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Yeah, good evening, er, friends, colleagues and anyone else that happens to have straight into the presentation and welcome to this evening's uh BOFA Virtual Journal Club, which is entitled Weights and Extraneous Measures Issues on the perioperative management of ankle fractures. We'll have a slight deviation from our normal uh presentation start tonight. Uh There will be two halves. Still, the first half will consist of discussion of uh Chris Brotherton S Wax trial from the Lancet um earlier this year, which will be presented uh by uh see your fellow Alex Bare. Then we'll have a, a reflection from uh Chris Brotherton and then take questions from the virtual floor. So please do uh add your questions to the chat. The second half will be slightly different in that there are essentially two papers, one from Mohamed Farhan Ali's unit discussing, discussing the use of the tourniquet in um ankle fractures and a second paper on the same topic from Matt Costa also on the use of tourniquets that will be chaired by my Cohost Nigel Vesti. Again, we'll have a presentation summarizing the two papers and then we'll have reflection by the two senior authors and finally, questions from the floor, we should be able to wrap up um in an hour's time about nine o'clock. Uh Before we begin, I'd of course like to thank very much uh the two fellows who have prepared the presentations, um Zander Beer and also Pfizer and Arshad. Um and also the senior authors who've taken the trouble to join us this evening. Uh Chris Breton, Mohammad Farhan, Alani and Matt Costa. I'd also like to thank Karen Malhotra, who as usual is uh holding the reins and keeping the I TT us all over. So, um uh one of house housekeeping announcement that by the way, which is that to uh obtain your uh certificates and feedback forms will be a link posted in the chat. So please complete that and it sure will happen quite swiftly for you. So, without further ado, um uh we'll move on to the first paper which, er, is written or the senior author is uh Chris Brotherton, who undertook his academic, er, training amongst the Dreaming Spies of Oxford and then transplanted himself to, er, Queen Mary's and er, the London in the east end of London where the spir are perhaps not quite as dreamy as in Oxford, but I'm sure it's a wonderful and gritty place to do trauma. Um Chris, er, is, er, a senior lecturer in Trauma or Phoenix and he has a particular interest interest in multicentre audit, randomized controlled trials and priority setting partnerships or So he tells me um you probably may know him as the past voter academic representative um a post which he denies getting because he could drink everyone else under the table. Um And he is the current Royal College of Surgeons B OA Associate Surgical specialty Lead for adult trauma. Um He tells me that he spends a lot of time hanging out at hashtag uh collaboration. Um Apparently this has nothing to do with occupied France and the vichy regime but rather to do with academic studies. So, um moving on, thank you, Chris. And I'd like to have the first presentation please from er Zan de Beer on early versus delayed weight bearing following um operative treatment of ankle fractures, the wax study. Thank you. Good evening. Um My name is Alexander Beer. I'm an orthopedic registrar with an interest in foot and ankle surgery. I'm currently working in leeds, teaching hospitals as part of the Yorkshire rotation. I'd like to thank both us for inviting me to present a journal this evening. And the journal I am presenting is the following one. It's early versus delayed weight bearing, following operatively treated ankle fractures. Um The wax study, it was a non inferiority, multicentre randomized controlled trial. The study was published in the Lancet in June 2024. And the first author Christopher Breton and senior author, Professor Griffin are associated with Queen Mary's University Bone and Joint Health and the Royal London Hospital part of NHS uh Barts trust the background of the study is that ankle fractures are very common, as we know has approximately 190 ankle fractures a day in the UK, most of which are treated non surgically, but those that are treated surgically, there's a lack of consensus on postoperative weight bearing restriction. Historically, surgeons would restrict the patient for six weeks due to fear of loss of position and malunion. But there is a growing trend towards early mobilization at two weeks. Possibly, this could reduce blood clots. It may improve functional outcomes. But there is currently a lack of evidence behind this. The existing evidence that we do have consists of a Cochrane review in 2010 which reported that there was insufficient evidence to support or guide weight bearing. The literature review performed as part of this study demonstrated that um there are some more recent studies which demonstrate favoring early weight bearing. Um but there was a small sample size and these studies had limited design. There was no large randomized controlled trials, nice concluded that the current evidence had a high risk of bias and was insufficient to guide clinical decision making. So the aim of this study was to determine the clinical and cost effectiveness of early weight bearing at two weeks postoperatively compared with delayed weightbearing at six weeks postoperatively for adults after ankle fracture surgery. The methodology of the study. So the wax trial was a pragmatic non inferiority, Multicenter randomized controlled trial um across 23 UK hospitals. It was conducted by the Oxford uh clinical Trials Unit. And in order to be included in the study, you had to be 18 years or older, you had to have your surgery within two weeks of your injury. And they intentionally included more complex injuries such as fractures, osteoporotic fractures and syndesmotic injuries to try and make it applicable to a broader range of patients. The exclusion criteria included being treated with a hind foot nail, having sensory loss or neuropathy, being unable to consent or if your surgeon gave strict non weight bearing instructions. Patients were randomized into two groups, early weight bearing, delayed weight bearing using computer randomization. The study was not blinded as both patient and clinician needed to know when the patient needed weight bearing. In the early group. At two weeks, the patient was changed either into a weight bearing cast or into a walking boot depending on the unit's preference. And in the delayed weightbearing group, they were not weight bearing until six weeks. Postoperatively. They were very specific on their patient instructions and the patients were well supported. They all had a information leaflet. Um They all got weekly emails and text messages to give them advice on when to start weight bearing. And all the units were sent a voice recorder to try and record the patient instructions in clinic to make sure this was done universally from one unit to another outcomes. So the primary outcome measure was the A score, which is the ood and Molander ankle score. It's a validated and reliable from scoring foot and ankle surgery and the minimal clinical difference, which um is thought to be significant is a score of 10 between the groups that's uh for reference about the difference of a patient needing a crutch or not needing a crutch. The secondary outcomes were the quality of life score, EQ five D and the return to work score WPA I. In terms of statistics, they looked at the largest study which had used the MR score to help them determine the following. And the standard deviation of 21.1 was used in an inferiority, margin of minus six was chosen. Uh They did a power calculation and sample size and it was determined they needed 436 patients and they also looked at significance and determined a cut off of 5% in patient recruitment. So 228 patients were screened for eligibility and around about 1400 were initially excluded. 100 and 64 had not had surgery within two weeks. And the largest group 938 were excluded because the surgeon had strictly said they had to be non weight bearing. 315 patients weren't able to consent in terms of results. 561 patients were therefore recruited and 280 in the early weight bearing 281 in delayed weight bearing, they had a median age of 50 64% were female and the other baseline characteristics were very similar. The primary outcome oa score at six weeks and four months in early weight bearing group was statistically significantly better. 4.42 points higher um with AP score of nt point naught six. However, at 12 months, there was no significant difference between the groups. It's important to know this is below the minimally clinically important difference, which is sort of be 10, the complication rates were similar between groups 16% in the early weight bearing, 14% in late weight bearing. Um and we'll go into that in slightly more detail in a second and the 12 month mean cost to the NHS. So they did a cost analysis. It was 725 lbs in early weight bearing and 785 in delayed weight bearing cost saving of 60 lbs. Therefore, and societal costing taking into account work losses um saved 2 722 lbs in the early weight bearing group have had broad competence intervals again, as I mentioned, looking slightly more into complications. Whilst there was no significant difference statistically between the two groups. There were slightly more surgical site infections, 15 versus 12 in early weight bearing, seven in early weight bearing versus five in delayed of wound decent. And four felt fixations in early weight bearing versus only one in delayed weight bearing. However, none of the patients in the early weight bearing got complex regional pain syndrome and four patients in delayed weight bearing got a complex regional pain syndrome. In conclusion, this study found that early weight bearing was not inferior to delayed weightbearing concerning their primary outcome. The A score, they had similar complication rates between the two groups which were not statistically different. And early weight bearing was more cost effective um than delayed weight bearing, which is also a significant finding. Early weight bearing is therefore a viable and potentially preferable strategy to delay weight bearing, analyzing the strengths and limitations. So I think the main strengths of this of this trial was that they had very large numbers of patients almost double that of previous studies. They, it was a very robust study design which was well considered well carried out. It being a randomized controlled trial. It included a wide range of patients. 28% of the patients were over 60 25% were trimalleolar, 30% needed syndesmosis fixation. So it clearly included a broad heterogeneous group of these patients both complex and simple, which may probably reflect what we're seeing in our clinics and therefore makes this easily applicable to most of our daily practice in terms of limitations. I think the main one is that 42% of the patients on 938 were excluded due to surge and weight bearing instructions. It's probably because they felt that the fixation was not stable. They were at risk of losing position and malunion that obviously limits how much we can apply this study broad brush to all of our patients. In that case, 14% of patients, there was a 14% attrition rate in primary outcome and only nine of the 23 centers recorded audio instructions to patients and returned them to the study. Um I think it probably would be better to have a longer follow up to look at degenerative changes in the long term rate of arthritis, et cetera and in the delayed weightbearing group, um 32% of patients about a third didn't follow the instructions and started weight bearing earlier. Uh within three weeks, postoperatively, the rebuttal to this in the paper, which I think is valid is that we can't control what patients do, we can only control what we tell them. And this study is doing a comparison of patient instructions. So if we tell them to that or not. Um So yeah, I think, I think that's a reasonable argument against this. So in conclusion, the wax trial is a well conducted study which has useful implications for clinical practice. While there are some limitations, the findings provide evidence that could shift the standard of care towards early weight bearing after ankle fracture surgery. Many thanks for listening to this presentation. I hope it provided a useful summary and thanks again for both fast for asking me to present this paper today. Ok. Well, thanks um Zander for a very concise summary of the paper. Um So be before I invite Chris to start to reflect it with, with us. I just remind everyone that you're more than welcome to submit questions uh to the senior authors. Uh There is no question. Too foolish. We're all friends here. Well, more or less. Um and do please put them on the chart if you have anything you wish to uh put to our, our senior panel. Um So Chris uh clearly a mighty piece of work on a very important topic. Um I, I'd like to share your thoughts on it with us first. Um So you have the floor, please. Things you felt were good about the study, things you might have done differently and of course your general thoughts on the message, although I think we probably all know what your thoughts on the message are, but please reflect now for us. Thank you. Hi. Yeah, thanks very much so. Yeah, thanks very much for um uh presenting that. That was nice to hear someone else, er, talk about it for once. Um And I think you've got all the sort of key key points there and messages, um the limitations and, and the strengths um obviously the strengths of the, it's a sort of big randomized clinical trial in 20 three. Centers, which is, you know, many more than any other sort of study in this, in this area, uh had the very few exclusion criterias. Um, and that really comes into also the limitation that, uh that was discussed in terms of, um, these and that's what the, the question that always comes up in that little screening diagram. Um, there were a high proportion of patients that were not included because they, um, well, because surgeons said, ah, you know what, ii don't want to put this patient in the trial because I just, uh, you know, I'm just not sure that they should be any weight bearing. Um, and the reality is that when we looked at, um, the number of sites that sort of went in, you, you generally had to pattern, you, you, you had a pattern in hospitals where every surgeon was supposed to put every single patient into the trial. Um, and then there was another pattern where basically there was one out of 10 consultants in that hospital that was interested in the trial and wanted to put patients in. And basically, yeah, 1 to 10% of those patients went in. So, um, that's really what explains that sort of screening diagram. But what, what I sort of say to people is that in terms of who actually went in the trial in the end, um, it was very reflected in the UK population in terms of the age, the, the demographics. The, you know, the type of fractures, the placenta were trimalleolar, the place that were. So, in terms of how it, in, in, in involves my practice, I'm pretty happy that I'm like, yeah, that all, all, all works for me. Um, perhaps the patients in this to our were slight, were slightly younger. The mean age was, er, this was 48 compared to 50 in a, um, in a normal UK population. Um, and so I think, yeah, it's all good for my, for my regular practice and the default throughout years, if you're fixing an ankle and you're, you're pretty happy with it, then, um, let them weight bear. Um, so that's the sort of message that I'd, I'd take home and then you then have to look at those complication rates. And again, this is something that I look at, um, there was a slightly higher risk of wound problems and the need for sort of revision surgery by a one or 2%. Um, and that wasn't anywhere needed being specifically significant but, you know, it's, it's still something that you've got to think about. And, um, yeah, what I would encourage you to do. So just yesterday we actually did a, an, an update for the core systematic review, um, on this topic and that was published yesterday and if you want to go through and have a look, um, there's a, there's a table in there that looks at all the complications in all the pooled studies of ankle fractures, basically all the studies in that review say your ankle fracture is good is fine, gives you better function or non non inferior function. Um But it, it just shows you the complications and um actually, yeah, the other tr in many other trials they favor um not uh they, they non weight bearing gave you more operations. Um So yeah, that, that, that was my other reflection and I guess the other reflection is, yeah, what would you do differently in the trial? And I think um I'm not sure there is a great deal. We do. You do differently? I've mentioned about that exclusion criteria. Why it was pragmatic and why I think that was important and why that still worked. And the other thing is about those patients that didn't follow their instructions um and were non compliant to their delayed weight bearing ie they started weight bearing sooner than we told them to. And I don, I can't really think if there's a way around that we did explore sort of doing sen putting sensors in shoes. We couldn't really do that at the time. Maybe that's possible now. Um But what do you, what do you get them if you then find that patients were the sensor show, they were weight bearing when they said they weren't. How do you analyze that? Do you are those protocol? The aviation? How do you, how do you, how do you find compliance. So, I don't think you, I don't think that really changes it. Uh, the only thing is whether you can give them a little electric shock if they start to weight, bear to stop the weight bearing. But that might have some ethical issues. So, yeah, I think, I think, you know, happy with the, how the study went and, um, yeah, I'm looking forward to sort of seeing if you've got any other questions or thoughts, um, about how about the study or how you might apply it to your practice. Chris? Thank you very much for sharing that. Um, um, uh, slightly facetiously. I am tempted to suspect that nowadays you can probably monitor who's weight bearing, who isn't with some sort of app. Um, if you can have an app in Kiev that tells you where the mass are gonna strike and where they're gonna come on your phone, then I suppose weight bearing patients is, is small bit. Um, but I entirely accept the, the very pragmatic nature of your study at the end of the day, none of us know really whether our patients weight bear or not unless you study the underside of the boot or, or something like that. And even that's, that's a bit dubious. So I think that's a very reasonable pragmatic approach to a common problem we all face. Um, there's one question I have from Janis Pacris, um, which you've sort of half addressed. Um, how can we put all operated ankle fractures in the same bag and draw a recommendation for early weight bearing at two weeks. POSTOP. Only the surgeon knows how happy he is with his fixation and confidence of early weight bear. Yeah. So I think you've um, II, think what, II, think since this, I published this study and came back, I probably fixed, er, about 12 ankles and, yeah, one of them, I didn't let them early weight bear cos I was worried. And, er, so that, that's just how it is. So, I mean, and, and so the way I'm interpreting it is and the way about the people that I've talked to the, the surgeons that put patients into this trial, um, it was people that, you know, you fix them and, and you're happy and the bones come together, not necessarily every screw is holding fantastically, but, um, you know, things fit together, they don't seem to be moving around. You're not sort of, you haven't gone at a four hour tourniquet time trying to, trying to fix stomach, all sorts of stuff. So, and, and again, the same in when we've had, when we did the system matter with you when we looked at the previous papers. Ultimately, it's a patient, a, a surgeon, uh, an ankle that you've taken from being unstable to stable and you're pretty happy with it. Um, is, is what I think this, this reflects to when you actually look cos although we did include patients with open fractures and whatnot. It was only about four patients in of the whole study that actually had open fractures. Right. Um, quite a few, quite a high proportion. I think it was about 40. I had X pictures before. So there were still these high energy ones. But, um, yeah, ultimately it's, er, if you've got a patient that you, you're happy with then, um, then weight bearer them in, in the patient where, you know, you're not happy, then I'm not sure I can necessarily, um, uh, yeah, like I say, II still love weight, bear some people if I'm just not happy pfizer, is it, is it fair to summarize the message of the paper as the, in those patients who you think it is a reasonable prospect to, to bear weight early, uh, that group will do as well or perhaps better with early weight bearing than in the ones you are particularly worried about for whatever reason. Yeah. Yeah. I mean, the assumption is, um, that you is that they do better, um, and they do slightly better and if you look at the, er, I haven't spoke to a statistician about this so I might get in trouble but I think the sort of intention to treat for it. So they're having like an unplanned return to theater or something like the number needed to treat was, er, 50. So basically you're, if you're gonna deny 50 patients slightly better, you know, function and generally better convenience to save you one reoperation. Um, is that right for me? Me? Probably not for me. Maybe what, what my number would be like? Maybe one in 20. Um, but in one in 50 I need to treat, you know, it wouldn't be, wouldn't be justified for me. Ok. Fine, thank you. Um, I have a question from, um, Mr Beer, whose presentation we just heard. um, if there is a wound issue at two weeks, would you then delay weight bearing until the wound is healed or do you crack on regardless? Uh, so this is, so I can't tell you from the, um, study. Um, I can't give you any evidence from this paper really um, about that because we didn't really look into that. Um, but if I look at my own work, um, not my own work if I look at other people's work, but I did do a systematic review as part of my phd, er, looking at um, some other papers and it will go to sort of Matt's asked a question about the systematic review for orthotics and casts as well. Um, so I'll, I'll mention that while I'm there in the same, same package. So, um, the systematic review shows that, um, sorry, the Cockran review shows um, a cast versus a boot, um, a boot is just fine and you get slightly slightly better function. Um, if you put people in boots but two weeks after their ankle fractures fixed, um, and you don't seem to get any increase in complications. So that's the sort of message from the, um, from the cockran you to, to sort of put that one to A b basically, if you're happy enough to pay, if you're happy enough of the fix, put them in a boo and get a money weight, be, um, again, now you, now you've got issues right? So, now you've got concerns about the wound or you're concerned about the fixation. So I did a sort of in depth analysis of, um, one of, of the main paper that looked at cast versus boots and when I sort of actually split up some of the complications, I actually found there was, there really was quite a, a higher risk of wound complications in patients, um, that had, had surgery in the trial that compared boots versus plasters. Um, so for me, based on the evidence I've had, I've looked at, I would be more inclined to sort of stop them moving. I might say. So, basically, what I'm saying is I think that early movement w if you've got a wound issue is probably, um, more harmful than, er, early weight bearing. Um, so, but yeah, so what, what I'd do is I'd, I'd, I'd, I'd probably restrict them if they had a wound issue, I'd, I'd strict, I'd restrict them moving the ankle. Er, but I'd probably let them better would be my my opinion, but it's not it it's only loosely evidence based that. Ok, thank you. Um Another question from Sugar Shaka. I thought um was there a correlation between the severity of the fracture and the complications of wound healing, stroke, infection in the early weight bearing group? Um No. Uh no, I don't. The answer is, I don't know. I don't, yeah, I don't know. I haven't looked at that. Um we looked at um, yeah, we looked at different types of fractures and severity of fracture and whether that changed the result or it didn't. But no, not that specific one. Correlation. I'm afraid. Sorry. Ok. No problem at all. Thank you for, for your honesty. Um One question, uh it's very interesting that the, the large exclusion group, the 980 odd that were excluded by surgeon instruction. I was very curious to hear your comment that that was essentially unit based or perhaps cultural rather than correlating to fracture particularly. Um I suppose that begs the question, doesn't it? Which is, should you be out there banging the drum? Um, even more for this. Um And secondarily would it be worth exploring with those surgeons? What why they made those decisions? What their preference was? Why it could vary so much between hospital A and hospital B? Mm. Oh, well, there is a paper I hopefully being published very soon on that. So I'll er, I'll make sure I tweet that. Oh, so, yeah, we did do interviews with, uh, with these surgeons and healthcare professionals and um, a lot of the, the issues were um, 01 of the issues when I interviewed those people, often, they were like advocates of early weight bearing, they were the early weight bearing champions. Er, but some of them that weren't some of the surgeons um, had, you know, medical legal issues, medical legal concerns again, just culture issues about, oh, yeah, there's been a problem. Um, you, you know, you fixed it, it was only weight bearing, there was a problem. You're the only one in our unit that does that. Oh, you're an idiot. Um, so that, that, that's the, that's the main reason really. So, um, and it's all about, ii mean, in this paper we also discuss about how, how, what actually changes people's opinions, um, and their views. So if it is medical legal concerns for instance, and, and that cultural issue, you've now got a randomized controlled trial published in the Lancet that tells you it's fine. You've got a cockran review just come out that says you, it's fine. So, you know, if you're standing up in court you've got some good, er, you know, I'll come and say I'll come and protect you but now, you know, you've got some, er, good papers now to say, hey, look, these are the b good papers in the best journals saying this is safe. Um, and then. Um, yeah, maybe a bit more drum banging. Thanks. Well, I mean, what changes people's opinion in practice is obviously the BFAs Virtual Journal Club. I mean, what, what else would, would one go back to, um, on that subject? Uh I suppose really what you say is we, we react as we all know as much to our own experience rather than to logic and, and, and evidence. But, um, one question about the study, if you had time again, would you run it with a longer follow up or would it be worth a 12 month follow up? Do you think the difference of early weight bearing will, will show a difference at 12 months? I am asking you to speculate, I suppose. But, yeah, well, I'll give, I'll give you the truthful answer first and then the w answer, the truthful answer is no, because we got it into the specific small funding pot which only let us do 12 months follow up. And, er, had we gone for a bigger funder, we probably wouldn't have done it and we'd never have got the results. So that's the answer. That's the truthful answer. And then the more speculative answer is, um, uh, yes. You know, it, it, it's good to sort of, um, it would be great to know that, you know, two or five year follow ups. We have, we have, we are harvesting X rays which has taken a hugely long time and we were all looking, be looking to see if there is any suggestion. Um, we've got x rays up to one year, um, whether there's any early signs of arthritis in any, in, in either group. Um, so, yeah, it would be great to have another follow up. And I think, er, Ska's, um, TSSA has mentioned something about if there's no difference at 12 months. Does it really matter when weight bearing is started? So, I guess you could say. Um, no, but ii, it, it's just about, you know, patient convenience if nonetheless cos all these scores we measure at sort of six or 44 months even if they are different. But you, you just realize and I did lots of qualitative interviews and it's just a nightmare hopping around on crutches, um, injection yourself with extra doubt of power. And, um, people, yeah, people can get really, really a couple of patients got really seriously depressed being, being non weight bearing. So if it's just for your, if it's just for that, I say one in 50 patients that you might think get a problem, I don't think it's, it's, it's justifiable to make people non weight bearing where it can be a real misery. Chris, thank you very much. Um, I'm afraid it's time that we, um, er, draw the first half of the evening to a close, um, the, um, b before I hand over to my colleague, Nigel Vascu to chair the, er, second half. Um There's a very poignant personal point made by Matt Costo who tells us that from his own personal experience, he's deeply scarred by being non weight bearing. Uh, it's utterly miserable. Um, and also more than a more you, you can't carry more than one pint, which is obviously life changing and crippling. Er, Matt. We will be offering counseling for this after the session vigil. Thank you very much. Please take over the second half. Thank you. Um Thank you James and uh thank you speakers. Um Thanks Karen again for running the show. Uh Now, uh we move on to another topical perioperative issue that is the use of tunica in uh lower limb trauma surgery. So there, there has been a lot of discussion and papers around the unica u use of tunica for knee replacement. Now, we are looking at the use of tunicate in lower limb trauma surgery. So we are discussing a systematic review uh from Mohammad Farhan, Alani. Uh This is from the European Journal of orthopedic surgery and trauma. So, it's titled Risk Associated With the Tunica Use in low and trauma Surgery. So this is being presented by uh mrfit. After this, we'll also discuss uh math costs annotation in the B JJ uh from 2021 around the same topic just briefly about our uh two guest authors. Uh uh Professor Matt Cost does not need any introduction. He is a professor of orthopedic trauma at University of Oxford and the honorary consultant, trauma surgeon. Um He's more known for as being the chief investigator for a lot of national trials, National LCD S and his special interest is the cost effectiveness of uh M SK trauma interventions. Our uh first of for the systematic review is uh Mohamed who's a orthopedic register on the rotation and he is a NIH funded phd candidate with his uh main interest around the use of T. So I'll hand you over to our uh presenter pfizer. Um And thank you to BOFA for giving me an opportunity to present at the virtual G club this September. Uh My name is Faan and I'm currently ST six registrar in the foot and ankle rotation at uh University Hospitals Birmingham. This evening, I'm going to be talking about Tonique use in ankle fracture fixation. Uh In this presentation, I will review and summarize two key articles. The first is an editorial published in the bone and John Journal Journal in 2021 led by Matt Costa. Uh This article provides a narrative review of the available literature on the use of tourniquets as well as findings from a survey that reflects current low limb trauma practices within the UK. The second article is a systematic review and meta analysis published in 2021. Um It reports the findings of six randomized controlled files and analyzes some of the outcomes um from these studies. The first author in both these papers is of course my friend and colleague from uh the commentary works uh rotation Mo Alani um Alex Tretter uh is also an author on both these papers. Uh We will focus on the editorial first. So tourniquets have a long history uh dating back to over 2000 years when they were used in amputations, often just bands of cloth tied around the thigh. Uh Today we use thigh tourniquets in surgeries like ankle fracture fixation for several reasons, we justify the use because we claim that they help us limit intraoperative blood loss, improve the surgeons view of the operating field and that they can shorten uh surgical time. But has the use of tourniquets become so ingrained in our surgical culture that we continue to use them simply because it's what we've always done. As Mark Twain famously said, the less there is to justify a traditional custom, the harder it is to get rid of it. Uh In 2020 a survey was conducted among uh 77 surgeons at the Orthopedic Trauma Society Conference. And the results provide some insight into the current practices in the UK. Uh According to the survey, 78% of the respondents preferred to use a tourniquet during these procedures in um low limb fracture fixation surgery. Uh The most common reason uh were to reduce blood loss in 65% of surgeons and to improve visualization of structures. Um In 32% of surgeons. However, while the survey gives us some interesting data, it's important to recognize its limitations. For one, we don't have information on the level or grade of the surgeons who participated. Uh we don't uh know whether they were trauma surgeons or specialists in for an surgery. Also, there's no clarity on the surgical settings. Um These surgeons, these surgeons were working in which could have an effect on their preferences. Another critical point is that the survey doesn't specify how the questions were framed. So this could potentially skew the results. Um In the article M Elani and Mister Costa explore uh the known effects and concerns that are surrounding the use of tourniquets during the surgery. While tourniquets um are widely used. Studies have shown that they come with significant risks. These include an increased likelihood of postoperative postoperative pain as well as skin injuries, venous thromboembolism, neurovascular injuries and infection. Additionally, tourniquet use has been associated with poorer functional outcomes and longer hospital stays. Um A major concern is uh the reperfusion injury that can occur when Toni is deflated at the end of surgery. Um the sudden return of blood flow can lead to swelling and increased the risk of complications like compartment syndrome. Um beyond the local effects, there are systemic concerns as well. Um such as change in heart rate, BP and even increased uh intracranial pressure which may cause microemboli in the brain. Uh The article also exposes uh explores the current RCT evidence in detail. Uh but this is explored more extensively and systematic systematically in the systematic review uh which takes us very, very nicely onto the second paper. Um This systematic review and meta analysis has updated on the previous reviews and expanded on it by comparing patient centered surgical and biochemical outcomes between surgeries performed with or without tourniquets. So um this is an overview of the methodology used in the um paper. So the authors a adhere to Prisma guidelines and they performed a comprehensive uh database search including multiple databases from up up to October 2020. Um This was supplemented by manual searches of uh bibliography, bibliographies um uh of the selected articles to identify any additional studies. Uh Only those RCD S were included that compared tourniquet used no tourniquet, um placebo or alternative methods like uh tonic stomach acid uh administration conference subtracts. Um Animal studies and Non English papers without accessible translations were excluded. Data extraction was done independently by two authors using standardized form and the quality of studies was assessed using the Cochrane risk of bias tool. Version two for statistical analysis, uh continuous outcomes were reported as mean differences and binary outcomes as risk for issues. Uh using the random effects meta analysis with rev 5.3 uh heterogenicity uh was assessed using the Higgins I square test and for outcomes where statis statistical analysis wasn't feasible. Uh They provided a narrative discussion instead. Yeah. Um This study is the most comprehensive meta analysis um comparing lower limb fracture surgery with and without a tourniquet. However, the quality of evidence is notably low with all randomized controlled trials judged as having a high risk of bias in at least two key areas such as lacking blinding for patients and surgeons. Additionally, the sample sizes uh limit the strength of findings. Importantly, there's no statistically significant differences in postoperative pain, wound complications or reoperation rates between the two groups. However, uh patient who had uh patients who had surgery without a tourniquet returned to full time work quicker, which could have a meaningful meaningful implication. One notable result was that using a Tonique tourniquet reduced uh surgical time by about six minutes. This um may reflect an improve surgical field of view. However, uh Tonique use was associated with greater ankle swelling for up to six weeks. Postoperatively, interestingly, even though patients who didn't have a Toni experienced less pain at the 24 hour mark, the reas the the result wasn't statistically significant. Um There were also no differences intraoperatively for br blood loss between the two groups. Um which really challenges the perception that tourniquet significantly reduces blood loss during surgery. The analysis faced challenges due to variability in the studies. So for instance, definitions for complications like non union and wound infection were varied and uh the restrictive cri criteria in some studies such as excluding diabetics or heavy smokers reduce the generalisability of the findings. Additionally, uh several important outcomes like cognitive function and uh biochemical markers were missing from the data as were long term uh patient reported outcomes. Uh These limitations underscore the need for a large multi multicenter trial to provide more different answers. In summary, while the use of tourniquet does reduce the duration of surgery. This review did not find a statistically significant difference in postoperative pain, blood loss function length of stay or complications between patients with or without um using a tourniquet. Although clinically important differences cannot be ruled out due to small sample sizes and low complication rates. Uh surgery without a tourniquet appears to avoid potential harms and remains a feasible option. It's important for uh patients to be fully informed about potential benefits, benefits and risks of Tonique use in their fracture fixation surgery. Both the editorial by Matt Costa and the systematic review have underscored underscored a significant gap in high quality RCT S on this topic. The current evidence is both limited and flawed with most uh studies exhibiting a high risk of bias. A large pragmatic RCT is needed. This study should involve multiple centers and a diverse range of surgeons across the country. Ultimately, this research will help to establish a clearer understanding of the comparative benefits and risks of using a tourniquet and lower limb fracture surgery. Thank you for. Thank you for time listening. Thank you. Thank you very much for that presentation. Uh Mister er um could I invite uh Professor Matt Costa and Mister Mo Farhan Alami. Yeah, they've joined the stage. Um And first of all, a gentlemen, could I have your thoughts on this issue? Um And as well as um you your reflection on the preparation of these studies because um this use of tunicate and the discussion around it goes back to uh knee surgeon, I mean, the my knee surgeon colleagues, you can split them down the middle uh as a group that so by the tunica, the group that don't want to use a tunicate. So was it something like that that uh stimulate you to look into this topic and uh take a be studies? So are we trying to follow our knee surgeons? I'll let you go first, Mike uh Matt. So well, the first thing thank you John, thank you for summarizing the papers very nicely. Uh Just to clarify, this is Mohammed's work. Um He was the first author on the annotation as well as a review. I was very much just a wing man myself and Alex Trumpeter were finding a bit of input from the orthopedic Drama Society. So I'm very happy to defer to Mohammed on this. Um to answer your question, the prospect of splitting knee surgeons in half is slightly appealing. But um it was nothing to do with knees really that changed my mind. It was um Crikey probably about 18 years ago. Now when I met a physiologist, actually from Israel who was talking about tourniquets and came to sort of speak to me about when he used to work at MO. Um And he presented data about the effects of tourniquet from a vascular point of view, vascular Vasi point of view. And he showed some really interesting sort of Doppler images showing that when you release the tourniquet, you got this meat shower of embolic something or other firing off into the blood system. And I presume that this was the vena cava. But he actually said, no, this is the carotid artery and that slightly unnerved me. And he pointed out that when you release the tourniquet because of the systemic inflammatory response from the um release of the tourniquet and the ischemia uh ischemic content has been released into the circulation. You get quite significant shunting through the circulation in the lungs. So actually even relatively large and black can bypass the pulmonary circulation completely fire through the left side of your heart and straight up into your brain. So while I've been very happily blaming the Anestis for POSTOP delirium with my patients where I've used the tourniquet, it suddenly occurred to me that I may be at least in part responsible for this. So after that, I um I started applying the tourniquet but not inflating it. And I did this initially for all the cases below the knee, as many of us did just by habit and by tradition, as you mentioned. Um, and I realized that was very seldom, uh, inflating it. In fact, I was never inflating it. So I stopped using it for simple injuries, ankles and so on foot fractures, I left it on for going around the back of the ankle or around the back of the knee. Um, but then after about three or four years of doing that, I realized I'd never inflated that either. So, over 10 years ago, now I stopped using a tourniquet, full stop for all trauma, upper limb, lower limb. And quite frankly, my life's been a better place for that because I don't have the patients in pain and recovery. Uh I know what the data says, but I certainly experienced that quite a lot and the blood loss issue I think is a red herring. In fact, I'm much more comfortable stopping the bleeding on the way in. And now I'm worrying about where the blood goes after I release the tonic at the end of the procedure. So that's my story. It's anecdotal. So I will defer to Mohammed for some science. Yeah, thanks Matt and thank you for having me this evening. And uh thanks also to phase. I hope that message gets to you. You're probably not here this evening, but I hope that message gets to you. Um, in response to your question, I think it's very interesting because the use of a tourniquet, you were talking about total knee replacement surgery. It's very different the indications why surgeons use a tourniquet in that operation is slightly different to why surgeons use it in ankle fractures. So one of the main reasons why um you know, arthroplasty surgeons use it is to is to improve the quality of the bone cement interface and try and reduce the risk of aseptic loosening. But also they do say, you know, you get a better view and they say, you know, you reduce, uh you reduce bleeding intraoperatively and you can do the surgery quicker. But you know, there's been a Cochrane review recently that's come out about uh tourniquet use and total knee replacement. And, and we've seen that, you know, the risks of, of using a tourniquet are, are present. You know, you've got increased risk of pain, you've got increased risk of infection, you've also got an increased risk of blood clots. Now, whether that, whether that you can translate that those results to trauma, we don't know yet because the studies that have been performed as an had presented about, they're quite limited in a number of ways. The quality is limited. The number of studies we've got is also limited. And frankly, there's just not enough data there to try and guide us to know whether we should be using these tourniquets or not in ankle fracture patients. One of the main concerns I think with using a tourniquet in ankle fractures or in trauma anyway, is that you've got that second hit or hypothetical second hit, you've got already traumatized issue and then you're using a tourniquet and you've got a environment now in the ankle where you've got low oxygen. And when you release the tourniquet, you've got the post tourniquet syndrome, you've got the inflammatory markers being released that Matt was talking about from the traumatized tissues. Um, and you've got the reactive oxygen species and you know, whether that has an effect on the traumatized tissues and increases the risk of the infection. We don't really know. And obviously infection is such a devastating complication that, you know, even one event is, is, is um you know, can be considered another event. And if it's, if it's preventable from not using a tourniquet, and so we, we need more data really to try and guide us about whether we should be using these devices or not and we don't have the data and people are using them without knowing if they're safe or not. So, my phd is actually focusing on tourniquet use and we're doing a number of studies, one of which is a feasibility trial trying to see whether it's possible to do a large, large scale trial in the future, comparing the benefits and the risks of tourniquet use and ankle fractures. And hopefully, that will give us a better idea and a better picture of whether we should be using these devices um in the background recently in the past couple of years since I've published that systematic review, there have been a couple of studies but only observational studies and they've looked at complications, obviously because they're observational, they've got the, the limitations associated with them confounding by indication and a number of other issues. But surprisingly, neither of them have yet shown there's any statistically significant difference in major complications and infection reoperation between patients who have surgery with a tourniquet without tourniquet. In fact, I think it was last month, there was an article that was published in the B JJ that was looking at the, um the comparing major complications between the two groups and that was a Danish Fracture Registry study. So that was quite interesting. And then there's the other study as well that was done by Heather in the States. And she and her team had looked at the same issue and they looked at, they looked at patients who may have been even higher risk, they looked at diabetic patients and they looked at smokers and they did a subgroup analysis and interestingly, they also found no difference in those subpopulations. Um But I think the question is still out there and I think there is merit to trying to do a big trial to get to get the answer for this research question. And I hope my phd study shows that it is feasible and that we'll be able to do that in the future. Yeah. Good. Um Another point, um, obviously you started off with a large number of studies and narrowed down to choose just six. I mean, you, you, you mentioned about the use of sham tunicate and the use of other agents like TriC acid. Did you come across any interesting comparisons? You know, using TriC stomach acid, uh o on one arm and to control bleeding and tunicate on the other arm. Interestingly, the only studies we found were the, we only focused on randomized controlled trials and we only found those six and they all compared surgery with a tourniquet to without a tourniquet. And we don't know whether, you know, some of these studies have been published quite a while back. They dated, I think from 1990 the most recent study was done in 2017. Um So in most of these studies T Xa was probably not used then in ankle fractures anyway. And uh, another interesting point. I mean, um, I've seen foot angle surgeons now move to using calf tunicate. So, were there any papers, you know, what are your thoughts on that calf Tonique versus a th tunic? Does that make any difference at all? Um To be honest, I'm not very sure because, um, we don't, I don't think we've got the data yet to be able to know whether, whether that would, that would make a difference or not. Um Yeah, I think, I think the question is still out there. I've not got particular thoughts on that, but um, Mat Costate, but I'm not aware of any, um, major evidence. Um, either way, deal in that. Um, to be honest, I stopped reading the literature. That's why I was very pleased to see Mohammed's review and his annotation because since I gave up using a tonic, I sleep better at night and that's just as important as the evidence to my mind. So given that I'd already given up on it, whether it was on the calf or on the thigh, I wasn't too worried about that. I just don't use them anymore. I don't see the point, but I totally take Mohammed's point that actually if the rest of the community, whether it's from ankle surgeons, trauma surgeons or anyone else, they're still using to case, maybe we should do the trial just to prove it one way or the other. I think as Mohammed said, the evidence contained in his review is necessarily limited by the quality of the primary trials, which is not great and a lot of them are out to date in terms of current practice, including things like TX A as you mentioned. So I think the jury is still out in terms of the evidence. But for me, I stopped using tourniquets a long time ago and um, I had struggled to be persuaded to put one back on these days. And I, is that for elective surgery as well, Matt or just trauma, you do really trauma. Is that correct? Yeah. So in jail, I've let you down. II just do trauma these days. But, um, I think a lot of my colleagues certainly in Oxford have stopped using tourniquets for knees and ankles and things as well. I mean, some still do, but I think when you ask them closely and Mohammed alluded to this and so you do a new introduction there, a lot of this is tradition on what we were taught and none of us have really made an active decision to use one or not use one. It's just, that's what we did. And therefore why wouldn't we carry on? But if you think about it, it doesn't really make a huge amount of sense. Cos where are the big scary blood vessels well around the shoulder and around the hip. We don't use the tourniquet there, do we? And we operate quite happily. So why do we put them on with the little tiny vessels around the ankle and the wrist? It's uh it makes little sense to me, to be honest and another practical point. I mean, I'll uh this is open to both the future. Um You know, the, is there any standardization or any rule around the pressures? Because I mean, in your annotation, you mentioned that ot S surgeons use anything between 200 to 350 MS of mercury pressures. Um WW what are your, what is your advice on that or any thoughts on that has any of these papers looked at any rule of thumb to BP goes up. Um It was reported in the paper, um interestingly, the pressures used are probably much higher than the pressures used in those trials are probably higher than the pressures that are currently used. Nowadays, I do remember just from the recall, one of the trials I think had set the pressure to something like 350 or 400 millimeters of mercury, which is pretty excessive considering systolic BP is probably about 100 intraoperatively. Anyway. So why you need to go up to that amount? I don't know. Um recently both guidelines have been published on the topic. Um off the top of my head, I can't remember. I think it's, I think it's 100 millimeters of mercury above systolic BP is the recommended um for if you're going to use a tourniquet is the recommended pressure to you. I think it's interesting. It's interesting as well that most of the, when you think about the benefits and the risks of a tourniquet, the outcomes are very skewed. So the benefits are all kind of in favor of the surgeon. You've got, you know, the theoretical benefit of reduced bleeding to allow the surgeon to see the structures in the operative field more clearly and you've got a reduced theoretical, reduced operative time. So all the potential benefits are in favor of the surgeon. And frankly, unfortunately, none of them, none of all the risks are then borne by the, by the patient and, you know, having interviewed and done focus groups for patients now and spoken to them about their experience of their recovery. Most of them tell me that none of them were actually made aware of whether a Tonique was used or not during the surgery. So it's quite interesting. Thank you. Thank you. Just one other point. Nil just, um, those of you are operating regularly on the local anesthetic, um will recognize the problems that the Toni causes. I appreciate that Mohammed's review didn't show a huge amount of difference in POSTOP pain, but certainly the pain you get from the tourniquet massively outweighs the pain you get from the surgical sides. And I remember back in the bad old days of doing carpal tunnels with tourniquets on when I was a trainee and I got quick at carpal tunnels and that wasn't cos I was a good surgeon. It was because the patients were screaming in agony from the tourniquet after 10 minutes of having it on. So the idea that tourniquets don't create a huge amount of pain, whatever pressure you use, II think is probably um, not true. So I'm another reason for trying to get rid of them, you may have detected. I'm a little bit um, opinionated on this topic. No, no, no. Yeah, you're right. I mean, and again, um, a lot of our foot foot surgeon colleagues are going towards uh regional blocks and local anesthetic, especially before foot surgery. And we're trying to copy a balance from our hand surgeon. Colleagues. Bring them into at least into a forefoot surgical practice, right? Um We may have a few uh senior fellows uh on the, you know, on the audience, any advice to them tomorrow morning, do they go and bring their tunic or continue what they're doing until a big, big uh RC comes out? I think from what I did and you can say go leave. This is if you are a tonier user, if you believe in them, try putting them on but not inflating them and just see how you get on because you can always put it on later, just elevate the arm and Sanin it however you like and carry on and then just see how often you end up inflating it because that's what I did. And I, after a while realized I just wasn't bothering inflating it. The other final point is, and Mohamed's reviewed wasn't able to look at this because there's little cost effectiveness data, but a lot of units used to you now using single use tourniquets and they're pretty expensive you to up the amount of money you're spending by just throwing this, applying this thing and throwing it away. Then it's not without cost for the NHS as well. So I think we, we shouldn't forget the cost implications of using the tonier Great, Matt and Mohamed. Thank you very much, uh, for a nice evening. Um, you know, passing on your experience, uh, both in your practice from your practice and from the study. Um, I'm sure we have got a few take home points from that. Thank you again. And to everyone, there is a link in the message box, the chat box, uh, to provide feedback and you can get your certificates once you give your feedback, um you can, you have noticed that James has come on. Uh That means it's uh time for dinner. So James your final words. Uh Well, thank you very much. Uh It seems I am indeed the prophet of doom. Uh Gentlemen, thank you for your um lovely academic menage ato, which I have very much enjoyed. Um It's now time to wrap up this session. Um I'd remind you all that BOFA is only four months away. The Golden BOFA of Brighton, which promises to be a great meeting. Um II note, the dinner is to be held in the Brighton Pavilion and I'm told by Joe Millard that er sedan chairs will be provided for those wishing to wear regency costume. So we don't have to get our silk stockings wet. Um Early bird registration is open, so please feel free to join. Um Thank you to all of our speakers tonight to um Alex Beer, to pfizer and our, to our senior authors, Mohammad Farhan, Alani, Matt, Costa Chris Brotherton. Of course, to my excellent colleague who manages to put up with my poor organization of this time and time and time again and to caramel hot for keeping everything going. The next general club will be in two months time, the details will be on the both us website. Um The link is already there so you can sort out your attendance certificates and thank you very much all for attending. Thank you to those who have contributed and I wish you all a good night.