Cauda equina syndrome (CES) is one of the emergency conditions that can lead to devastating permanent functional disabilities, if misdiagnosed. Multiple studies have questioned the reliability of clinical assessment in diagnosing CES, whether some of the features should be considered to be potential red flags. Bladder dysfunction can reflect CE compromise. The post-void residual (PVR) volume bladder scan is useful in CES diagnosis, but to date there has been no single systematic review supporting its use. Furthermore, there is no clear cut-off point to consider PVR statistically significant. The aim of the study is to perform a systematic review of the current evidence behind the use of the PVR bladder scan as a diagnostic tool for CES diagnosis. This was a comprehensive search using Medline, PubMed and Embase. All articles included post-void bladder scans with the mentioned clear cut-off volume as a diagnostic parameter. A total of five study articles from 1955 fit with our inclusion and exclusion criteria. The total number of patients who had a bladder scan was 531. CES was confirmed in 85 cases. Bladder scan diagnosed 70 cases and excluded 327. The best results for both sensitivity and specificity in correlation with the sample of the study were for PVR more than 200 ml. Measuring the post-void urine volume using a bladder scan is an essential tool in the diagnosis of CES. There is a significant correlation between the PVR volume more than 200 ml and higher sensitivity and specificity.

The Risk Assessment and Prediction Tool (RAPT) was developed to predict patient discharge destination for arthroplasty operations. However, since Enhanced Recovery After Surgery (ERAS) programs have been utilized in the UK, the RAPT score has not been validated for use. The aim of the current study was to evaluate the predictive validity of the RAPT score in an ERAS environment with short length of stay. Data were compiled from 545 patients receiving a primary elective total hip or total knee arthroplasty in a district general hospital over 12 months. RAPT scores, length of stay, and discharge destinations were recorded.Patients were classified as low, intermediate, or high risk as per their RAPT score. Length of stay was significantly different between groups (p = 0.008), with low-risk patients having shorter length of stay. However, RAPT scores did not predict discharge destination; the overall correct prediction was only 31.9%. Furthermore, the most likely discharge destination was directly home in ≤3 days in all groups (68.5%, 60.2%, and 40% for the low-, intermediate-, and high-risk groups, respectively).The RAPT score is not an adequate tool to predict the discharge disposition following primary total knee and hip replacement surgery in a UK hospital with a standardized modern ERAS program. Alternative predictive tools are required.

IntroductionThe COVID-19 pandemic has brought unprecedented challenges in health care, leading to a dramatic change in service provision and impacting surgical training. The availability of a virtual meeting platform allowed our team to develop a new educational programme aiming to maintain an ethos of education safely, focusing on providing an opportunity to develop nontechnical skills and maintain reflective practice. Materials and MethodsMicrosoft Teams was used to conduct two streams of weekly education: a journal club focussing on developing critical evaluation skills, and case-based in-depth discussion forum to develop presentation skills and evidence-based management. A questionnaire after 10 weeks was used to evaluate the effectiveness and engagement of the two streams. ResultsFifty-three responses were received. Seventy-two percent felt that their engagement in teaching was increased on a virtual platform. There was 88% satisfaction with the platform. Reflective practice increased and 40% of respondents felt their non-technical skills improved. Sixty-eight percent stated that they would like to continue the virtual format going forward and 88% would recommend this to their peers. Ninety-two percent felt that the platform played a pivotal role in helping maintain team morale during this period. ConclusionOur experience of using a virtual tool to maintain education within our department is very positive. There has been good engagement with positive reflection and learning at a time of great change in the NHS. Both trainees and non-trainees have benefited. With ongoing COVID still influencing clinical practice, we recommend utilising virtual platforms to maintain education in surgical departments.

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Category: Midfoot/Forefoot Introduction/Purpose: The most common presentation of Morton's neuroma is that of a single neuroma in a single interdigital space. However, the occurrence of multiple neuromas in adjacent interdigital spaces of the same foot is not uncommon, with this scenario reported in 3-4% of all cases. Treatment of Morton's neuroma has been studied extensively, with most authors recommending surgical intervention only after failure of non-operative approaches such as steroid injection orthoses or shockwave therapy. Whilst systematic reviews on the management of Morton's neuroma have been performed previously, these focus on the treatment of a single neuroma in a single foot. This review aims to address this gap in the literature by systematically reviewing studies reporting treatment of multiple neuromas in adjacent intermetatarsal spaces of the same foot. Methods: A systematic review was performed according to PRISMA guidelines. A thorough computer-based search was performed by two reviewers independently in Pubmed, Embase, Cinahl, Emcare, Web of Science and Scopus databases using relevant terms such as 'interdigital', 'Morton's', 'intermetatarsal', 'neuroma', 'neuralgia', 'adjacent' and 'multiple'. Title/abstract and full text screening was performed independently by the same two reviewers, using a-priori selection criteria. All original research articles (randomised control trails, cohort studies and observational studies) reporting any management strategy for multiple adjacent Morton's neuromas in the same foot were included. Studies describing treatment of both single and multiple adjacent neuromas in the same article were included if results were clearly separated according to these distinct presentations. The methodological index for non-randomized studies (MINORS) was used to assess risk of bias and methodological quality of included studies. Results: A total of 253 unique articles were identified, with seven studies, including 383 patients included in the final review. Of these seven studies, four describe treatment of both single and multiple neuromas in the same article, whilst three include only patients with multiple adjacent neuromas in the same foot. Simultaneous excision using a single incision was the most common strategy, reported in three studies. Whilst two studies each reported use of simultaneous excision with two distinct incisions and delayed excision respectively. Of the four studies reporting treatment of both single and multiple neuromas, the pooled proportion of patients with the later presentation was 51/354 (14.4%). Only two studies, both describing simultaneous excision with a single incision, used scoring scales to assess treatment outcomes. These articles find significant increases in Manchester Oxford Foot questionnaire (MOXFQ), 12 item short form health survey (SF-12) and American Orthopaedic Foot & Ankle Society (AOFAS) scores. Conclusion: There is currently no evidence favouring use of a delayed excision or multiple incision approach in the treatment of multiple adjacent neuromas. However, there is a paucity of literature describing this presentation, with a number of studies failing to separate outcomes of single and multiple neuroma treatment. Given that the presentation of multiple adjacent neuromas may not be as rare as previously thought, it is important that further high-quality comparative research is performed to enable clinicians to draw firm, evidence-based conclusions to guide clinical practice. Future research should also investigate the role of alternative strategies such as non-operative treatment.