Improving the Consent Process with The Use of Bespoke Patient Literature

Nicholas Howard, Simon Platt, Christopher Cowan, Michael Hennessy , Gillian Jackson

Background: Previous studies have shown poor patient comprehension during the consenting process. Improving the readability of consent form documents and patient information leaflets have been recommended. Readability of these documents were compared with novel patient specific letters introduced to the consent process to observe the effect on information recall and satisfaction for patients undergoing elective surgery.

Methods: The bespoke letter system was compared to the two existing methods of consent process; signing for consent at their outpatient encounter at which they were listed for surgery and a separate consent clinic without bespoke literature.

Results: Standardised consent forms had the poorest readability with patients requiring a higher level of education for comprehension. Readability of information leaflets is better with an average reading age of 15-16 years of age and patient specific letters 14-15 years. 111 patients (87 female: 24 male) undergoing elective surgery were assessed on the day of surgery for recall of the procedure, risks, post-operative course and satisfaction with the process. Patients receiving a bespoke letter recalled more than those who attended a routine pre-operative consent clinic and significantly more than those who were consented at their last clinic visit. Patient satisfaction with consent process was also higher in this group

Conclusions: The readability of generic consent forms is poor and should therefore be supplemented by both information leaflets and can be further improved by patient specific letters.

Patients receiving a bespoke letter recalled more than those who attended a routine pre-operative consent clinic and significantly more than those who were consented at their last clinic visit. Patient satisfaction with consent process was also higher in this group.

Our study suggests that consent process is improved by the use of routine pre-operative consent clinics; most notably by the addition of patient specific literature to improve recall and patient satisfaction.

Virtual Fracture Clinic – The Mid Cheshire Hospitals NHS Foundation Trust patient experience

Marieta Franklin, Nicholas Boyce-Cam

Background: In 2016, NICE called for research comparing Virtual Fracture Clinic (VFC) to the traditional face-to-face fracture clinic model. The Mid Cheshire Hospitals NHS Foundation Trust serves approximately 300,000 people. In 2014-5 its Fracture clinic saw 5577 new and 7085 follow-up appointments. Our aim was to evaluate the patient reported experience pre- and post- VFC introduction.

Methods: Two surveys were run, Round 1 before VFC was introduced and Round 2 after. In Round 1 a 27-part questionnaire was developed with the hospital’s Patient Experience Team, 60 patients completed this. The business case for a Consultant-led VFC Service was proposed and in October 2017 VFC was introduced. Following this in Round 2 46 patients completed a questionnaire to re-evaluate and close the audit loop of this quality improvement project. Round 2 was conducted 4 months after the introduction of VFC, targeting patients who had experienced VFC management for their initial appointment and who had had subsequent face-to-face review.

Results: Round 1 found that 80% of patients spent between £5-15 on their journey to hospital. 45% were not seen on time, with 10% waiting more than 45 minutes. 43% of patients had to take time out of work to attend appointments. Round 2 analysis found that over 50% of those responding to the question found there were benefits to having a VFC appointment for their 1st appointment. Approximately only a quarter of people would have preferred their VFC appointment to have been a face-to-face one. Nearly 80% of patients rated their overall experience as 8 or more out of 10 and 94% would recommend Leighton’s fracture clinic to friends/ family as compared to 80% in Round 1.

Conclusion: VFC has been well received by patients in this District General Hospital setting.

The incidence of traumatic posterior and combined labral tears in patients undergoing arthroscopic shoulder stabilisation

Fagir M, Javed S, Gheorghiu D, Torrance E, Monga P, Funk L, Walton M

Background: Posterior and combined shoulder instabilities have been reported as accounting for only 2% to 5% of cases. More recently an increased incidence of posterior instability has been reported. We aim to assess the incidence in a large cohort of patients with surgically treated shoulder instability. The purpose of this study was to describe the demographics, incidence and nature of capsulolabral pathology in a large cohort of patients with surgically treated traumatic shoulder instability, both in sporting and non-sporting populations. Furthermore, we aimed to determine how often posterior and combined labral tears were treated compared with isolated anterior injuries.

Methods: This was a retrospective study which evaluated 442 patients who underwent an arthroscopic stabilisation surgery over a three-year period. Patients were categorised according to the location of their labral pathology and whether their injury was sustained during sporting or non-sporting activity. Proportions of labral tears between sporting and non-sporting populations were compared using the chi-square test.

Results: There were 442 primary arthroscopic labral repair procedures performed over the three-year period. Patients had a mean age of 25.9 years and 89.6% were male. Isolated anterior labral tears occurred in 52.9% with posterior and combined anteroposterior labral tears accounting for 16.3% and 30.8% respectively. The frequency of these lesions was greater in the sporting population (17.5% and 34.7%) compared to the non-sporting population (12.6% and 18.9%) (p=0.013).

Conclusion: Posterior and combined labral tears are more prevalent than previously reported, particularly in the sporting population.

Pain and outcomes of carpal tunnel release under local anaesthetic with or without a tourniquet: a randomized controlled trial

H J Iqbal, A Doorgakant, N N T Rehmatullah, A Ramavath, P Pidikiti, S Lipscombe

Open carpal tunnel decompression (CTD) is one of the most common procedures in orthopaedics and is routinely performed under local anaesthetic using an arm tourniquet. The use of tourniquet is no longer considered routine by many surgeons.

Methods: We conducted a prospective randomised controlled trial of day case CTD under local anaesthesia. 37 procedures were performed using an arm tourniquet and 36 with adrenaline and local anaesthetic mixture but without tourniquet. Our primary outcome measure was the overall pain and discomfort experienced by patients during the procedure as assessed by the VAS scores. The secondary outcomes were Levine scores and Mini DASH scores.

Results: Patients undergoing carpal tunnel decompression with an arm tourniquet experienced significantly more pain and discomfort (median VAS. 5) as compared with those who had their operation performed without a tourniquet (median VAS. 2.5) (p. 0.003, 95% CI. 0.60 to 2.98). Both tourniquet and no tourniquet groups reported a significant improvement in function after the surgery as assessed by mini-DASH (95% CI. 13 to 25, p. 0.000), Levine SSS (95% CI. 13 to 17, p. 0.000) and Levine FSS questionnaires (95% CI. 4 to 8, p. 0.000).

Conclusion: We conclude that carpal tunnel decompression performed with a tourniquet causes patients unnecessary pain with no additional benefit as compared with the wide-awake carpal tunnel decompression without use of a tourniquet.



MLT Jayatilaka, M Argyropoulos R Parmar, I Guisasola , M Kent, MG Smith, J Gibson, P Brownson

Background: Traumatic dislocation of the glenohumeral joint is the most common joint dislocation. Our aim was to evaluate and improve our unit’s management of this patient group.

Method: An audit of management of 36 consecutive first time anterior shoulder dislocation patients, prior to the creation of a shoulder instability clinic, was performed from February to October 2016. A patient pathway was created based on the BESS guidelines. This was administered through the Virtual fracture clinic and a new weekly shoulder instability clinic. This clinic was staffed with shoulder consultants, had immediate access to ultrasound scans and specialist physiotherapists. The audit cycle was repeated from March to September 2017 yielding 22 patients.

Results: The results showed improvement in adherence to the BESS guidelines. Early referral for physiotherapy went from 78% to 91% . 100% of patients from 72% had an appointment to see an upper limb consultant within 6 weeks. All patients undergoing arthroscopic stabilization had this within 6 months in comparison to 1 patient in the 1st cycle. 78% from 0% of patients over 40 years of age had an USS at their first clinic appointment and cuff repair surgery was performed at a mean of 7.7 weeks when required. We found a high non-attendance rate in those aged below 40. 100% of patients aged 25 – 40 did not attend follow up and 83% of the sub 25 age group did not attend follow up.

Conclusion: The combination of VFC and an instability clinic lead to improvements in recommended early management of the first-time anterior shoulder dislocation. However, this has resulted in a waste of resource particularly in the 25 – 40 age group. We recommend that this age group should be managed primarily with physiotherapy and referral into a specialist clinic only if required.

An Audit of the Management of Shoulder Dislocations

Graeme Wilson, Jochen Fischer

Background: Shoulder dislocations are a common presentation to Accident & Emergency Departments and their management after initial reduction is important for long term morbidity. There are guidelines published by the British Elbow & Shoulder Society (BESS) regarding the management of these injuries. All patients under 25 years should have early specialist decision making, patients between 25-40 years should be reassessed at the 3-6 month mark and scanned if symptomatic, and patients over 40 years should have early diagnostic imaging and early rotator cuff repair.

Aim: To audit management of first time shoulder dislocations against BESS Guidelines.

Method: This was a retrospective audit of adults presenting to Macclesfield DGH with a first time dislocation between August 2016 – July 2017 who were followed up at Macclesfield DGH (n=24). Patients were identified using clinical coding and all imaging was reviewed to confirm the diagnosis. Clinic letters and investigations were subsequently reviewed. The management was then audited against the BESS guidelines depending on the patients’ age group: <25 (n=1), 25-40 (n=3), and >40 (n=20). ‘Early’ was classified as 6 weeks or less and this was decided locally.

Results: In the <25 group, 0% compliance with guidelines. In the 25-40 age group, 67% compliance with guidelines. In the >40 age group, 0% compliance with guidelines, however 40% of these patients had early imaging, and overall 60% of patients had imaging. 83% of patients scanned had a rotator cuff tear, and the remaining 17% had labral tears. All patients who went on to rotator cuff repair (n=3) were delayed in time to theatre.

Recommendations: Virtual Fracture Clinics to streamline patients into specialist shoulder clinics, investigation of all >40s with Ultrasound scan, and patients requiring rotator cuff repair should be managed on the trauma list and not elective lists.


Muscle Activation and Coordination in Patients with Subacromial Impingement Syndrome: An EMG Study

David H Hawkes, Omid Khaiyat, Ahmed T Makki, Graham J Kemp, Jo Gibson, Simon P Frostick

Background: Shoulder pain from impingement syndrome is common and can have a negative impact on patients’ quality of life. A recent multi-centre randomised control trial has questioned the role of surgery in favour of a conservative approach. However, current rehabilitation strategies are poorly evidence based and hampered by an inadequate understanding of the pathophysiology of the condition. The aim of this work is to evaluate aberrant muscle activation and coordination in patients with subacromial impingement using electromyography (EMG).

Methods: Thirty nine patients with subacromial impingement syndrome (SISG) and 34 healthy controls (CG) were recruited. Subjects completed self reported outcome measures and the Functional Impairment Test-Hand Neck Shoulder and Arm (FIT-HaNSA). EMG was recorded from 15 shoulder girdle muscles, using a telemetric system, during a task designed to replicate activities of daily living. The Pearson Correlation Coefficient (PCC) was used to study the coordination between muscles.

Results: Significant differences were demonstrated between the study groups for all patient reported outcome measures (p=<0.01) and the FIT-HaNSA test (p=<0.01). There was no difference in activation levels between any of the peri-scapula muscles (p=0.137-0.991). Aberrant coordination was seen between the upper trapezius and both the deltoid (PCC=0.25 SISG, 0.46 CG; p=0.04) and serratus anterior (PCC=0.41 SISG, 0.59 CG; p=0.35) in the patient group.

Discussion: Normal scapula motion positions the glenoid effectively, creating the basis for arm movement. The upper trapezius and serratus anterior elevate and upwardly rotate the scapula which is balanced by the middle and lower trapezius. This coordinated force couple is absent in patients with subacromial impingement syndrome. This effectively narrows the subacromial space causing painful compression of the soft tissue structures.

Implications: The findings of this study indicate that shoulder rehabilitation strategies need to focus on restoring the normal balance between of the peri-scapular muscles and deltoid.

Documentation of Assessment in Supracondylar Fractures of the Humerus in Children – Compliance with BOAST 11 Guidelines

Miss Laura Bowen, Miss Neala Glynn,

Background: Supracondylar humeral fractures are a common injury seen in children. There is a risk of significant complications including nerve injury, vascular compromise, compartment syndrome and clinical deformity. They can be difficult to manage. BOAST (British Orthopaedic Association Standards for Trauma) published guideline 11 in 2014 which lists criteria which should be assessed and documented for each child with this injury.

Method: A retrospective review of the available trauma admissions lists between 1st January 2017 and 31st October 2017 was undertaken to identify all patients admitted with a supracondylar fracture. Plain radiographs were reviewed and classified according to the Gartland system. Gartland Type 1 fractures were excluded. 16 cases were included. The electronic admission clerking was audited against BOAST 11 recommended standards for documentation of peripheral pulses, capillary refill time, and median, ulnar, radial and anterior interosseous nerve function.

Results: There were 7 cases of Gartland 2 and 9 cases of Gartland 3. Patients were assessed by either SHO or registrar level doctor, in 1 case there was a dual assessment. The radial pulse was referenced in 56% of cases and capillary refill time in 37% of cases. Documentation of individual nerve function was present in 69% of cases for the radial nerve and ulnar nerve, 75% for the median nerve, and 50% made reference to the anterior interosseous nerve. In the case of assessment by both SHO and registrar 100% of the documentation criteria were met. 100% of patients underwent surgery within 24 hours.

Conclusions: Documentation of the neurovascular status children presenting with supracondylar fractures is variable across all grades of assessing doctor. The phrase ‘neurovascular intact’ was frequently used, but is of inadequate standard for documenting the exact neurovascular status at the time of presentation according to BOAST guidelines.

A survey of patient use of social media for information about Clubfoot: The Alder Hey experience

Benjamin-Laing H, R. Everett, J. Carter, N. Garg

Background: The accessibility of information on the internet and social media has increased patient and carer access to healthcare information. Whilst previously patients were fully reliant on healthcare professionals to provide the most up to date information about their care, they are now able to access this online. Clubfoot is being increasingly detected prenatally and often affects patients throughout their lifetime. It is therefore a suitable condition to study social media use.

Method: The aim of this study was to evaluate the use of social media in patients and carers of patients with Clubfoot at a tertiary referral centre between August 2017 and February 2018. This was done using a questionnaire to evaluate patients in the outpatient setting. All patients and carers were given the option to fill in the questionnaire.

Results: Most surveys were completed by carers and a small number by patients. 90% of respondents used the internet for information about their own or their child’s condition. 75% used written forms of information. 65% used social media and 40% were part of an online support group. The leading forms of social media used were; Facebook, Instagram, Googleplus and Youtube. Participants cited the accuracy and reliability of information available as barriers against using the internet to source information about Clubfoot. 90% stated they would use Youtube videos about Clubfoot and available treatments if produced by healthcare professionals.

Conclusion: Social media platforms are being extensively used by patients and their carers as sources of healthcare information. Online information is increasingly being used over more traditional written forms of healthcare information. Our study has identified a demand by patients and carers for accurate and reliable online information about Clubfoot, in the form of educational Youtube videos produced by healthcare professionals.

The Salter’s Innominate Osteotomy does not lead to acetabular retroversion

Shelton J, Airey G, Dorman S, Wright D, Bruce C

DDH is present in 3.6/1000 live births in the UK. Patients who have a delayed diagnosis or refractory DDH will require a redirectional osteotomy to provide enhanced acetabular coverage allowing the femoral head to mould the acetabulum and create a congruent joint. Previous studies have demonstrated acetabular retroversion in patients who underwent Salter’s osteotomy on plain radiographs assessed for crossover sign. Acetabular retroversion has been shown as a risk factor in FAI and OA of the hip.

This study aims to accurately assess acetabular version using cross-sectional imaging in the immediate per-operative period.

All patients undergoing salter’s osteotomy were identified using the AHCH DDH database. Inclusion criteria were: Salters osteotomy for DDH, unilateral with a post op CT scan and adequate notes available. We excluded bilateral DDH and those without CT scan. Axial images were assessed for acetabular version (AV) with a modification of Abousamra’s technique by two authors with any discrepancies reviewed by a senior author. Measurements for the pathological hip and control hip were taken and Wilcoxon signed-rank test (<0.05) used for statistical analysis. Inter-observer reliability was assessed with Intra-class correlation coefficient (>0.7).

108 patients were identified with 92 included. Average age was 20.5 months, 81.5% female and 65% left sided. No acetabular retroversion was identified with mean AV 15.86® in salters hips and 12.99® in control hips (p=<0.001). Interrater reliability was 0.765 controls and 0.9 salters. No crossover sign was seen on follow up radiographs.

This is the largest study assessing AV after salters osteotomy and provides compelling evidence that retroversion post salters is a fallacy especially in conjunction with emerging evidence from comparative studies between cross-sectional imaging and radiographs showing poor reliability of retroversion on radiographs. This will aid adult hip surgeons with acetabular positioning as the TAL is excised in the majority of DDH surgeries.