This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering interventions for treating distal femur fractures in adults; ultrasound and shockwave therapy for acute fractures in adults; and local corticosteroid injection versus placebo for carpal tunnel syndrome.

In a decidedly upper limb themed series of reviews this edition of Cochrane Corner summarises four new and updated reviews published by the Cochrane Bone, Joint and Muscle Trauma Group over the last few months. The tenacious reviewers at the Cochrane collaboration have turned their beady eyes to conservative treatments for shoulder dislocations and clavicle fractures along with evaluation of femoral nerve blocks in knee replacement and how to best manage entrapment injuries in children.

The first Cochrane Corner of 2014 reports on a bumper number of new and updated reviews from the Cochrane Collaboration. Since November the Cochrane collaboration have turned their beady eye to scrutinise several topical (and sometimes controversial) orthopaedic issues such as pin site care, the use of Continuous Passive Motion (CPM) in the rehabilitation of total knee replacement (TKR) and the efficacy of nerve blocks.

While the Cochrane Collaboration have been busy over the last four months, only a handful of their published reviews have been of any relevance to orthopaedic and trauma surgeons. Those that are provide the reader with an overview of work on imaging modalities, antibiotic therapy, changes to the surgical site dressing and practices surrounding post-operative wound management, including post-op bathing and negative pressure wound therapy for use in the treatment of diabetic foot wounds.

Things have not been quiet in the Cochrane Collaboration in the four months since the last 'Cochrane Corner', with the publication of six new or updated reviews summarised here, all conducted with the bulletproof Collaboration's methodology representing the pinnacle of evidence relevant to orthopaedic surgeons.

Aims

Bone is a common site of metastatic disease. Skeletal complications include disabling pain and pathological fractures. Palliative surgery for incurable metastatic bone lesions aims to preserve quality of life and function by providing pain relief and stable mobility with fixation or replacement.

Current literature has few treatment studies. We present a 5 year longitudinal cohort study of surgery for metastatic bone disease at our large teaching hospital reviewing our complication and mortality rates.

Purpose

The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation.

Aim: To assess the implications of nerve conduction study for carpal tunnel syndrome.

Methods and Materials: A retrospective audit of the patients who underwent carpal tunnel release at the district general hospital from July 2000 till June 2005. Due to the un-availability of facility for nerve conduction study at our district general hospital, the patients had to be referred to other hospitals in the region for the same. A total of 263 carpal tunnel releases were performed during the study period in 206 patients (57 were bilateral). 61 patients were males and 145 were females.

Results: Of the classical presentation group, the nerve conduction study was requested in 76 of the 172 patients while in the atypical presentation group 53 of the 91 patients had a nerve conduction study prior to the operative treatment. The intra-operative findings of thickened flexor retinaculum and thinned median nerve were statistically similar in the 2 groups: Nerve conduction not performed and Nerve conduction study performed.

Discussion: The average duration between the first consultation and the operative treatment was 72 days in the patients who did not undergo the nerve conduction study, whereas the average duration between the first clinic appointment and the operative treatment for the patients who had the nerve conduction study was 180.5 days. The request for nerve conduction study in cases with classical presentation leads to an average 108.5 days delay in the final management of the patient’s problem. It also causes a significant loss of time and finances.

Aim: To assess the implications of implementation of the NICE Guidelines for indication for CT scan in head injury patients.

Methods and Materials: A retrospective audit of the patients attending our district general hospital with head injuries over a period of one year from October 2004 till Sept 2005. A total of 3150 patients attending the A & E during the study period were diagnosed to have head injuries. The study involved review of the case notes and radiology results of the 135 patients requiring inpatient treatment for head injury. During this tenure the CT scan was requested depending of the clinical judgement of the attending physician.

Results: Rigid compliance with the NICE Guidelines during the study tenure would have entailed an additional workload of 36 patients requiring a CT scan, of which 28 patients justified the scan during out of hours period.

One elderly patient with a fatal intracerebral bleed was found to have justified an early CT scan on the criteria of more than one vomiting episode and a history of unconsiousness.

Discussion: The NICE Guidelines were found to be implemented in most cases admitted during working hours. A reluctance to perform CT scan was encountered during out of hours. A strict compliance with the guidelines would entail on average one additional CT scan every fortnight during the ‘out of hours’ period. Implementation of NICE Guidelines was found to tighten the net (justify CT scan) in order not to miss subtle early signs of potentially fatal head injuries.

Our study investigated a consecutive series of 53 cal-caneal fractures treated at Southend General Hospital during a 4 year period. In total 75% were intrarticular and 25% extrarticular. Overall 51.92% of patients underwent operative intervention 66.67% of these being intrarticular. All patients underwent AOFAS scoring. The minimum followup period was 6 months and the average was 18 months.

In the non-operative group (Undisplaced intra/extrarticular with Bohler’s angle 20–40 degrees) the < 50 year old group had an average AOFAS score of 86.3 versus 63.64 in the > 50 year old group.

In the operative group the AOFAS score was heavily dependent upon restoration of Bohler’s angle. This study shows that if Bohler’s angle is < 20 degrees the average AOFAS score after followup was 51.00 but if the angle has been restored to > 20 degrees the average score is 69.53. This result is reinforced by the fact that 75% of patients returned to work in the > 20 degree Bohler’s angle group wheras only 33.34% returned to work in the < 20 degree group.

This study shows that surgical restoration of Bohler’s angle to > 20 degrees gives a better outcome than for conservative treatment.

The aim of this study was to validate the use of three models of fracture fixation in the assessment of technical skills. We recruited 21 subjects (six experts, seven intermediates, and eight novices) to perform three procedures: application of a dynamic compression plate on a cadaver porcine model, insertion of an unreamed tibial intramedullary nail, and application of a forearm external fixator, both on synthetic bone models. The primary outcome measures were the Objective Structural Assessment of technical skills global rating scale on video recordings of the procedures which were scored by two independent expert observers, and the hand movements of the surgeons which were analysed using the Imperial College Surgical Assessment Device.

The video scores were significantly different for the three groups in all three procedures (p < 0.05), with excellent inter-rater reliability (α = 0.88). The novice and intermediate groups specifically were significantly different in their performance with dynamic compression plate and intramedullary nails (p < 0.05). Movement analysis distinguished between the three groups in the dynamic compression plate model, but a ceiling effect was demonstrated in the intramedullary nail and external fixator procedures, where intermediates and experts performed to comparable standards (p > 0.6). A total of 85% (18 of 21) of the subjects found the dynamic compression model and 57% (12 of 21) found all the models acceptable tools of assessment.

This study has validated a low-cost, high-fidelity porcine dynamic compression plate model using video rating scores for skills assessment and movement analysis. It has also demonstrated that Synbone models for the application of and intramedullary nail and an external fixator are less sensitive and should be improved for further assessment of surgical skills in trauma. The availability of valid objective tools of assessment of surgical skills allows further studies into improving methods of training.