Commercial aviation has recognized since long time that the so called “human factor” is the main responsible for the majority of accidents or near-accidents, which are always reported in aviation but almost never in medicine. Therefore I strongly support the idea that we could much learn from aviation in order to cope with the major cause of our accidents. Like airmen, pilots, air traffic controllers and so on, we also make errors. The first step to reduce the burden of our errors is to be able to admit them in order to analyse their causes, which up to now we are unable to do. Only one medical journal, the Lancet, has started to publish our errors. But beware not to make confusion between, complication, negative outcome and medical error. The “human factor” must not be understood as human error; on the contrary the human factor is related to the majority of accidents, where the human error is only a minor and final cause. To understand how “human factors” can play a role in determining the “accident”, we must first distinguish between active and latent failures. Active failures are unsafe acts committed by those at the sharp end of the system: the pilot, air traffic controller, anaesthetist, surgeon. Latent failures arise from fallible decisions, usually taken within the higher levels of the organization or within society at large. A clear example is the crash of the SAS aircraft in Milano Linate with a small aircraft of the general aviation on the same runaway. No ground radar was available and the fog made the rest. But only the “sharp end” of the system, i.e. the traffic controllers paid for their error, not those responsible for not buying the ground radar. We must develop a new culture of error but this will remain difficult until our legal systems do not change their approach towards negative outcomes. This vicious circle needs to be cut for the benefit of all, patients and doctors

Venous Thromboembolism (VTE) prophylaxis is an essential part of orthopaedic surgeries in preventing life-threatening thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopaedic surgery has the highest incidence rate of thromboembolic events as compared to any other surgical specialities, making it an essential component in managing any orthopaedic case. At Queen's Medical Centre (QMC), a major trauma centre in the United Kingdom (UK), sees up to 750 NOF fracture cases annually, making it one of the busiest trauma and orthopaedic centres in the UK. Our study aims to evaluate how VTE Prophylaxis is conducted in a UK Major Trauma Centre for NOF and pelvic fragility fractures and how human factors can improve its efficacy. The Nottingham University Hospitals (NUH) Trust has implemented new guidelines from August 2019 that patients with fragility fractures such as NOF and pelvic fractures are prescribed with 28 days VTE prophylaxis with Enoxaparin, or their own anti-coagulants if risk of thrombosis exceed the risk of bleeding. This is an adaptation from the trust to align their guidelines closer to the NICE 2018 guidelines. We will be evaluating the initial compliance of VTE Prophylaxis, identify and utilise human factors, then re-analyse the department after implementing interventions on the same batch of junior doctors working in the department. Data of 100 patients with fragility fractures were collected, 50 consecutive patients in the pre-intervention window during August 2019 and 50 in the post-intervention window during November 2019. The pre-intervention data had 43 NOF and 7 Pelvic fractures. Our study showed that 93% of NOF fracture and 100% of pelvic fracture received the correct course of VTE prophylaxis. The data was presented at the local department junior doctor academic session. Three simple human factor interventions were implemented over the course of September and October: Education to the trauma and orthopaedic department on the new guideline, extended VTE labels on drug charts for patients with fragility fractures, VTE reminder labels at doctors' stations. Another 50 consecutive patients' data were collected during November 2019. Data shows that 97.8% of NOF (p>0.05) and 60% of pelvic fracture (p>0.05) received the correct course of VTE prophylaxis. Our data has shown an increase in correct VTE prescription for NOF fracture patients, which is the main bulk of our fragility fracture patients whilst we see a drop in pelvic fracture patients. Due to the limited time frame of four months where junior doctors in the UK rotate between specialities, we are only able to collect data during the first month, implement interventions between datasets and collect data on the final month of the four-month rotation. A future bigger study might provide a more significant result on the department. We believe that the key to achieving 100% VTE prophylaxis in the T&O department is optimising human factors, educating junior doctors, who are not orthopaedic trained, with sufficient information of the guidelines, and evidence of the risk and benefits of providing prolonged VTE prophylaxis for orthopaedic patients. In conclusion, we found that QMC, a major trauma centre with high patient volume and turnover, has a high level of compliance with VTE prophylaxis for fragility fractures and it is imperative that utilising human factors will inch the department closer to its goal of 100% VTE compliance

The World Health Organisation (WHO) Surgical Safety checklist is an evidence-based tool shown to reduce surgery-related morbidity and mortality. Despite audits showing 96% checklist compliance, our hospital had 3 surgical never events in 10 months, 2 of which were in orthopaedics. By March 2018, the authors aimed to achieve 100% compliance with all 5 sections of the WHO Five Steps to Safer Surgery bundle for all surgical patients. Additionally, the authors aimed to assess the impact of the quality of bundle delivery on preventable errors related to human factors. Quantitative assessment involved direct observations of compliance in theatres. Qualitative data in the form of rich, descriptive observations of events and discussions held during checklist delivery was analysed thematically. Interventions included trust-wide policy changes, awareness sessions, introduction of briefing and debrief proformas and documented prosthesis checks. For elective surgeries, checklist compliance increased to 100% in 4 of 5 sections of the bundle. The incidence of reported preventable critical incidents decreased from 6.7% to 2.4%. A chi-squared test of independence demonstrated a significant relationship between the implementation of changes and completion of the checklist, X2 (1, N = 1019) = 25.69, p < 0.0001. Thematic analysis identified leadership, accountability, engagement, empowerment, communication, and teamwork as factors promoting effective checklist use. Our findings highlight the benefits of a qualitative approach to auditing checklists. Exploring the role of human factors and promoting staff awareness and engagement improves checklist compliance and enhances its effectiveness in reducing surgery-related adverse outcomes

INTRODUCTION. Finite element analysis (FEA) is widely used to study micromotion between the glenoid baseplate and bone, as a pre-clinical indicator for clinical stability in reverse total shoulder arthroplasty (rTSA). Various key parameters such as the number, length, and angle of screws have been shown to influence micromotion [1]. This study explores the influence of screw preloads, an insufficiently studied parameter. Specifically, two rTSA configurations with 18mm and 48mm peripheral screws (PS) were analyzed without screw preloads, followed by analysis of the 48mm PS configuration with an experimentally measured screw preload. METHODS. FEA models were created to simulate a fixation experiment inspired by ASTM F2028-14. The rTSA configurations used here have a superior and an inferior PS. The assemblies were virtually implanted into a synthetic bone block as per surgical technique. Sliding contacts were defined to model the interface between screw threads-bone, and between baseplate-bone. To determine the screw preload experimentally, the 48mm screw (n=5) was inserted through a hole in a metal plate, which rested on top of a Futek washer load cell, placed on top of the foam block with a predrilled pilot hole (Figure 1). The screw was inserted using a torque driver until the average human factors torque for the screw driver handle was reached. The resulting axial compressive load due to screw insertion was measured by the washer load cell. Two step analyses were performed using Ansys version 17.2 for 18mm and 48mm PS, where 756N axial and shear loads were applied sequentially. The model with the 48mm PS was then analyzed in a four step analysis; preload inferior and superior screws, followed by applying the axial and shear loads (Figure 2). Peak overall micromotion including tangential and normal components at the baseplate-bone interface was compared for all three models. RESULTS. From the experimental study, the mean screw preload for the 48mm screw was determined to be 141±8 lbs. Peak micromotion was predicted at the inferior edge of the baseplate (Figure 3A). In the two models without screw preloads, the model with the 48mm PS predicted 42% lower micromotion than the model with the 18mm PS. The 48mm PS model predicted 63% further reduction in micromotion by including the preload for the two PS. Figure 3B presents the micromotion comparison between these three models. DISCUSSION. This study demonstrates the significant influence that screw preload can have on evaluating either absolute values or differential performance of rTSA micromotion within the same design family. It further demonstrated that the inclusion of preload in simulation can have as much (or greater) impact on micromotion as other key parameters such as shorter versus longer screws. These findings indicates that it is important to include appropriate values of screw preloads in simulations when comparing designs with different number of peripheral screws or studying the effects of including a central screw on rTSA micromotion

Aims

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.

Aims

Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre.

Negative outcomes, accidents and complications are unavoidable. In surgery as in aviation a major role is played by human factors contributing to 30 to 90 per cent of accidents. However in aviation accidents and near-accidents are investigated and all errors are reported. Surgical errors and near-accidents are never reported nor investigated and no lesson can be learned

Aims

The purpose of this study was to evaluate the cost of reverse shoulder arthroplasty (RSA) for patients with a proximal humerus fracture, using time-driven activity based costing (TDABC), and to compare treatment costs with reimbursement under the Healthcare Resource Groups (HRGs).

Introduction: Closed reduction and percutaneous pinning techniques for displaced supracondylar fractures of the humerus in children have overcome disastrous ischemic complications and long inpatient treatment. Closed reduction of those highly unstable fractures and the demanding pin placement itself are potential sources of failure for the inexperienced reflected by the rate of cubitus varus which is still about 5 to 15% in recent series. Rotational primary and residual displacement has to be appreciated to prevent permanent cosmetic deformity. Malrotation is the major source of instability since bicolumnar support is lost which allows the distal fragment to tilt. Anatomy: The transverse section of the distal humerus is the key to all stability related problems faced in supra-condylar fractures of the humerus in children. In the supracondylar region the radial and ulnar column are only connected by a thin bony wafer which results from the presence of the cubital and olecranon fossa. In case of a fracture. In case of a fracture rotation leads to decrease of bony contact and hence to instability. Epidemiology: Elbow fractures account for 7–10% of all pediatric fractures whereof 80–90% are located at the distal humerus with 80% involvement of the supracondylar region. Most of the supracondylar fractures occur between ages 5 and 10 years. Mechanism of injury: Fall from a height, usually from a household object in the age group < 3 years or from a playground equipment in children > 4 years on the outstretched nondominant arm (indirect elbow trauma). 96% of all supracondylar fractures are extension type injuries. Open fractures, mostly grade 1, occur when the anterior spike of the proximal fragment pierces through the brachialis muscle and the skin of the cubital fossa. Their incidence is about 1–3% in major referral centers. Differential diagnosis: Supracondylar fractures have to be differentiated from transcondylar fractures and dislocations of the elbow. In a supracondylar fracture the fracture line stays proximal to the distal humerus physis. If it runs across it, it is most likely a supracondylar fracture. Dislocations of the elbow typically after the age of 10 years. Neurologic compromise: Fracture related peripheral neuropathies have an incidence of 10 to 17%. With rare exceptions concomitant nerve lesion recover spontaneously within a time range of 1 to 4 months. The rate of iatrogenic nerve injuries is 3%–16% with the ulnar nerve being the most susceptible due to inadvertent pinning. Despite a high recovery rate, they are a nuisance for the patients. Vascular compromise: Early recognition of vascular compromise with subsequent reduction and fixation of the fracture and avoidance of extreme flexion at the elbow have decreased the incidence of ischemic complications. An initially absent radial pulse is found in up to 19% in displaced fractures. Closed reduction restores pulsation in about 80%. Patients with postreduction lack of pulse or poor capillary refill should undergo vascular revision. There is still controversy regarding the management of a post reduction pink, warm but pulse less hand with adequate capillary refill. Simple observation and conservative management leads to a favourable clinical outcome in most cases but cold intolerance or exercise induced ischemic symptoms is a potential sequel. Treatment:. Undisplaced fractures: simple immobilisation e.g. collar and cuff. Incomplete displacement: in case of malrotation and/or age-related unacceptable extension (> 20° in patients older than 6 years) closed reduction and pinning otherwise conservative management. Complete displacement: Attempt for closed reduction and percutaneous pinning. Irreducibility is found in up to 22%. Open reduction is most widely as a last resort. Complications:. Infection. Occasionally, superficial infection after pinning occurs despite all preventive measure (wires left protruding through the skin should not be covered by plaster to prevent rubbing; pin care instruction for the parents; regular follow-up for pin site inspection). Cubitus varus. Most common complication with an overall incidence of about 20%. As a malunion in the coronal plane it has no capacity for remodelling. Although this deformity is mainly a cosmetic problem and does not interfere with the range of motion, it may be a functional problem in some activities e.g. in apparatus gymnastics. Malunion/Stiffness. Even after perfect reduction, lack of full extension is common and usually takes over 6 months to improve. Impaired range of motion may be prolonged or even persistent due to an underlying pathology. Malunion is the most common one. In the sagittal plane, antecurvation leads to hyperextension and reduced flexion of the elbow. Significant remodelling with growth can only be expected below the age of 6 and in antecurvations of less than 20°. Rotatory malunion with an anterior spur restrains flexion. Complete remodelling of the spur usually takes place even in older children. Volkmann’s contracture represents the most severe complication after supracondylar fractures. Fortunately, it has become a rarity. Conclusion:. The human factor, in view of the particular anatomy of the supracondylar region and the extreme fracture instability seems to be more decisive for the end result than any biomechanical differences of various pin configurations. Repeat instruction by an experienced surgeon for proper reduction technique, assessment of achieved reduction and technically correct pin placement is crucial to further improve the outcome of this challenging fracture

The April 2015 Trauma Roundup³⁶⁰ looks at: Negative presure wound therapy in open tibial fractures; Priority-driven approach to pelvic injuries; Early surgery essential in hip fracture management; Sheer fractures to the posteromedial plateau; Fasciotomy closure under the spotlight; Why do patients die from hip fracture?; Acetabular fractures down the line; Biomechanics of femoral neck fractures reviewed