2021 SORTED Annual Report

Annual Report 2021

Spine & Orthopaedic Trauma Epidemiological Database (SORTED)

SERT Institute

Contents

SORTED Royal North Shore Hospital

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Foreword

Snapshot

Executive Summary

Ray Hollings Surgical Excellence Award

2021 Data Summary

Royal North Shore Hospital. Published November 2022

Patient characteristics

Case details

Trainee case load

Fracture classification

Adult fracture location

Paediatric fracture location

Spine surgery

Spinal cord injuries

Complications

Length of stay

Acknowledgements

Glossary

Foreword

SORTED 2021 Snapshot

Royal North Shore Hospital (RNSH) has a long and proud history of providing world-class healthcare service to the community. The SORTED project is a great example of how the spinal and orthopaedic trauma services within RNSH are striving to continue this high standard of care. Despite a challenging year due to the COVID-19 pandemic, the project maintained its momentum and continued to grow year-on-year. We are proud to present the second SORTED annual report, which is another great achievement of the project. The report details the progress of the project, as well as highlighting some of the next steps in our journey. Seeing the data in this way allows us to understand in more detail the types of injuries that we are treating. The project also brings a deeper appreciation of the effects of our treatment, and allows us to identify potential areas of improvement that will ultimately lead to improved patient care and outcomes. Chairman of the Department of Orthopaedics & Traumatic Surgery

Head of the Department of Orthopaedic Surgery, RNSH It is with pleasure that I present the 2021 Annual Report for the Spine and Orthopaedic Trauma Epidemiological Database (SORTED). The ongoing development of this database has been a big achievement for our department and it has gone from strength to strength in 2021. The project has already been successful in improving patient care, driving research and creating a culture of empowerment and engagement for the multidisciplinary teams involved in orthopaedic trauma patient care. The major highlight for this year was Dr Michael Symes being named a recipient of the inaugural Ray Hollings Surgical Excellence Award for SORTED. The funds received from this award will be used to roll out the next phase of SORTED, by purchasing iPads to collect data on patient-reported outcome measures (PROMs). I would like to express my gratitude and appreciation to the Data Analysis & Surgical Outcomes (DASO) Unit team for their expertise, contribution and involvement with SORTED.

2049

Total ortho-trauma surgeries A total of 2049 operations were captured from January–December 2021. The reporting period includes the continuing COVID-19 global pandemic. Of the 2049 operations, 1784 were for general orthopaedic cases and 269 were for spine surgeries.

1304 99.6%

Total fractures A total of 1304 fractures were treated surgically between January—December 2021.

Data compliance rate The data compliance rate was 99.6% excluding neurosurgery cases. There has been a 5.6% increase in the data compliance rate since 2020.

1911

Emergency surgeries In 2021, there were 1911 (93%) emergency surgeries and 138 (7%) elective surgeries.

Dr Andrew Ellis Head of Orthopaedic Surgery, RNSH

Professor Bill Walter Chairman of the Department of Orthopaedics & Traumatic Surgery

SORTED Annual Report 2021

Executive Summary

Ray Hollings Surgical Excellence Award

Dr Michael Symes receives inaugural Ray Hollings Surgical Excellence Award On behalf of the RNSH Department of Orthopaedics and Trauma Surgery, Dr Michael Symes was named a recipient of the inaugural Ray Hollings Surgical Excellence Award in February, 2022. The award is named after Dr Ray Hollings who was a General Surgeon at RNSH for more than 60 years and was passionate about providing high quality patient care and supporting innovation and quality improvement activity across surgery. The RNSH Surgical Education Research & Training (SERT) Institute was proud to facilitate the inaugural Ray Hollings Surgical Excellence Award, in recognition of the contribution Dr Hollings has made to surgery across Northern Sydney Local Health District (NSLHD). The Award is to encourage and support consultant surgeons at RNSH to undertake quality improvement projects that drive innovation, and improve service delivery and patient care. The quality improvement project application submitted by Dr Michael Symes on behalf of the Department of Orthopaedics and Trauma Surgery was to continue the next phase of the SORTED. The database, which was established in 2020 with the help of the Data Analysis & Surgical Outcomes (DASO) Unit, has been successful in achieving its initial goals of improving patient care, driving research and creating a culture of empowerment and engagement for the multidisciplinary teams involved in orthopaedic trauma patient care. Key outcomes of the next stage of SORTED include transitioning and incorporating patient reported outcome measures (PROMs). To facilitate this, the award funds will be used to purchase iPads to collect PROMs data directly from patients.

This report provides an overview of the Royal North Shore Hospital (RNSH) Spine and Orthopaedic Trauma Epidemiological Database (SORTED) for 2021. Since commencing in February 2020, SORTED has had a considerable impact on improving the culture of research and use of data to drive improvements in patient outcomes within the RNSH Orthopaedic and Trauma departments. Data integrity is highly valued in our department and over the past 12 months we have seen a significant improvement in data accuracy and completeness. Compared to last year’s annual report which reported 7.0% missing or incorrectly entered data, the figure dropped to just 0.4% in 2021. During the reporting period from 1 January to 31 December 2021, a total of 2049 operations were entered into the database. Of these, 1780 were general orthopaedic cases (performed by 11 surgeons), and 269 were spine surgeries (performed by four surgeons). Two operations were entered as combined single-stage orthopaedic and spine surgeries. A highlight for the department was that SORTED received the Ray Hollings Surgical Excellence Award, providing a major boost for the project. The award will be used to roll out the next phase of SORTED, which will involve collecting data on patient reported outcome measures (PROMs).

• Establishing a six-month development and training period until a testing and trial period is ready mid-next year (including information on key steps, timeframes and project stakeholders).

The combination of PROMs and complication data will not only be valuable for research and publications, but ultimately in improving the quality of care for patients. Speaking at the Ray Hollings Surgical Excellence Award and Harry Cumberland Travelling Scholarship awards night, Dr Symes explained how the funds from the award would enable the Department of Orthopaedics and Trauma Surgery to continue the momentum of SORTED. “It’s going to accelerate the next phase of SORTED which involves the collection of PROMs, help us collect more in-depth complication data, as well as increase collaborative engagement across departments at RNSH such as Trauma and Burns and Plastics,” he said. “This award will also help us work towards our goal of expanding SORTED across the Northern Sydney Local Health District in the next five to ten years.” The Ray Hollings Surgical Excellence Award will be awarded each year by the SERT Institute, giving recipients the opportunity to receive up to $10,000 towards a quality improvement project at RNSH.

The next stage of SORTED will focus on:

• Collecting more detailed complications data and collaborating with other departments including Trauma, Burns, and Plastics to improve patient outcomes. • Training for junior medical doctors, nurses, allied health and non-medical staff to ensure high quality data capture across multiple points of care including in wards, clinics and operating rooms.

SORTED Annual Report 2021

2021 Data Summary

Dr Michael Symes with Professor Bill Walter (left) and Professor Tom Hugh

Dr Michael Symes

SORTED Annual Report 2021

Patient characteristics

Patient residence Figure 2 demonstrates that the majority (73.2%) of the 2049 patients in this cohort resided within NSLHD.

General orthopaedic cases

Total operations

Spine surgeries

Gender and age A total of 2049 patients were included for this reporting period. Figure 1 illustrates the distribution of male and female patients across each age group. Distribution was relatively even across all age groups, with the majority of cases performed on male patients (60.5%) when compared with female patients (39.5%).

Age and Gender

Female Male

202

174

171

142

134

127

126

122

120

112

105

102

8.9% 12.9% 10.0% 8.7% 9.6% 12.7% 11.5% 12.1% 13.6% <10 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+

Figure 1: Age and gender bands of all patients

Figure 2: Patient distribution across Local Health Districts

SORTED Annual Report 2021

Rural and regional LHDs

Outside NSW

Insurance classification A high number of patients undergoing emergency surgery were privately insured at the time of their surgery. However, due to compulsory third party (CTP) insurance claims, the insurance status for several patients changed after surgery. Insurance Classification

Local Health District Percentage (%)

Western NSW

2.9

Queensland

0.2

Deferred No Insurance Overseas DVA Work Cover Motor Vehicle Unknown Public Private

976

Hunter New England 1.6

Victoria

0.2

Australian Capital Territory

795

Mid North Coast

0.4

0.1

172

Southern NSW

0.1

Unknown Address

0.1

Murrumbidgee

0.1

South Australia

0.0

Table 1A: Percentage of patients in rural and regional LHDs

Table 1B: Percentage of patients who resided outside NSW

1 1

Figure 3: Insurance classification

SORTED Annual Report 2021

Case Details

Consultant caseload Figure 4 shows that over two-thirds (67.3%) of emergency orthopaedic cases were shared among three consultants for this reporting period.

Notes: • During this period one orthopaedic surgeon retired and one was appointed Consultant Caseload

Trainee case load

506 500

373

At RNSH, junior medical staff have terms of variable durations, however, during this reporting period the majority of cases performed by trainees were conducted by two trainees who both completed a full 12-month clinical year in 2021. In the majority of cases, trainees performed the role of assistant for a greater number of cases than those in which they were primary operators, as shown in Table 2.

183

172

84 88

15 5 6

9 2

1 8 S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12 S13 S14 S15

Figure 4: Total number of cases per consultant

SORTED Annual Report 2021

Position Trainee 1 Trainee 2 Trainee 3 Trainee 4 Trainee 5 Trainee 6 Trainee 7 Trainee 8 Trainee 9 Trainee 10 Trainee 11 Trainee 12 Trainee 13 Trainee 14 Trainee 15 Trainee 16 Trainee 17 Trainee 18 Trainee 19 Trainee 20 Trainee 21 Trainee 22 Trainee 23 Trainee 24 Trainee 25 Trainee 26 Trainee 27 Trainee 28 Trainee 29 Trainee 30 Trainee 31 Trainee 32

Operator

Assistant 1

Assistant 2

Assistant 3

Assistant 4

Mechanism of injury Falls-related injury was the most common mechanism of injury resulting in surgical cases reported here. Road-related and sports injuries also contributed significant portions to the overall burden of cases. A focus of data reporting in 2022 will be the burden of cases linked to road-related trauma (motor vehicles/pedestrians/cyclists). Several cases may have multiple mechanisms of injury entered and may appear multiple times in this data.

6 2 2

1 1

Mechanism of Injury

1 1 1

20 25

110

56.4% 13.9%

1061

Fall related trauma Other Traumatic wound Sport Cyclist trauma

261

6.7% 6.0% 5.4% 4.9% 3.8% 1.7% 1.2% 0.1%

126

106 129

113

1 1

101

MBA MVA Post-op complication Pedestrian Uber Eats/Menulog delivery driving

42 71 13

3 3

105

3 5 6 3

105

17 17

16 18 41

Figure 5: Mechanism of injury

1 1 1 1 1 1

9 4

1 1

4 5

154

139

1 1

Orthospine Fellow

64 42

Resident

18 16 20

Intern

1 1

Medical Student

Scrub nurse

Fellow - other

Table 2: Trainee caseload

SORTED Annual Report 2021

Fracture Classification

Adult fracture location

Total fractures

A total of 962 adult fractures were treated in 2021. Figure 6 shows the case numbers and locations of all fractures in adult patients. More than three-quarters (76.1%) of adult fractures were pelvis/lower limb fractures with 23.9% being upper limb fractures. Fractures of the femur accounted for 30.7% of all adult fractures.

Adult Fracture Locations >100 81-100 61-80 41-60 21-40 1-20

Fractures are classified according to a modification of the Fracture and Dislocation Compendium – Combined Orthopaedic Trauma Association and AO Foundation Classification system – Journal of Orthopaedic Trauma – 2018 (see Appendix for further details and reference for this classification system). A total of 1304 fractures were treated surgically in this period. Of these, 770 (59.0%) were upper-limb fractures, 534 (41.0%) were pelvic and lower limb fractures. It should be noted that at RNSH, any fractures involving the distal radius and more distal to this are treated by a separate unit and this data is not reported here. A total of 70 (5.9%) fractures were classified as open; more detail on the Gustillo-Anderson grade and wound management of the open fractures is available but not presented in this report.

Upper-limb fractures

Clavicle: 70

Scapula: 6

Humerus: 78

Pelvic/lower-limb fractures

Ulna: 45

Radius: 31

Pelvic Ring: 26

Acetabulum: 19

Femur: 295

Patella: 15

Tibia: 159

Fibula: 113

Malleolus: 39

Foot: 66

Adult Fracture Locations >100 81-100 61-80 41-60 21-40 1-20

Figure 6: Case numbers and fracture locations for adult patients

SORTED Annual Report 2021

Clavicle: 70

Scapula: 6

Adult fracture location - segment

Fractures occurring at the proximal segment (AO/OTA – 31) of the femur were the most common fracture requiring surgical treatment in 2021. There were 235 fractures (79.7% of all femur fractures) in this location. Tibia/fibula fractures accounted for 28.3% of all adult fractures. The majority of these fractures (68.8%) occurred at the distal segment.

Humerus fractures were the most common upper limb fractures in adults, accounting for 8.1% of all adult fractures. The majority of these fractures (56.4%) occurred at the proximal segment. The majority of radius/ulna fractures (60.5%) were also on the proximal segment.

Humerus - 78

Femur - 295

Proximal

56.4%

79.7%

235

Diaphyseal

14.2%

26.9%

Distal

6.1%

16.7%

Figure 9: Total humerus fractures by segment

Figure 7: Total femur fractures by segment

Radius/Ulna - 76

Tibia/Fibula - 272

Proximal

60.5%

15.8%

Diaphyseal

15.4%

31.6%

Distal

68.8%

7.9%

187

Figure 8: Total tibia/fibula fractures by segment

Figure 10: Total radius/ulna fractures by segment

SORTED Annual Report 2021

Spine surgery

Paediatric fracture location There were a total of 342 paediatric fractures in 2021. Figure 11 shows the fracture location for paediatric patients requiring surgery at RNSH. The vast majority (88.9%) are upper limb fractures in this population and many patients appear twice, reflecting the commonality of having both forearm bones fractured simultaneously. Paediatric Fracture Locations >100 81-100 61-80 41-60 21-40 1-20

There were 269 spine surgery cases entered into the database during this period, with 267 involving spine only and two additional cases that involved single-stage combined orthopaedic and spine surgery. Note, data is only reported for orthopaedic spine cases and is not inclusive of neurosurgical spine data.

Spine surgery cases

Clavicle: 1

Figures 12, 13 and 14 summarise aetiology of cases undergoing spine surgery and location of spine fractures. Classification is aligned with data collected in the Australian spine registry where possible (disc and degenerative disease). The four most common reasons for spine surgery were trauma, degenerative disease, disc-related pathology and tumour.

Humerus: 58

Aetiology of Spine Surgery Cases

Radius: 178

29.2% 28.2% 19.5%

Trauma Degenerative Disease Disc Tumour Infection Deformity Revision surgery Unclassified Spondylolisthesis Inflamation

Ulna: 67

8.3% 5.8% 2.5% 2.5% 2.2% 1.4% 0.4%

Femur: 4

7 7

Fibula: 4

Tibia: 24

Figure 12: Aetiology of spine surgery cases

Foot: 6

Adult Fracture Locations >100 81-100 61-80 41-60 21-40 1-20

Figure 11: Case numbers and fracture locations for paediatric patients

SORTED Annual Report 2021

Clavicle: 70

Scapula: 6

Spinal cord injuries

Fracture Location for Spine Surgery Cases

Fracture location for spine surgery cases

A total of 46 spinal cord injuries were treated in this reporting period, as summarised in Table 3. More than half (52.2%) of spinal cord injuries were the most severe grade according to the American Spinal Cord Injury Association (ASIA) impairment scale. This data is not inclusive of spine injuries treated during the same period by the neurosurgical department. ASIA Category n

ASIA A: Complete, no motor or sensory function is preserved below the level of the injury, including the sacral segments S4 - S5. 9

Cervical

Thoracic

Lumbar

Spinopelvic

Figure 13: Fracture location for spine surgery cases Location for Tumour, Disc and Infection Aetiology

ASIA B: Incomplete Sensory, but not motor function is preserved below the neurological level of injury, and includes the sacral segments S4 - S5. 6

Location for tumour, disc and infection aetiology

ASIA C: Incomplete, motor function is preserved below the neurological level of injury, but more than half of the key muscles below the level have a muscle grade less than 3 (i.e. unable to move against gravity) 7 ASIA D: Incomplete, motor function is preserved below the neurological level of injury, and at least half the key muscles below the injury level have a muscle grade of 3 or more (i.e. joints can be moved against gravity) 24

Total

Table 3: Summary of spinal cord injuries in 2021

Cervical

Thoracic

Lumbar

Spinopelvic

Disc

6 5 2

3 2 0

Tumour Infection

Figure 14: Location for tumour, disc and infection aetiology

SORTED Annual Report 2021

Complications

Length of stay

Figure 15 shows the number of complications by type of event. The most common complication reported was an unplanned return to theatre, occurring for 1.2% of total operations. Figure 16 shows the reason for the 24 cases of unplanned return to theatre; the majority of cases returned for revision of fixation (66.7%). Further details on complications is available but has not been published here. Morbidity and mortality data fields have been amended and aligned with the NSW Health reporting guidelines for surgical complications.

The median length of stay for general cases was 2 days (IQR: 1-7) and 8 days (IQR: 4-19) for spinal cases. The maximum length of stay for one patient was 218 days.

Length of Stay

Complications

General

1.2%

Unplanned return to theatre

0.1%

Superficial Infection

Spine

0.1%

Other

100

150

200

250

0.0%

Unplanned readmission

Length of Stay (Days)

Number of Complications / Total Operations

Figure 17: Length of stay

Figure 15: Number of complications by type of event

Unplanned return to theatre reason

66.7%

25.0%

4.2%4.2%

Revision of fixation Infection Dislocation Other

Figure 16: Unplanned return to theatre reason

SORTED Annual Report 2021

Glossary

Acknowledgements

Abbreviation

Definition

Benjamin Cass Myles Coolican Consultants

Preet Bubra Codey Burton Registrars

Nursing Team

AO/OTA

AO Foundation/Orthopaedic Trauma Association

Preet Bubra Codey Burton

Andrew Cree Andrew Ellis Randolf Gray Nathan Hartin Joseph Isaacs Terence Moopanar Dimitri Papadimitriou

Donald Cawthorne Matthew Donaldson Cameron Handford

ASIA

American Spinal Cord Injury Association

CTP

Compulsory Third Party

Sachin Kher Denis Koong Sarah Nicholls Kurt Seagrave Joel Steiner

Sachin Kher Denis Koong Sarah Nicholls Kurt Seagrave Joel Steiner Kathy Chung Ewan Driver Kenneth Vuong Data Team

DASO

Data Analysis & Surgical Outcomes Unit

David Parker Stephen Ruff Sean Suttor Michael Symes Bill Walter Andrew Wines

IQR

Interquartile Range

SRMOs

LHD

Local Health District

Nicholas Coulshed Ibrahim Darwish Mitchel Fung Sahand Imani Brendan Miles Miranda Norquay JMOs / Interns

MBA

Motor Bicycle Accident

Fellows

Darren Krusi Administration Team

MVA

Motor Vehicle Accident

Yasser Alhaddab Johanna Elliot Carrie Lobb Peter Lorentzos Samuelt Mackenzie

NSLHD

Northern Sydney Local Health District

Report Design & Development

NSW

New South Wales

Daniel Antaw Jeremy Bishay Ryan Campbell Gareth Crouch Rhea Darbari Michael Duan Gabriel Gregory

Rajat Mittal Tofunmi Oni Shaan Patel

Nadine Chidiac Kathy Chung Timothy Pollicina

Paediatric

Patients aged 16 and below

PROM

Patient Reported Outcome Measures

Robery Piggott Ramsay Refaie Ramsay Refaie Ravi Rudraraju Andrew Sefton Majooran Sinnathurai Milos Spasojevic Dion Tsinas Jonathan Warnock Vout Weltman

REDCap

Research Electronic Data Capture - An online data collection platform to manage online surveys and databases

Christopher Harvey Mudith Jayasekara Breanna Johnson Mickey Kondo Luke McKinnon Sahan Nanayakkara Anita Niu Paulina Salamat David Shen David Wei Brent Whittaker Joshua Xu Fumi Yasutomi

RNSH

Royal North Shore Hospital

SERT

Surgical Education, Research and Training Institute

SORTED

Spine & Orthopaedic Trauma Epidemiological Database

28 SORTED Annual Report 2021

SORTED Annual Report 2021 28

SORTED Annual Report 2021

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SORTED Annual Report 2021

Northern Sydney Local Health District Royal North Shore Hospital Reserve Road St Leonards NSW 2065

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