Postoperative Advice Research Articles

Type 1 Tympanoplasty by Interlay Technique for Management of Tympanic Membrane Perforation

Tympanic membrane is the partition between the external ear and middle layer which is a vital component of the human ear. Neglected or maltreated earache, ear discharge and trauma lead to perforation of tympanic membrane. Tympanoplasty is the surgical procedure performed to repair a perforated tympanic membrane, with/without reconstruction of the ossicles, with the aim of preventing reinfection and restoring hearing ability. Type 1 tympanoplasty is the simple closure of the tympanic membrane perforation. To study the outcome of type 1 tympanoplasty operation by interlay technique, a descriptive longitudinal study was conducted among 200 patients in Community Based Medical College Hospital and in private clinics of Mymensingh from January 2012 to December 2021. Our inclusion criteria was population of age ranging from 15 to 55 yrs of both sexes having dry central perforation for at least 6 weeks and exclusion criteria was patient with active stage of chronic suppurative otitis media (CSOM), ossicular discontinuity, sensory neural hearing loss. Data was analyzed by SPSS version 20.0. Prevalence of taking graft was 96.00%. Measured by difference of preoperative air bone gap (ABG) and postoperative ABG of 15 decibel (dB) hearing improvement rate was 90%. Complication was minimal (1%). The complication was infection due to non-compliance with postoperative advice and treatment. Type 1 tympanoplasty done by interlay technique has excellent results both in terms of graft taken and hearing improvement with minimal complications.
 CBMJ 2023 January: Vol. 12 No. 01 P: 67-72

Driving, work, wound care and rehabilitation after carpal tunnel release: Consensus recommendations from a UK Delphi study.

There is variability in the information available for patients after carpal tunnel release (CTR). We aimed to establish (i) what advice should be provided regarding return to driving after CTR; (ii) how work activities should be categorised and defined in relation to CTR, and when patients should be recommended to return to these activities; (iii) what wound care and rehabilitation advice should be provided after CTR. We developed consensus recommendations from an expert panel of hand surgeons, primary care surgeons and hand therapists using an electronic Delphi process. Participants were recruited from clinical organisations using pre-defined criteria. Delphi questionnaires included open text and tick-box responses. Consensus was defined as ≥75% agreement and summary feedback was provided after each round. There were 33 panellists (21 surgeons and 12 hand therapists), of which 27 (82%) completed all rounds. Expected return to driving was agreed as 5-14days. Expected timescales were also agreed for return to seven selected occupational activities. Post-operative advice focused on using and moving the hand, rather than specific rehabilitation. While consensus was reached for most items, there were important areas of disagreement, including divergent views on driving with sutures in situ and the need to inform car insurers. Recommendations from this study expand on existing advice by including functional descriptors for occupational activities and guidance timescales generated through a formal consensus process. Areas where consensus was not reached warrant further exploration to assess whether different practices impact clinical and functional outcomes for patients.

Global preferred practice patterns in manual small incision cataract surgery

Objectives: Manual small incision cataract surgery (MSICS) has become the surgery of choice in developing countries and setups with a high cataract load; being non-inferior to phacoemulsification, with minimum dependency on technology, and a shorter learning curve. There exist high variability and multiple differing personal preferences in its instrumentation and techniques. Through our study, we aimed to analyse different MSICS practice patterns across the globe to be able to summarise the commonly performed variations and carve a path for MSICS training programmes and help novice surgeons learn the state-of-the-art methods. Materials and Methods: Ours was an online, questionnaire-based cross-sectional observational study. The Google form was floated among ophthalmologists through social media, globally. The preferences for each step of MSICS from the type of anaesthesia used to post-operative advice were asked and responses analysed. Results: Out of 278 respondents, 234 (84.17%) ophthalmologists used peribulbar anesthesia; 214 (77.3%) preferred to do capsulorrhexis first followed by corneoscleral tunnel incision; 145 (52.15%) preferred frown incision; and 152 (54.7%) considered astigmatism management important during tunnel-making. The majority (226 [81.3%]) surgeons used anterior chamber maintainer. Viscoexpression, wire-Vectis, and irrigating Vectis were practiced by 122 (43.9%), 96 (34.5%), and 64 (23%), respectively. As for the intraocular lenses, 175 (62.9%) surgeons preferred non-foldable and non-premium while 65 (23.4%) used multifocal. Viscoimplantation was preferred by 256 (92.1%) surgeons. Only 13 (4.7%) surgeons sutured the tunnel at the end while a subconjunctival antibiotic-steroid injection was used by 166 (59.7%) surgeons. Conclusion: Studying the variability in MSICS can help to carve future MSICS training programs and help novice surgeons to better perform the surgery.

SP7.2.7 Consenting practice in open inguinal hernia mesh repair and compliance with the British Hernia Society Standards

Abstract Aims Inguinal hernia repairs (IHRs) are one of the most frequently performed procedures worldwide with approximately 100,000 taking place in the UK each year. This study analyses open IHR consent practice against British Hernia Society standards, in particular, whether the term ‘mesh’ and significant postoperative complications were stated on consent forms. We also identified whether adequate post operative advice was given upon discharge in order to prevent recurrence. Methods This was a retrospective audit of all patients above 18 years old, who underwent open IHR 1 January - 31st December 2019. A total of 94 patients were included. Results Although in all cases a prolene mesh was inserted, 8.5% of patients received no mention of mesh in either the clinic letter or consent form. Postoperative readmission was 5.3% at one week, and 8.5% at one month. Reasons for readmission included pain (1%), haematoma (2%), and wound dehiscence (1%). In over 90% of consent forms, non-specific complications (bleeding, infection) were documented. However, common IHR postoperative complications, such as chronic pain (not mentioned in 15%), were not mentioned in consent forms. Only 38% of patients received written postoperative advice. Conclusion Adherence to consenting standards benefits both patients and doctors. Our study highlights that further intervention is required to ensure surgeons are consenting patients adequately, as well as providing sufficient postoperative advice. We advise use of pre-filled forms and patient information leaflets, both in line with GMC guidance, to improve the quality of service offered.

864 Adherence to British Hernia Society Standards in Consenting Practice for Inguinal Hernia Repair

Abstract Objectives Evaluation of adherence to BHS Standards in IHRs Consent. Primary goal was the documentation of “Mesh” on clinic letter and consent form. Secondary points were the enlisted postoperative complications and advice given to reduce the risk of complications. Introduction Mesh repair is the gold standard for elective inguinal hernias. Recurrence rate is 1-3%. Chronic pain, for different causes, is documented in 10-15% (Most frequent complication). Method Retrospective study looked at first 100 patients, who were subjected to open inguinal hernia repair, in one year time. Patients under 18 years, history of previous repair and laparoscopic repair were excluded. The sample was reduced to 94, as 6 cases had untraceable and insufficient records Results Despite using mesh in all patients, it was not written in 11.7% of the consent forms and half of the clinic letters. Postoperative readmissions were 6.4% ,8.5% and 1.1% at week, month and year, respectively. The main causes were pain (1%), wound dehiscence (1%), hematoma (2%), and recurrence (1%). Overall complications rate after one year was 5.5%. Although recurrence and chronic pain are linked to hernia repair, they were not mentioned in 10% and 15%. In contrast, non-specific complications were documented in > 90%. Damage to cord structures and post-operative advice were found in 60% and 30%. Conclusions All grades surgeons were not adequately adherent to BHS, exposing the firm to negligence and complains. Preprepared forms and leaflets are advised to improve the quality of service, in respect to the GMC Domains.

57 A Closed Loop Audit of Post-Operative Driving Advice Documentation

Abstract Aim The Driving and Vehicle Licensing Agency state post-operatively it is between the patient and doctor to establish when would be safe to resume driving, providing recovery does not exceed three months. This audit aimed to assess and improve the documentation rate of driving advice in the discharge summaries given to patients post abdominal surgery. Method Retrospective data collection from electronic records over the months of August and September 2020. 132 discharge summaries were screened to assess the baseline rate of verbal/documented driving advice given on discharge. Following the 1st cycle, posters encouraging the inclusion of driving advice and demonstrating how to access driving advice to discharge summaries were developed and distributed across the surgical wards. A 2nd cycle re-audit was conducted in October 2020 to measure the effect of change, and a further 3rd cycle audit was conducted in November 2020. Results 1st cycle included 132 patients. 62% had documented advice on their discharge summaries, while 38% had no proof of driving advice. After intervention, 2nd cycle included 30 patients. Results showed a significant increase in advice documentation (80%). A 3rd cycle was carried out with 47 patients. This showed a reduction in advice documentation (66%). Conclusions Driving advice on discharge in post-operative patients is crucial part of patient safety. Implementation of intervention has increased the documentation of driving advice showing enhancing patient safety. However, 3rd cycle after registrar’s changeover showed a decrease in the rate of documentation. A teaching session is planned for new doctors followed by 4th cycle.

1394 Operation Notes Performa: The Way to Optimise Hand Trauma Service

Abstract Aim To assess the effect of the introduction of British Society for Surgery of the Hand (BSSH) guided operation note Performa on the hand trauma service in St. George’s University Hospitals. Method First cycle was done in October 2019. This included retrospective evaluation of accuracy of documentation for closed hand fracture audit. Reassessment was done in September 2020 after introduction of surgical Performa guided by the latest BSSH guidelines. Results 27 patients have been included in the first cycle compared with 81 patients in the second cycle. While 82% of first cycle patients underwent operation, only 40% of second cycle patients were treated surgically. Overall documentation has improved by a mean of 40% in all parameters. This includes documentation of discussion of shared decision making regarding conservative and surgical management, documentation of level of competency of the operating surgeon and mobilisation advice given to patients before their first appointment with a hand therapist. This led to improvement in overall patient outcome including rate of infection falling from 14% to 1% and reoperation rate from 23% to 1%. Conclusions Op notes Performa is a useful tool in the armamentarium of hand trauma management. It helps junior trainees to memorise critical information to document especially in the ones usually missed like detailed post-operative advice.

473 Post-Tonsillectomy Advice: What Are UK Patients Being Told?

Abstract Background Tonsillectomy is one of the commonest surgical procedures performed in the UK, with just over 45,000 recorded in England in 2018-2019(1). Despite this there is wide variation in, and a lack of evidence for, the post-operative advice given to patients. Method Post-tonsillectomy patient advice sheets were obtained from 110 UK NHS Trusts and equivalent organisations. Their contents were analysed and compared with published literature on post-tonsillectomy management to determine whether the advice is evidence-based or not. Results Post-tonsillectomy dietary and fluid intake advice varied between hospitals; whilst many recommend eating and drinking a normal diet (88%), many recommended eating a ‘hard’ (26%) or ‘soft’ (8%) food diet. Literature written for adults was more likely to encourage adequate fluid intake than that for children (75% versus 25%). Non-evidence-based advice including avoiding fizzy drinks (21%), fruit juices (9%), and using chewing gum (51%), was frequently given. Reported post-operative risks and safety-netting also varied, with 71% advising urgent hospital attendance if any bleeding was experienced whilst 12% suggested that bleeding up to a spoonful was to be expected and should not necessarily be acted upon. Conclusions Much of the advice given appeared to be anecdotal and not based on, or contrary to, published evidence.

Indian endocrine surgery websites are they comparable?

IntroductionIn modern day surgical practice, patients and their relatives garner more knowledge through websites rather than direct interaction with the consultant physician. We aimed to assess whether Indian endocrine surgery websites matched with their counterparts abroad. Materials & methodsWe identified 60 endocrine surgery websites worldwide and 12 endocrine surgery websites maintained by trained endocrine surgeons from India. The website parameters, demographic data of the websites, rank, and other parameters were assessed using a professional website (www.Alexa.com). An endocrine surgeon along with a technical website advisor rated the content, presentation, and likes from a scale of 1–5 (1 minimum score and 5 maximum score). ResultsA total of 72 individual endocrine surgery websites, out of which 60 were from abroad and 12 were from India, were analyzed. A majority of foreign websites were ranked (43/60), whereas 2/12 Indian websites were ranked (P < 0.0001). Foreign websites had a better landscape profile. Except for pancreatic facts, which were significantly different (P = 0.006) between Indian and foreign websites, there was no significant difference in thyroid facts, parathyroid facts, adrenal facts, photographs, videos, postop advice, contact information, publications, and complications. ConclusionMost parameters were comparable in both groups. Postoperative advice and complications were present in only a few websites. A well-designed endocrine surgery website can aid both the patient and the treating physician.

"Parachute" Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base.

"Parachute" Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base.

Smart orthopaedic implants: A targeted approach for continuous postoperative evaluation in the spine

Real-time health monitoring systems are emerging in diverse medical fields, tracking biological and physiological signals for direct feedback to the user. Orthopaedics is yet to adapt to innovative trends in health monitoring. Despite an evident entry point during orthopaedic surgeries, clinicians remain unable to objectively examine the structural integrity and biomechanics in the operated region through implantable sensors. As such, postoperative advice can be non-specific and poorly guided. This perspective discusses the clinical need for load-sensing implants that address biomechanical postoperative monitoring, taking the example of spinal interbody cages. Research has attempted to establish sensing approaches in different orthopaedic settings; however, they fail to meet mechanical sensing requirements or lack in vivo translatability, especially in the spine. Polymeric flexible sensors and Microelectromechanical Systems (MEMS) have favourable attributes aligned to the required features for in vivo load-sensing, although these approaches are yet to be tested extensively in orthopaedics. While inductive powering is promising, wireless energy transfer and telemetry are areas of ongoing research. This perspective proposes a thorough understanding of the relevant biomechanics to identify the pertinent sensing parameters, concurrent treatment of sensing and powering aspects, and utilisation of energy harvesting for sensing and data transmission. While sensing advancements have contributed to the rise of real-time health monitoring in other fields of medicine, orthopaedics has so far been overlooked. It is the application of these innovations that will lead to the development of a new generation of ‘smart’ implants for continuous postoperative evaluation.

Postoperative treatment after partial nail ablation of ingrown toenails — does it matter what we recommend? A blinded randomised study

Trial design: In this blinded randomized study we analyzed patient reported outcome of three different treatments after nail surgery. We compared daily footbath with either alkaline or acidic soap or just a simple bandage of gauze dressing.Method: After partial nail ablation surgery, patients were randomized into three postoperative treatment modalities. Outcome in terms of reduction in pain, improvement of function, reduction of signs of infection and postoperative soothing effect were reported after one and two weeks. A generalized linear mixed model was used to analyze possible statistical differences between the groups.Results: 97 patients, 57% women, mean age 31 years, were included. Men reported significantly less pain and better function than women. Despite a registered lower growth of invasive pathogenic microbes following the use of acidic soaps, this did not lead to less infections than in the groups using either alkaline soap baths or bandaging. On the contrary, patients keeping the bandage on had significantly lower signs of infection after one week. Two patients using soap baths had growth of MRSA. Two weeks postoperatively, all three treatment alternatives had similar patient reported outcome in all parameters, and nobody needed antibiotics.Conclusions: This prospective randomized study was unable to prove that footbath with either acidic or alkaline soap should be preferred to just leave the postoperative bandage on for a week after partial nail ablation. We recommend that postoperative advice should be given on an individual basis, especially since our study did not involve patients with high risk of infections.

Water penetration of grommets: an in vitro study.

The insertion of grommets has been one of the most common procedures carried out by ENT surgeons for patients with persistent middle ear fluid. There has always been apprehension at the use of grommets by patients undertaking swimming or other water sports due to concerns of grommet penetration by water into the middle ear. Despite this, no common consensus exists amongst otolaryngologists regarding post-operative advice following grommet insertion. Most studies focus on surface swimming and do not consider other activities such as diving that patients may undertake. This study aimed to determine the hydrostatic head required for water to pass through a grommet using different water-based solutions. These were selected to simulate conditions such as swimming and showering or bathing. An improved model of a grommeted middle ear (based on previous work by Ricks et al.) was constructed using two 5-ml plastic syringes, latex (from a surgical glove), two rubber neoprene membranes and a Shah Ventilation Tube (1.14mm). Different water solutions were added to the system and the hydrostatic head measured using digital calipers. The results revealed that the hydrostatic head required to penetrate a grommet is lowest using soapy water and highest with distilled water. The differences between chlorinated water and 3% saline were not significant. We hope that this study can be used in conjunction with previous work to better prepare the ENT surgeon in giving suitable post-operative advice following grommet insertion.

Banter can help get the message across.

When giving postoperative advice to older ophthalmic patients who have a spouse in tow, I often feel like a stand-up comedian with the audience in the palm of my hand.

Dermatological postoperative patient information leaflets: is it time for more uniformity?

Patient information leaflets (PILs) are an important source of information for patients postoperatively. There are currently no nationally agreed standards by dermatologists for postoperative advice following skin surgery. To assess the common themes and areas of variation in advice given in PILs after skin surgery across all National Health Service (NHS) hospitals in England and Wales. All acute trusts in England (n=159) and local health boards in Wales (n=7) were requested to provide their postoperative dermatological PILs for general sutured wound care or excision biopsy. Eight preselected parameters were assessed: minimum dressing duration, duration of pressing on a bleeding wound, postoperative analgesia, explanation of infection signs, application of petroleum jelly, scarring, whom to contact if there is a problem, and the recommended postoperative time for abstaining from active exercise. PILs were received from 137 different dermatology departments belonging to 127/166 (76.5%) organisations across England and Wales. Of these, 102 PILs gave a specific duration for dressings: 45/102 (44.1%) advised a minimum of 48h, but 28/102 (27.5%) recommended leaving dressings in place until suture removal. Regarding duration of pressing on a bleeding wound, 117 PILs gave advice, with the most common recommendation being 15min (30/117, 25.6%), followed closely by 10min (26/117, 22.2%). Of the 137 PILs received, 125 gave advice regarding postoperative analgesia, with paracetamol alone being the most common recommendation (24/125, 19.2%). For the remaining parameters, 111/137 (81.0%) PILs described ≥2 signs of infection, 42/137 (30.7%) recommended the application of petroleum jelly, 65/137 (47.4%) mentioned scarring, 137/137 (100%) highlighted whom to contact if there were postoperative problems and 87/137 (63.5%) PILs gave advice regarding postoperative abstinence from active exercise. The advice given in dermatology postoperative PILs across England and Wales is highly variable. A nationally agreed template or set of postoperative advice should be considered to improve consistency.

Consistency of written post-operative patient information for common urological procedures.

Following urological procedures, it is common for patients to receive written handouts containing pertinent post-operative information and advice. This study aims to assess the consistency of procedure-specific post-operative advice provided to patients in Australia. Post-operative handouts for common urological procedures were obtained from a selection of Australian hospitals and practising urologists' websites. Handouts were examined for consistency with regard to post-operative advice and the Flesch-Kincaid grade level was calculated to determine readability. In total, 209 handouts were reviewed comprising seven urological procedures. The majority of handouts provided information regarding expected symptoms (88%) and when to seek medical attention (70.8%). Overall, 85.2% of handouts provided advice about which activities should and should not be performed. Instructions for return to work (32.1%), driving (45.5%), sex (32.1%) and physical activity (56%) were less universal. Infection, bleeding, pain and swelling were the principal reasons to seek medical attention. Duration of expected symptoms and timing for resuming normal activities were the most common sources of discordance between handouts. The mean Flesch-Kincaid grade level was 9.7 with a range of 6.7 to 13.6. Only 9.6% of patient information handouts had a grade level of 8 or less and no handouts were at or below the suggested grade 6 readability level. There is a significant degree of variability in written post-operative advice provided to patients in Australia. Individual surgeons and hospitals should provide specific and tailored advice directly to their own patients, written at a grade level suitable for the majority to understand.

Returning to work and driving after spinal surgery: A web-based survey investigating the opinions of UK spinal surgeons

Background/Aims: The UK spinal surgical community has no published recommendations advising when patients can return to driving or to work following spinal surgery. This article aimed to establish the advice given by UK spinal surgeons on these two issues to determine whether specific recommendations can be made. Methods: Members of the British Association of Spinal Surgeons were invited to complete a web-based survey examining the post-operative advice given to patients following: (i) lumbar spine discectomy for radicular leg pain; (ii) single level lumbar spinal fusion for mechanical back pain; (iii) anterior cervical decompression and fusion for radicular arm pain. Results: The opinions of 131 spinal surgeons were obtained, revealing a wide variation in the post-operative advice given. Following lumbar discectomy, an earlier return to driving and work is advised compared with patients who have had lumbar and cervical fusion, with 55% of respondents recommending returning to driving within two weeks. Returning to driving four weeks post-operatively was advised following discectomy, anterior or posterior lumbar fusion, or anterior cervical fusion by 83%, 60% and 68% of respondents, respectively. More than half of respondents recommended returning to work in a light manual capacity after four weeks following discectomy and anterior cervical spine and fusion, and after six weeks following lumbar fusion surgery. Longer time frames were indicated for manual and ‘heavy manual’ workers, with the majority of respondents recommending six to eight weeks following discectomy and 12 weeks following cervical and lumbar fusion surgery. Conclusions: Recommendations on when patients can resume driving and return to work following spinal surgery cannot be definitively made on the basis of this study. Limited evidence suggests that post-operative driving restrictions may not be justified based on driver reaction times and many patients may be safer immediately following surgery than pre-operatively. Advice on returning to work appears justified. This survey may be useful in providing empirical evidence for the post-operative advice for patients undergoing surgical interventions such as lumbar discectomy, posterior lumbar fusion, anterior lumbar interbody fusion, and anterior cervical discectomy and fusion.

Employment and professional outcomes in 803 patients undergoing bariatric surgery in a French reference center for obesity.

Background: Very few studies have been performed on small populations about the links between employment and bariatric surgery. Objective: To determine if rates of employment are increased among patients who have undergone bariatric surgery, to assess their post-operative health consequences (post-prandial weakness, diarrhea), and patients' ability to maintain post-operative advice (ie, 30 minutes of daily physical activity, 6 small meals daily) compared to non-employed post-surgical patients. Methods: This cross-sectional study was performed in the Regional Reference Centre for Obesity, which is a partnership between the University Hospital and a clinic in Angers, France during 2012 using a self-administrated questionnaire completed by patients hospitalized for post-operative follow-ups after bariatric surgery. Issues investigated were their professional situation before and after the surgery, compliancy to post-operative advice, and any postoperative side effects. Results: Employment rates were 64.4% before and 64.7% after the surgery (p=0.94). Of these, 30.6% maintained 30 minutes of daily physical activity vs. 41.0% of non-workers (p=0.02). 50.5% of employed patients and 57.3% of non-workers maintained 6 small meals a day after surgery (p=0.09). 8% of working patients reported post-prandial weaknesses and 8% reported diarrhea that caused problems at work. Conclusion: Employment rate remained stable after surgery. Having a job seemed to be an obstacle to managing 30 minutes of daily exercise, especially among women, but not maintaining 6 small meals a day. Therefore, working environment needs to be assessed to improve job quality and retention for patients who have undergone bariatric surgery.

Risk Behavior in Patients Operated for Spontaneous Pneumothorax

Objectives: Spontaneous pneumothorax (PTX) is a common disease frequently operated at specialized thoracic surgery units. It may arise in adolescents with healthy lung tissue (primary PTX) or in elder patients with preexisting lung disease (secondary PTX). Videothoracoscopic surgery (VATS) has become the surgical standard for treatment and recurrence prevention. While there is broad consensus regarding indications and techniques of PTX surgery, potential postoperative risks and consecutive patient behavioral advice have not been sufficiently elucidated to date. Methods: Single-center cohort analysis of 646 patients operated for primary PTX by VATS over a time period of 10 years. Putatively recurrence prone lifestyle activities (smoking status, flying habits, scuba diving) and actual occurrence of recurrences were correlated. Results: Follow up rate was 43% (279/646 patients). Mean time interval between primary operation and follow up was 61 (range 5–177) months. In 10 patients (3.6%), a PTX recurrence was observed. Regarding postoperative risk behavior reported at follow-up, 28% of patients were active smokers (in average 15 ± 7 cigarettes/day), 59% travelled by plane repeatedly, and only 2 patients did scuba diving (0.7%). Neither smoking nor flying or scuba diving could not be identified as statistically significant risk factors for PTX recurrence. Conclusions: In our study, none of the supposed “classic” lifestyle-associated risk factors for PTX recurrence after VATS proved to be a significant threat. Thus, postoperative patient behavior might not necessarily be constrained by overcautious medical advice.

The change in energy absorbed post removal of metalwork in a simulated paediatric long bone fracture.

PurposeThe surgical treatment of paediatric fractures is increasing. Open reduction and internal fixation (ORIF) with plates and screws is long established, whilst the use of elastic stable intramedullary nailing (ESIN) has become increasingly popular. This study quantifies, in terms of the energy required to produce a fracture, the biomechanical sequelae of both techniques post removal of metalwork, to provide clinicians with evidence to guide post-operative advice.MethodsAn immature bovine model was adopted to ascertain whether these techniques exposed the bone to a greater re-fracture risk following removal of the device. Bones were prepared to reflect ORIF or ESIN techniques, or prepared intact for the acquisition of control data. Each bone was tested to failure at 90 °/s, with the absorbed energy then being calculated to determine the relative difference between each technique and versus control data. Data describing peak shear stress and torque were recorded.ResultsAbsorbed energy was reduced by 47 % in the ORIF group compared to both the control (p = 0.011) and ESIN (p = 0.018) groups. The peak shear stress and torque were also significantly different. All ORIF bones failed through drill holes, suggesting stress localisation around the defects.ConclusionThis study suggests that there is a significantly higher re-fracture risk following the removal of ORIF plates when compared to both ESIN and the control environment. Whilst this may reflect the intuitive view of many clinicians, this study provides a quantitative value of the reduction in strength and should help clinicians to appropriately caution patients and parents prior to surgery.