Publications by authors named "Michael Stoddart"

11 Publications

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Early results from a single centre's experience with the STRYDE nail : a cause for concern?

Bone Joint J 2021 Jun;103-B(6):1168-1172

Limb Reconstruction Unit, Royal National Orthopaedic Hospital, Stanmore, UK.

Aims: The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device.

Methods: This is a retrospective review of prospective data collected on all patients treated in our institution using this implant. We report the demographics, nail accuracy, reliability, consolidation index, and cases where concerning clinical and radiological findings were encountered. There were 14 STRYDE nails implanted in nine patients (three male and six female) between June 2019 and September 2020. Mean age at surgery was 33 years (14 to 65). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies.

Results: At the time of reporting, eight patients (13 implants) had completed lengthening. Osteolysis and periosteal reaction at the junction of the telescopic nail was evident in nine implants. Five patients experienced localized pain and swelling. Macroscopic appearances following retrieval were consistent with corrosion at the telescopic junction. Tissue histology was consistent with effects of focal metallic wear debris.

Conclusion: From our early experience with this implant we have found the process of lengthening to be accurate and reliable with good regenerate formation and consolidation. Proposed advantages of early load bearing and the ability for bilateral lengthening are promising. We have, however, encountered concerning clinical and radiological findings in several patients. We have elected to discontinue its use to allow further investigation into the retrieved implants and patient outcomes from users internationally. Cite this article:  2021;103-B(6):1168-1172.
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http://dx.doi.org/10.1302/0301-620X.103B6.BJJ-2020-2165.R1DOI Listing
June 2021

Definitive fixation outcomes of open tibial shaft fractures: Systematic review and network meta-analysis.

J Orthop Trauma 2021 Mar 27. Epub 2021 Mar 27.

Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom. Department of Orthopaedic Surgery, The Royal National Orthopaedic Hospital, Stanmore, United Kingdom. Department of Orthopaedic Surgery, McMaster University, Ontario, Canada Department of Orthopaedic Surgery, Boston Medical Center, Boston, USA.

Objectives: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures.

Data Sources: MEDLINE, EMBASE, CENTRAL, OpenGrey.

Study Selection: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type.

Data Extraction: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics and follow up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing (RN), plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and GRADE systems were used for quality analysis.

Data Synthesis: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modelled direct and indirect data was conducted to provide precise estimates (relative risks (RR) and associated 95% confidence intervals (95% CI)).

Results: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43 - 1.05, p=0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared to EF was larger (RR 0.61, 95% CI 0.37 - 1.01, p=0.05, moderate confidence). UN had a lower reoperation risk compared to RN (RR 0.91, 95% CI 0.58 - 1.4, p=0.68, low confidence), however this was not significant and did not demonstrate a clear advantage.

Conclusion: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared to EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002090DOI Listing
March 2021

Acute Compartment Syndrome in Type IIIB Open Tibial Shaft Fractures Utilising a Two-Stage Orthoplastic Approach.

J Orthop Trauma 2021 Mar 22. Epub 2021 Mar 22.

Department of Trauma & Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. Department of Trauma & Orthopaedics, Stanmore Hospital, London, United Kingdom. Department of Trauma & Orthopaedics, Southmead Hospital, Bristol, United Kingdom Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom.

Objective: To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific two-stage orthoplastic protocol.

Design: Consecutive cohort study.Patients/Participants: Ninety-three (n =93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated utilizing a two-stage orthoplastic approach, between August 2015 and January 2018. Following exclusions, eighty-three (n=83) were eligible for analysis.

Intervention: Colloid resuscitation and two-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage one consists of "three-vessel view" early debridement and temporary internal fixation, with stage two consisting of a single-stage fix and flap.

Main Outcome Measurements: Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion and flap failure.

Results: Eighty-three (n = 83) patients were included for analysis. Median age was 45.4 years (Interquartile range (IQR) 35) with a median follow up of 1.6 years (IQR 0.8). Median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of zero (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, eighteen patients (18/83, 21.7%) experienced non-ischaemic arterial injury, five patients (5/83, 6.0%) experienced nonunion, with four patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (p=0.025) and nonunion (p<0.001).

Conclusions: Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a two-stage orthoplastic protocol, which includes early "three-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow up.

Level Of Evidence: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002129DOI Listing
March 2021

Is Research in Simulation as Accessible as Traditional Clinical Research? A Review of the 'Association for Simulated Practice in Healthcare' Conference.

Cureus 2020 Aug 17;12(8):e9798. Epub 2020 Aug 17.

Paediatric Orthopaedics, Royal National Orthopaedic Hospital Stanmore, London, GBR.

Background Meta-analysis of simulation teaching has shown to be an effective teaching methodology. The Association for Simulated Practice in Healthcare (ASPIH) annual international, multidisciplinary conference is recognised as the leading UK meeting for simulation-based education. We hypothesise that simulation-based research presented at this conference is currently less accessible than more traditional clinical research presentations. Method We reviewed the abstracts of all research presented at the 5 ASPIH Conference, 2014 and then utilised the Bhandari methodology to assess whether an abstract had subsequently been published in a peer review journal. Our secondary aim was to assess for recurring themes that may predict publication. Results Twenty-seven of 197 (14%) abstracts presented at the 2014 meeting were subsequently published. The mean lead time to publication from the conference was 23 (2 - 61) months. Two positive predictive factors for publication were oral presentations (vs poster), and a Kirkpatrick level above 1. Conclusion The publication rate for abstracts from respected clinical conferences is 30%, but the publication rate for ASPIH abstracts is significantly below this. The potential reasons for this may include a lack of simulation specific journals. Authors should aim to publish simulation-based research in peer reviewed publications to help progress the role and the value of simulation in medical education.
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http://dx.doi.org/10.7759/cureus.9798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494415PMC
August 2020

Proximal Humerus Fractures: Reliability of Neer Versus AO Classification on Plain Radiographs and Computed Tomography.

Cureus 2020 Jun 9;12(6):e8520. Epub 2020 Jun 9.

Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, GBR.

Introduction: Several classifications for proximal humeral fractures exist, with excellent reliability and reproducibility of such classifications being a desirable feature. Despite their widespread use, these systems are variable in both reliability and accuracy. We aimed to, a) assess and compare the reliability of the Neer (complete and abbreviated versions) and Arbeitsgemeinschaft für Osteosynthesefragenbeing (AO) classifications, and b) identify if computed tomography (CT) made any difference to the reliability of Neer and AO classifications when compared to plain radiographs alone.  Materials and methods: This is a single-centre retrospective study identifying all proximal humeral fractures presenting between February 2016 and February 2017 as a result of trauma that subsequently proceeded to CT. Two specialty orthopaedic trainees analysed the plain radiographs as well as CT images over two rounds, spaced two weeks apart. The Neer 16-grade, abbreviated Neer 6-grade and AO classifications were used. Intra- and inter-observer reliability of each classification system was assessed using the Kappa coefficient.  Results: Twenty-two patients were included. The mean age was 62 years (SD 14.5). Management changed in 9/22 patients based on CT. Computed tomography changed Neer-16 type in 16% observations, Neer-6 in 10%, and AO in 23%. This was significant when comparing Neer-6 and AO classifications (p = 0.04). Neer-6 had the best inter-observer reliability (0.737) with the management of one patient changing after CT. On X-ray and CT, intra-observer agreement was substantial, >0.7, using Neer-16 and Neer-6 (p<0.005). Inter-observer agreement for Neer-16 and Neer-6 was substantial, >0.7 (p<0.005). In comparison, intra- and inter-observer agreements for AO were lower on X-ray and CT, 0.4-0.6, (p<0.005).

Conclusion: Our study shows that simplicity is key with a high degree of reliability in the abbreviated Neer classification. Computed tomography allowed greater reliability than radiographs in classifying fractures, affecting management decisions in 41% of patients. The comprehensive Neer classification showed similar intra- and inter-observer reliabilities to AO.
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http://dx.doi.org/10.7759/cureus.8520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346293PMC
June 2020

Plate-Assisted Intramedullary Nailing of Gustilo Type IIIB Open Tibial Diaphyseal Fractures: Does Adjunctive Plate Retention Affect Complication Rate?

J Orthop Trauma 2020 Jul;34(7):363-369

Departments of Orthopaedic Surgery; and.

Objectives: To investigate the complication rates after use of retained adjunctive plate (RAP) fixation with intramedullary nailing of Gustilo-Anderson type IIIB open tibia fractures, as part of a 2-stage orthoplastic approach.

Design: Consecutive cohort study.

Patients/participants: One hundred and thirty-seven consecutive patients with a Gustilo-Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) treated between May 2014 and January 2018. Ninety-eight patients (RAP = 67; non-RAP = 31) met the inclusion criteria and underwent 2-stage reconstruction. All patients were treated using a small fragment adjunctive plate to hold the fracture reduced before intramedullary nailing.

Intervention: At stage 2, the temporary small fragment (in-fix) plate was removed and the site further thoroughly debrided. After this, the fracture is reduced and held with a new small fragment plate to facilitate the definitive intramedullary nailing. This new plate was either retained (RAP) as part of the definitive fixation at second stage or removed before wound coverage.

Main Outcome Measurement: The main outcome measures were reoperation rate, deep infection, nonunion, and flap-related complication.

Results: Six patients (6/98, 6.1%) proceeded to nonunion (RAP 5/67, non-RAP 1/31). This was not significant (P = 0.416). Two hundred twelve operations were undertaken, and the median was 2. Sixteen (16/212, 7.5%) complication-related reoperations were undertaken, affecting 8 patients (8/67, 11.9%) in the RAP group. Eight patients (8/98, 8.2%) developed a deep infection (RAP 6/67, non-RAP 2/31). This was not significant (P = 0.674).

Conclusions: In the context of an orthoplastic approach, the use of a RAP with definitive intramedullary nailing does not seem to significantly increase the rate of deep infection or nonunion in patients with type IIIB open tibial shaft fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001738DOI Listing
July 2020

Introducing a post-operative proforma for elective lower limb arthroplasty patients - improving patient care and junior doctor confidence.

BMJ Qual Improv Rep 2017 8;6(1):e000043. Epub 2017 Jun 8.

Royal United Hospital Bath.

The assessment of post-operative patients is vital to identify early complications and ensure patient safety. Good clinical record keeping is essential for effective continuity of care and patient safety in the post-operative period. A group of foundation year 2 (FY2) doctors noted a disparity in levels of confidence and ability in performing this assessment. The aim of the project was to improve documentation and understanding of day one lower limb arthroplasty reviews by FY2 doctors. The Plan-Do-Study-Act model for continuous improvement was adopted from September 2015 to July 2016. A composite score comprising the twelve most important review parameters for documentation was used to score the quality of documentation on an ongoing basis. An electronic survey was completed by every FY2 rotating through the department. Interventions included registrar-led teaching sessions and an integrated review form placed in the medical notes. Further iterations of the proforma and further interventions were coordinated with the ward clerks, sisters, physiotherapists and senior clinicians. The baseline mean composite score was 6.3/12. Following implementation of a standardised proforma this score improved to 10.5 in those who had used the proforma, but 5.7 in those who hadn't. Electronic survey responses showed the proforma and teaching were effective in improving knowledge and understanding of post-operative reviews. The use of an integrated proforma in the medical notes and teaching it's use at induction, improves the documentation and understanding of day one post-operative reviews. Coordinating ward-based change across a cohort of FY2s, with involvement from the multidisciplinary team and management, affects sustained improvements in patient reviews.
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http://dx.doi.org/10.1136/bmjquality-2017-000043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5492475PMC
June 2017

Does involvement in clinical trials make trainees better surgeons?

BMJ 2015 May 26;350:h2774. Epub 2015 May 26.

Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.

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http://dx.doi.org/10.1136/bmj.h2774DOI Listing
May 2015

Involvement of medical students and junior doctors in research.

BMJ 2015 Jan 20;350:h283. Epub 2015 Jan 20.

Royal United Hospital, Bath BA1 3NG, UK

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http://dx.doi.org/10.1136/bmj.h283DOI Listing
January 2015

Congenital amegakaryocytic thrombocytopenia (CAMT) presenting as severe pancytopenia in the first month of life.

Pediatr Blood Cancer 2013 Sep 26;60(9):E94-6. Epub 2013 Apr 26.

Imperial College School of Medicine, London, UK.

Congenital amegakaryocytic thrombocytopenia (CAMT) is characterised by neonatal thrombocytopenia, with reduced or absent bone marrow megakaryocytes, leading eventually to pancytopenia. The mean age for progression to bone marrow failure is four years, with the earliest reported being six months. We describe a CAMT patient with compound heterozygous mutations of the causative MPL gene (one being a previously unreported splice site mutation in intron 11) who developed pancytopenia within the first month of life. This report emphasises the importance of considering CAMT in the differential diagnosis of congenital aplastic anaemia or idiopathic aplastic anaemia in babies.
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http://dx.doi.org/10.1002/pbc.24566DOI Listing
September 2013

Effect of the odour of weasels (Mustela nivalis L.) on trapped samples of their prey.

Oecologia 1976 Dec;22(4):439-441

Department of Zoology, University of London King's College, Strand, London.

The presence of weasel anal gland secretion on rodent live traps substantially depresses population estimate by greatly reducing the catch of Microtus agrestis. The catch of Apodemus sylvaticus remains almost unaffected.
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http://dx.doi.org/10.1007/BF00345320DOI Listing
December 1976
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