)increase in the number of patients seen in the VFC across the study period with 248 patients being seen in September 2022, increasing to 373 in March 2023. The number of patients with acute traumatic orthopaedic injuries that were assessed within 72 hours on average was 94.5% per month. There was an increase of 7.3% during the study period from September 2022 to March 2023, 89.9% to 96.5%, respectively. Conclusion We believe that Hive VFC is a clinically sound and effective way of assessing acute traumatic orthopaedic patients and increasing compliance with BOA and NICE guidelines. The number of patients needing acute orthopaedic assessment is rising steadily, and this should alert us to find more convenient, time and cost-saving methods of delivering safe and effective patient care.

The British Orthopaedic Oncology Management (BOOM) audit.

Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion. A total of 846 patients with pelvic and appendicular MBD were analyzed, after excluding those with only spinal metastatic disease. A designated MBD lead was not present in 39% of centres (33/84). Adequate radiographs were not performed in 19% of patients (160/846), and 29% (247/846) did not have an up-to-date CT of thorax, abdomen, and pelvis to stage their disease. Compliance was low obtaining an oncological opinion (69%; 584/846) and prognosis estimations (38%; 223/846). Surgery was performed in 38% of patients (319/846), with the rates of up-to-date radiological investigations and oncology input with prognosis below the expected standard. Of the 25% (215/846) presenting with a solitary metastasis, a tertiary opinion from a MBD centre and biopsy was sought in 60% (130/215). Current practice in the UK does not comply with national guidelines, especially regarding investigations prior to surgery and for patients with solitary metastases. This study highlights the need for investment and improvement in care. The recent publication of British Orthopaedic Association Standards for Trauma (BOAST) defines auditable standards to drive these improvements for this vulnerable patient group.

Management of displaced supracondylar fractures in children and adherence to the BOAST guideline- experience in a District General Hospital, UK

BackgroundSupracondylar fracture is the most common elbow fracture in children. These fractures can be associated with significant complications, including nerve injury, vascular compromise, compartment syndrome and clinical deformity. The British Orthopaedic Association Standards for Trauma (BOAST) provide clear and comprehensive guidance for managing the supracondylar fracture. AimsWe reviewed the management of displaced (Gartland type 2 and 3) supracondylar fractures and adherence to BOAST guidelines between 1st audit and re-audit following the introduction of supracondylar assessment proforma. MethodsWe retrospectively analysed the adherence to BOAST guidelines for 103 patients operated between 2014 and 2020. Documentation of vascular status and individual nerve functions were assessed during presentation to the emergency department, immediately before surgery, and postoperatively before discharge from the hospital. We also reviewed the documentation of the K-wire's size utilised for fixation, the medial wire fixation technique, and post-fixation stability during the operation. A new supracondylar fracture assessment proforma was designed and implemented after the 1st audit as part of the quality improvement measure. During the second stage of the audit cycle, we reviewed 22 patients and used the same methodology as the first audit to analyse the data. ResultsResults: We found significant improvements in the documentation of capillary refill time from 65 % to 95.5 % (p = 0.0038), radial pulse from 59.2 % to 95.5 % (p = 0.0009), and documentation of individual nerve function from 37.9 % to 72.7 % (p = 0.0040) in the emergency department during 2nd stage of the audit cycle. Individual nerve function documentation by the operating team immediately before surgery changed from 42.7 % to 50 %. The use of 2 mm K-wires improved from 53.3 % to 89.5 % (p = 0.0037) Documentation of medial wire fixation technique and post-fixation stability increased to 100 % from 82.9 % to 89.5 % from 42.7 % (p = 0.0002), respectively. Postoperatively, we noted improvement in both radial pulse and capillary refill time documentation from 27.2 % to 54.2 % (p = 0.0216) and the individual nerve function from 9.7 % to 50 % (p = 0.00005). ConclusionPoor adherence in stage 1 of the audit cycle to BOAST standards was significantly improved in stage 2 (Re-audit) after introducing a simple supracondylar fracture assessment proforma and focussed educational sessions.

457 Tourniquet Pressures in Orthopaedic Surgery - Is the Standard 250mmHg Safe?

Abstract Aim To determine safe levels of tourniquet inflation pressures in trauma and orthopaedic surgery. Method Data was collected on 150 patients retrospectively from the intraoperative and anaesthetic records of patients undergoing trauma and elective orthopaedic surgery at a single site. Data collected included demographic data, tourniquet inflation pressures and maximum intraoperative systolic blood pressures. British Orthopaedic Association (BOA) standards for safe intraoperative tourniquet use were used to determine safe tourniquet inflation pressures. Results The average maximum intraoperative systolic blood pressure was 125mmHg. In 134 cases (91%) the tourniquet pressure used was 250mmHg. Of the cases studied 54% of upper limb and 33% of lower limb tourniquets were overinflated when compared with BOA standards. Given the average maximum intraoperative systolic blood pressure, standard tourniquet inflation pressures of 200mmHg for upper limbs and 225mmHg for lower limbs should be used in preference to the more commonly used standard used pressure of 250mmHg. Conclusions All patients should ideally have an individual tourniquet pressure set based on their systolic blood pressure. However, if a standard pressure is to be used, values of 200mmHg for upper limbs and 225mmHg for lower limbs should be used in preference to 250mmHg as appears to commonly used currently.

385 Neurovascular Status Documentation in Fracture Manipulation

Abstract Aim To improve standards of documentation of neurovascular status before and following manipulation in keeping with standards set by the British Orthopaedic Association (BOAST guidelines: Peripheral Nerve Injury1). Method At a major trauma centre, we retrospectively collected data on thirty orthopaedic patients who underwent fracture manipulation in October 2022. Data included documentation of sensory, motor and vascular neurovascular status, prior and following manipulation. Posters were displayed in the emergency and orthopaedic departments on adequate neurovascular documentation, and an autotext proposed to aid senior house officers with electronic documentation. Prospective data was then collected on the subsequent thirty patients. Results Prior to manipulation, sensory neurological status was documented in 40% of patients and motor neurological status in 43.3% in patients. Post-manipulation documentation was 10% and 13.3% respectively. Documentation of vascular status prior to and post-manipulation was 40% and 16.7%. Following our intervention, pre-manipulation documentation of sensory and motor neurological status was 60% and 63.3%; post-manipulation was 20% and 13.3%. Documentation of vascular status prior and post-manipulation was 70% and 20%. Conclusions Following our intervention, there was an improvement in documentation of both sensory and motor neurological status prior to manipulation, however there was no change in motor status post-manipulation. The intervention used may not provide a sustainable improvement in documentation. Use of a designed electronic form, which can be accessed easily for electronic documentation, may improve results further.

1181 Surgical Sample Collection and Non-Touch Technique for Tibial Fractures Treated with Fine Wire Frames: First Cycle Audit

Abstract Aim Tibial osteomyelitis can be an incredibly complex condition to treat, and often causes great pain and reduced quality of life for the patient throughout the treatment and rehabilitation phase. Often, fine wire fixators (FWF) are used for the most severe cases, with infection and concordant bone loss/deformity correction required. A robust diagnostic protocol is required to ensure the correct antibiotics are used for treatment. Method The microbiology sampling and diagnostic process for patients with tibial osteomyelitis treated with FWF were audited at a major trauma centre according to British Orthopaedic Association (BOA) guidelines. Fifty-one patients met inclusion criteria. Results Poor compliance was defined as <70% guidelines followed. Empirical antibiotics free period prior to diagnostic sampling was achieved in 46/51 cases (90.2%), five separate documented samples for microbiology sampling was achieved in 26/51 cases (51.0%), and documentation of sterile, non-touch, separate instrument technique for microbiology samples was documented in 5/51 cases (9.8%) We recommend a pre-written template for clinicians on admission of patients with suspected osteomyelitis detailing empirical antibiotic status prior to diagnostic sampling, a template for the surgical team to detail site and technique used for microbiology sampling, and increased communication between surgeons and microbiologists to confirm and document number of samples taken. Conclusions Tibial osteomyelitis can be very difficult to manage, with the initial culture-specific antibiotic(s) being employed crucial in the treatment process. Achieving a robust and error-free diagnostic process is vital in combating this debilitating condition, and a key goal for the trauma and orthopaedics department.

1307 Infection After Surgical Fixation of Fractures – a Multidisciplinary Approach in the Prevention and Early Detection of Fracture-Related Infections

Abstract Aim Infection after surgical fixation of fractures is a serious complication in Trauma and Orthopaedic surgery. A recent study has reported that the incidence of fracture related infections (FRI) may be as high as 30% in patients with open fractures post-surgical fixation. FRI can have significant and devastating impact on the patients as well as causing a huge financial burden on the national healthcare system in the United Kingdom. According to the British Orthopaedic Association (BOA) guideline, all patients with surgically managed fractures should have readily available guidance on how to respond in the event of suspected fracture related infection. The purpose of this audit was to evaluate the standard of practice in the prevention of FRI at a large teaching hospital. Method Patient notes and discharge documentation for all Trauma and Orthopaedic patients with surgically managed fractures between 01/10/2022 and 31/10/2022 were reviewed and results analysed. Results During this study period, 58 patients underwent surgery for surgical fixation of fractures. Among these 58 patients, only 5 patients (9%) had readily available information on how to respond in the event of suspected fracture related infection in their discharge documentations. Conclusions The results from this first cycle of audit shows that our current standard of does not meet the BOAST guideline. Actions must be taken to address this critical issue promptly. We are currently implementing interventions such as patient information leaflets and multidisciplinary approach with the aim to improve our standard of practice. We plan to reaudit the effectiveness of these interventions in January 2023.

107 OPEN to Change: Can District General Hospitals Deal with Open Fractures Too?

Abstract Introduction Fractures compromising soft tissues puts patients at risk of significant morbidity, therefore require timely multidisciplinary management. The British Orthopaedic Association Standard for Trauma (BOAST) Guidelines, updated December 2017, state “Patients with open fractures of long bones, hind foot or midfoot should be taken directly or transferred to a specialist centre that can provide Orthoplastic care.” Northern Ireland’s population is estimated at 1.8 million, within this there are between 370 and 500 cases of major trauma each year. Method This review looks at patients presenting to Craigavon Area Hospital in Northern Ireland, between October 2021 to October 2022, with open fractures. Results Over the study period, 41 Open fractures presented, 12 meeting criteria for transfer to a major trauma centre with orthopastic’s present as per BOAST Guidelines point 1. However, 11 patients were managed in Craigavon Area Hospital and 1 patient required transfer to a site with plastics available. Conclusions Can we learn from this same subgroup of patients? There is an ever-growing demand to major trauma centres in Northern Ireland some of the burden on which can be dealt with by DGH’s. This data should help contribute to any future updates of BOAST’s guidelines.

91 Introduction of a Simple Proforma Improves Documentation of Neuro-Vascular Status in Paediatric Supracondylar Humerus Fractures (Closing Loop Audit)

Abstract Introduction Supracondylar fractures of the humerus are the most common fracture around the elbow in children. There is a risk of significant complications including nerve injury, vascular compromise, compartment syndrome and clinical deformity. BOAST (British Orthopaedic Association Standards for Trauma) published guideline 11 in 2014 (updated in Oct 2020) which lists criteria that should be assessed and documented for each child with this injury. Aim Assess whether an introduction of a simple proforma will Improve documentation of the neuro-vascular status in paediatric supracondylar humerus fractures. Method a closing loop Audit to review the accuracy of documentation of the neuro-vascular status in the admission clerking against the standards published in the updated BOAST guidelines both before and after introduction of a simple documentation proforma. Results In the first audit cycle 30 patients were included and detailed documentation of the Neuro-vascular status as per the BOAST guideline was less than 40 %. After the proforma was introduced, the second closing loop cycle included 31 patients and detailed documentation of the Neuro-vascular status as per the BOAST guideline was 70 %. Conclusions The introduction of a simple proforma has improved significantly the documentation of the neurovascular status in children presenting to the ED with a supracondylar humerus fracture.

998 Distal Radius Fractures – Assessing Time to Surgery

Abstract Background The British Orthopaedic Association Standards for Trauma (BOAST guidelines) recommend that intra-articular distal radius fractures should be operated within 3 days and extra-articular fractures within 7 days of a decision to operate (1). Aim The objectives of this audit were to assess compliance with BOAST guidelines for operative management of distal radius fractures within a local trauma unit. Method Three audit cycles were completed between 2018 and 2021 over 3 -4-month periods. The second and third cycles were completed after elective orthopaedic cases were moved to an elective orthopaedic centre, and commencement of a weekly half day dedicated hand trauma list. All skeletally mature patients with acute distal radius fractures were included. Results Despite the addition of a dedicated hand trauma list and elective services moving to a dedicated site, compliance with BOAST guidelines remained almost unchanged. Compliance was at 100% for extra-articular fractures. However, for intra-articular fractures, compliance only slightly improved from 50 % to 53.3%. The average time to surgery improved from 4.25 days to 3.66 days for intra-articular fractures. Average time to surgery for extra-articular fractures was 3 days. Proposed reasons for delay included lack of trauma theatre time, prioritisation of other urgent cases such as femur fractures and lack of appropriate surgeon. Conclusions No distinction was being made to prioritise intra-articular distal radius fractures over extra-articular fractures for surgery. Trauma and Orthopaedic (T&O) staff have been educated and changes made to the T&O department’s trauma database to resolve this.

581 Documentation of Peripheral Sensory Function Assessment in Hand Trauma at a Regional Referral Unit

Abstract Aim This audit aimed to assess the quality of documentation of sensory function assessment in hand trauma patients treated at a regional referral unit. The audit was based on The British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) “Peripheral Nerve Injury” national guideline, last updated in December 2021. Method The scope included all hand trauma referrals received between the 1st and 10th of March 2022. Initial case screening excluded missed appointments, telephone consultations, missing hand assessment sheets and reviews of old injuries. Following that, patients with diagnoses of pulp injury, amputation, closed central slip injury, mallet injury, phalanx infection, old injuries, and removal of metalwork, which were not relevant to the audited guideline, were excluded. All remaining records were analysed for any description of sensory assessment and description of the sensation level using a 1-10 scale. Additionally, cases of volar lacerations were checked for documentation of two-point discrimination (2PD). Results The search yielded 97 patient records. Following the initial screening, 10 cases were excluded. 56 out of 87 remaining cases had diagnoses relevant to the audit. 24 cases were classified as volar injuries. 73% of hand assessment sheets contained any description of peripheral sensory assessment (41/56). 1-10 assessment was documented on 23% of records (13/56). 17% of volar injury records contained 2PD examination documentation (4/24). Conclusions Documentation of sensory assessment in hand trauma, especially two-point discrimination in volar lacerations, requires improvement. One possibility to improve the adoption of 2PD evaluation would be an introduction of a cheap and widely available assessment device.

304 Does Vitamin D Deficiency Lead to Poorer Health Outcomes After (Total) Knee Arthroplasty? a Systematic Review and Meta-Analysis

Abstract Aim Vitamin D deficiency is a predictor of poorer musculoskeletal disease outcomes and affects approximately 1-in-4 people. Prior literature has assessed the effects of vitamin D deficiency in joint arthroplasties. This updated systematic review and meta-analysis aims to evaluate and collate evidence available on vitamin D supplementation in total knee arthroplasty (TKA). Method A targeted terms search related to vitamin D and TKA outcomes was conducted (data inception until 01/09/2021). PubMed, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, American Academy of Orthopaedic Surgeons and British Orthopaedic Association databases were used. Analyses consisted of forest plots with I2 heterogeneity statistics, pooled effects with 95% confidence intervals (CI) and, p-values. A p < 0.05 was considered statistically significant. Results 10 studies fitted inclusion criteria for narrative description and 3 for meta-analysis. 6 studies showed improved outcomes in revision surgery risk, joint infection incidence and postoperative function. Additionally, there were poorer outcomes in postoperative stiffness, prosthesis explanation and postoperative vascular events. Meta-analysis of the length of hospital stays (LOS) demonstrated a significant decrease in LOS between vitamin D sufficiency versus deficiency (standard mean difference = -0.54, 95% CI [-0.69, -0.38], p<0.00001) favouring vitamin D sufficiency. Conclusions Vitamin D supplementation demonstrated a statistically significant benefit for TKA patients regarding LOS. Most studies found positive effects of vitamin D supplementation improving patients’ health, reducing hospital resource use, and decreasing the burden on surgeons. Further research with standardised assessment scores is required to definitively prove the vitamin D screening and supplementation benefits in TKA.

860 Intra-Operative Tourniquet Use in Elective Trauma & Orthopaedic Surgery – Do We Accept or Reject Guidelines? (A Multi-Centre Clinical Audit)

Abstract Aim Pneumatic tourniquets are used in Trauma & Orthopaedic (T&O) surgery to provide a bloodless field. Their use can give rise to preventable complications. British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) 2021 guidelines aim to improve tourniquet safety, highlighting strict documentation and pressure based on intra-operative blood pressure. We evaluated intra-operative tourniquet use in elective T&O surgeries across 3 centres in North London, focusing on adherence to BOAST guidelines. Method One month of elective T&O surgeries employing tourniquet were reviewed, totalling 88 cases (17 upper limb, 71 lower limb). Tourniquet pressure ranges were calculated from anaesthetist intra-operative blood pressure records. Tourniquet documentation was retrieved from scrub-nurse, anaesthetist, and surgeon operative records. Adherence to BOAST guidelines was assessed. Results 14.0% of surgeon notes did not comment on tourniquet use and 86% had incomplete documentation. 97.6% of nursing notes had incomplete documentation. Average tourniquet pressure was 237 mmHg (SD ± 21.6) and 261.7 mmHg (SD ± 25.3) for upper and lower limb surgery, respectively. Upper limb tourniquet pressure was above guideline recommendations in 70% of cases. Mean pressure was 12.5 mmHg above calculated maximal pressure (95% CI -7.98 - 32.98; P = 0.22). Half (47.5%) of lower limb pressures were above maximal calculated pressure. Tourniquet pressure was on average 5.6 mmHg above guidelines (95% CI -4.12 - 15.26, P = 0.26). Conclusions Tourniquet use is poorly documented, which does not comply with BOAST guidance. Inappropriately high torniquet pressures may lead to preventable complications. Education on current guidelines is pertinent to improve adherence to national standards.

531 Virtual Fracture Clinic Management During the COVID-19 Pandemic at Glasgow Royal Infirmary: The MAVCOV Study

Abstract Aim To evaluate the efficacy of the Virtual Fracture Clinic (VFC) in terms of patient satisfaction and clinical outcome, pre and during COVID at Glasgow Royal Infirmary (GRI). The impact of the pandemic on the quality of patient management was assessed by comparing two sets of patients who (1) presented to the clinic when British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) COVID-19 guidelines were first introduced (Pre-Lockdown Cohort) and (2) presented after practitioners were familiar with these guidelines (Lockdown Cohort). Method This was a retrospective review of VFC patients. Data extracted included demographic information, management plans and three-month follow-up outcomes. Patients discharged without further follow-up underwent a telephone questionnaire to assess patient satisfaction. Results 286 patients were included in this study. 96.7% of patients in the pre-lockdown cohort presented to the VFC within 3 days of presentation as opposed to 93.3% of the lockdown cohort. 54.1% of the pre-lockdown cohort were referred to face-face/specialty clinics as opposed to 44.8% of the lockdown cohort. 6.9% of a subset of the lockdown cohort had an unplanned re-attendance to hospital for associated pain as opposed to 1.12% of a subset of the pre-lockdown cohort. 72% of the pre-lockdown cohort reported they were ‘very satisfied’ as opposed to 40% of the lockdown cohort. Conclusions The data reflects that there was a net shift from face-face consultations to discharge with nurse call between the pre-lockdown cohort and lockdown cohort however, this came with a substantial drop in patient satisfaction and an increased re-attendance rate.

62 Does vitamin D deficiency lead to poorer health outcomes after (total) knee arthroplasty? A systematic review and meta-analysis

Abstract Aims Vitamin D deficiency is a predictor of poorer musculoskeletal disease outcomes and affects approximately 1-in-4 people. Prior literature has assessed the effects of vitamin D deficiency in joint arthroplasties. This updated systematic review and meta-analysis aims to evaluate and collate evidence available on vitamin D supplementation in total knee arthroplasty (TKA). Methods A targeted terms search related to vitamin D and TKA outcomes was conducted (data inception until 01/09/2021). PubMed, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, American Academy of Orthopaedic Surgeons and British Orthopaedic Association databases were used. Analyses consisted of forest plots with I2 heterogeneity statistics, pooled effects with 95% confidence intervals (CI) and, p-values. A p < 0.05 was considered statistically significant. Results 10 studies fitted inclusion criteria for narrative description and 3 for meta-analysis. 6 studies showed improved outcomes in revision surgery risk, joint infection incidence and postoperative function. Additionally, there were poorer outcomes in postoperative stiffness, prosthesis explanation and postoperative vascular events. Meta-analysis of the length of hospital stay (LOS) demonstrated a significant decrease in LOS between vitamin D sufficiency versus deficiency (standard mean difference = -0.54, 95% CI [-0.69, -0.38], p<0.00001) favouring vitamin D sufficiency. Conclusion Vitamin D supplementation demonstrated a statistically significant benefit for TKA patients regarding LOS. Most studies found positive effects of vitamin D supplementation improving patients’ health, reducing hospital resource use, and decreasing the burden on surgeons. Further research with standardised assessment scores is required to definitively prove the vitamin D screening and supplementation benefits in TKA.

Fracture-related infections.

Fracture-related infection is a serious complication which can occur following musculoskeletal injury and is associated with significant morbidity. These complications can be challenging to recognise, and experts have provided a clearer definition of fracture-related infection to help with the diagnosis and detection of these infections. This system includes clinical, radiological and laboratory-based diagnostic features which are either confirmatory or suggestive of fracture-related infection. Treatment requires a multifaceted approach with multidisciplinary involvement, and generally a combination of surgical techniques and prolonged antibiotics, the timing and choice of which should be optimised. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of fracture-related infections.

Questions, answers and challenges: Summarising the guidance for distal radius fractures

Purpose and methodsThis article summarises the current recommendations from the American Academy of Orthopaedic Surgeons (AAOS), the British Orthopaedic Association (BOA), the British Society for Surgery of the Hand (BSSH) and the National Institute of Health and Care Excellence (NICE) for the management of distal radius fractures (DRF). We performed an audit of DRF management at our local emergency hospital. Results and conclusion: Despite DRF representing a large portion of our workload, there remains a paucity of evidence to base recommendations on. Recommendations can be conflicting, and some seem aspirational rather than achievable. Our local audit highlights the challenges of putting guidelines into practice. Treatment plans should incorporate best practice guidance but ultimately be individualised to each patient.