Abstract
Tibial fractures are common, occurring with an incidence of between 7 and 8 per 10000 population per annum, and continue to represent a clinical challenge in orthopaedic trauma surgery. For a patient suffering tibial trauma, the journey is often considered simplistically from diagnosis to treatment, usually over a short period of time culminating in an operation to fix the fracture. That is a typical picture, but there is so much more to this journey. The considerations in how the diagnoses are made, for example in open fractures how we grade the severity of injury and the prognostic implications, through to rehabilitation which often accounts for the vast majority of time the patient experiences on their journey to recovery. All of this needs appreciating if we are to look to improve standards of care and contemplate new approaches to injury management.This thesis provides an overview of the body of my academic work on the topic of tibial trauma conducted in the last 10 years, since being appointed as a Consultant in 2013. All of this academic work has been conducted whilst in full time clinical practice in the National Health Service (NHS) and without an academic job plan. The research questions considered in these works have in the main come about from my curiosity and what I have asked of myself and others over the last 20 years spent in orthopaedics through junior doctor training, fellowships and as a consultant.
The aim here is not to provide a comprehensive analysis of every aspect of tibial trauma – from each fracture pattern to every intervention, in every patient population, or considering the entire nuances of post-operative care and rehabilitation. Instead, I shall identify and reflect on key areas both interesting and challenging in my career to date. To consider these works as to how they improve outcomes of surgery, the patient journey, or indeed surgeon and patient safety. Measured outcomes may be technical or functional, patient reported or radiographic, or can impact on service provision and societal costs.
This thesis is written in a narrative tone allowing the reader to understand my approach to often challenging scenarios, and to appreciate the careful thought that is needed when challenging the established pathways, interventions and processes when managing these patients. The research work presented is divided into four key themes: Acute injury, Rehabilitation, Complications and Professional Practice. For each of these themes, the specific impact and contribution my own work has had on the patient journey and orthopaedic community is considered and includes the following:
Acute Injury – an early adopter of the suprapatellar nailing technique, becoming a recognised educator on such; changing the way we classify open fractures to focus on the patient journey as opposed to infection as an outcome measure; established as an expert in the production of national guidelines.
Rehabilitation – working to overcome barriers to weight bearing after injury, including standardising terminology used by all health care providers in rehabilitation prescriptions; setting up big data national audit studies as a model for future research work.
Complications – questioning traditional approaches to non union management, focussing on deeper understanding of the interplay between biological and mechanical factors; research studies to support the unified theory of fracture healing.
Professional Practice – Development of registries and databases for orthopaedic trauma; development of core outcome sets for specific injury groups; becoming a recognised national leader in orthopaedic trauma care.
These themes are intertwined: one piece of work begets the next - one research question leads to the generation of others. I have always taught my trainees and students as well as peers, to come on a journey of understanding. To ensure that the fundamental basic reasoning and logic behind an argument or complex topic is thoroughly considered. This then affords an appreciation of the context of the work and the implications it has. All of the presented works have come about from the same inquisitive approach I have to the management of my patients and the pursuit of answers.
It is hoped that this body of published work entitled An analysis of technical advances, whilst challenging dogma and improving outcomes in fractures of the adult tibia will enhance the existing knowledge in this field and demonstrate its value to the orthopaedic community.
| Date of Award | 4 Jan 2024 |
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| Original language | English |
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| Supervisor | Graham Mills (Supervisor) |