Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures

BACKGROUND: Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties. OBJECTIVE: The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England. METHOD: We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes. RESULTS: We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest “wrong implants” (n = 94; 45.63% and n = 91; 44.17% respectively). There were 197 “Wrong-site surgery” incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. There were 18 (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each. CONCLUSION: We identified 47 different themes of NE specific to orthopaedic surgery. Awareness of these themes would help in their prevention. Site marking can be challenging in the presence of cast and on operating on the digits and spine. Addition of a Real-time intra-operative implant scan to the National Joint Registry can avoid wrong implant selection while Fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.

Development of an Automated Mass-Customisation Pipeline for Knee Replacement Surgery Using Bi-Planar X-rays

For standard ‘off-the-shelf’ knee replacement procedures surgeons use X-ray images to aid implant selection from a limited number of models and sizes. This can lead to complications and the need for implant revision due to poor implant fit. Customised solutions have been shown to improve results but require increased preoperative assessment (Computed Tomography or Magnetic Resonance Imaging), longer lead times and higher costs which have prevented widespread adoption. To attain the benefits of custom implants, whilst avoiding the limitations of currently available solutions, a fully automated mass-customisation pipeline, capable of developing customised implant designs for fabrication via additive manufacturing from calibrated X-rays, is proposed. The pipeline uses convolutional neural networks to extract information from bi-planar X-ray images, point depth and statistical shape models to reconstruct the anatomy, and application programming interface scripts to generate various customised implant designs. The pipeline was trained using data from the Korea Institute of Science and Technology Information. Thirty subjects were used to test the accuracy of the anatomical reconstruction, ten from this dataset and a further twenty independent subjects obtained from the Osteoarthritis Initiative. An average root mean squared error of 1.00 mm was found for the femur test cases and 1.07 mm for the tibia. 3D distance maps of the output components demonstrated these results corresponded to well-fitting components, verifying automatic customisation of knee replacement implants is feasible from 2D medical imaging.

Treatment of small breasts and inverted nipples

Augmentation mammoplasty is one of the most popular aesthetic surgical procedures in the world and the number of cases performed continues to increase yearly. This chapter presents a comprehensive review of this topic which includes implant selection, surgical approaches, management of complications, and some of the pitfalls associated with this popular procedure. The chapter also covers the classification and treatment of inverted nipples.

Incomplete Partition Type III: Computed Tomography Features and Cochlear Implantation Complications

In this case report, we review a male child who presented with severe bilateral hearing loss. Preoperative high-resolution computed tomography (HRCT) evaluation facilitated the initial diagnosis of the disease, which revealed typical findings of cochlear incomplete partition type III anomaly (IP-III), surgical planning, and cochlear implant selection to avoid possible complications. The child underwent cochlear implantation, which resulted in gushing and misplacement of the electrodes into the internal auditory canal (IAC) as postoperative complications. Postoperative imaging was used to determine the position of the implant and to assess the complications. The child’s postoperative X-ray revealed misplacement of the cochlear implant, the extent of which was further assessed by a HRCT scan for preplanning the revision surgery and electrode selection. Following the revision surgery, a further HRCT scan confirmed proper implantation and ruled out any further complications.