Aims. Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems. Methods. A cross-sectional survey of 774 orthopaedic surgeons and trainees in five countries (Australia, Canada, New Zealand, UK, and USA) was conducted in 2019. Respondents were asked to complete the Mayo Clinic Well-Being Index and the Stanford Professional Fulfillment Index in addition to 31 personal/demographic questions and 27 employment-related questions via an anonymous online survey. Results. A total of 684 participants from five countries (Australia (n = 74), Canada (n = 90), New Zealand (n = 69), UK (n = 105), and USA (n = 346)) completed both of the risk assessment questionnaires (Mayo and Stanford). Of these, 42.8% (n = 293) were trainees and 57.2% (n = 391) were attending surgeons. On the Mayo Clinic Well-Being Index, 58.6% of the overall sample reported feeling burned out (n = 401). Significant differences were found between nations with regards to the proportion categorized as being at risk for poor outcomes (27.5% for New Zealand (19/69) vs 54.4% for Canada (49/90) ; p = 0.001). On the Stanford Professional Fulfillment Index, 38.9% of the respondents were classified as being burned out (266/684). Prevalence of burnout ranged from 27% for Australia (20/74 up to 47.8% for Canadian respondents (43/90; p = 0.010). Younger age groups (20 to 29: RR 2.52 (95% confidence interval (CI) 1.39 to 4.58; p = 0.002); 30 to 39: RR 2.40 (95% CI 1.36 to 4.24; p = 0.003); 40 to 49: RR 2.30 (95% CI 1.35 to 3.9; p = 0.002)) and trainee status (RR 1.53 (95% CI 1.15 to 2.03 p = 0.004)) were independently associated with increased relative risk of having a ‘at-risk’ or ‘burnout’ score. Conclusions. The rate of self-reported burnout and risk for poor outcomes among orthopaedic surgeons and trainees varies between countries but remains unacceptably high throughout. Both individual and health system characteristics contribute to physician wellness and should be considered in the development of strategies to improve surgeon wellbeing. Level of Evidence: III. Cite this article: Bone Jt Open 2021;2(11):932–939

Introduction. Although we know that smoking damages health, we do not know impact of smoking on a patient's outcome following primary knee arthroplasty (KA). In the UK, clinical commissioning groups (CCGs) have the authority (& funds) to commission healthcare services for their communities. Over the past decade, an increasing number of CCGs are using smoking as a contraindication for patients with end-stage symptomatic knee arthritis being referred to a specialist for due consideration of KA without any clear evidence of the associated risks & benefits. The overall objective of this study is to compare clinical outcomes after knee arthroplasty surgery in smokers, ex-smokers & non-smokers. Methods. We obtained data from the UK Clinical Research Practice Datalink (CPRD) that contains information on over 11 million patients (7% of the UK population) registered at over 600 general practices. CPRD data was linked to Hospital Episode Statistics, hospital admissions & Patient Reported Outcome Measures (PROMs) data. We collected data on all KAs (n=64,071) performed over a 21-year period (1995 to 2016). Outcomes assessed included: local & systemic complications (at 6-months post-surgery): infections (wound, respiratory, urinary), heart attack, stroke & transient ischaemic attack, venous thromboembolism, hospital readmissions & GP visits (1-year), analgesic use (1-year), surgical revision (up to 20-years), mortality (90-days and 1-year), & 6-month change from pre-operative scores in Oxford Knee Score (OKS). Regression modelling is used to describe the association of smoking on outcomes, adjusting for confounding factors. Results. Smoking was associated with an increased risk of lower respiratory tract infections (LRTI) (4.2% smokers vs. 2.7% non-smokers) (Odds Ratio (OR) 0.76, p-value 0.017). LRTI were similar in ex-smokers & smokers at 3.9%. There was no association with any of the other 6-month complications. Pain medication use over 1-year post surgery was higher in smokers compared to non-smokers: gabapentinoids 7.4% vs. 5.2% (OR 0.74, p< 0.001), opioids 45.9% vs. 35.3% (OR 0.79, p< 0.001), NSAIDs 51.6% vs. 46.1% (OR 0.91, p = 0.044). Mortality was higher in smokers at 1-year compared to non-smokers (hazard ratio (HR) 0.53, p<0.001) & ex-smokers (HR 0.65, p = 0.037), but there was no difference observed at 90-days. There was no association of smoking on revision surgery over 20-years follow up. Smoking was associated with worse postoperative OKS being 3.1 points higher in non-smokers (p<0.001) & 3.0 points higher in ex-smokers (p<0.001). The overall change in OKS before & after surgery was 13.9 points in smokers versus 16.3 points in non-smokers (p<0.001) & 15.7 points in ex-smokers (p<0.001). Over the year following surgery, smokers were more likely to visit their GP, but there was no association with hospital readmission rates. Conclusion. This is the largest study with linked primary care & secondary care data highlighting impact of a preventable patient factor on outcome of a routinely performed planned intervention. Smokers achieved clinical meaningful improvements in patient reported pain & function (OKS) following KA, although their attained post-operative OKS was lower than in non-smokers & ex-smokers. Levels of pain medication use were notably higher in both smokers & ex-smokers. As smokers achieved good clinical outcomes following KA surgery, smoking should not be a barrier to referral for or consideration of KA. However, the study does highlight particular risks a patient is taking if he/she continues to smoke when being considered for elective knee arthroplasty. This study will help the family physicians as well as patients to make an informed decision on whether to go ahead with a planned intervention whilst patient continues to be an active smoker or not. Key Words: Knee Arthroplasty, Smoking, Patient Reported Outcomes, Epidemiology, Complications

Purpose: Patients hospitalized for osteomyelitis due to multi-resistant strains are often given prolonged parenteral antibiotics. Ambulatory parenteral antibiotic therapy is an alternative allowing outpatient care. The purpose of this study is to assess tolerance, cost and efficacy of this type of treatment. Material and methods: Thirty-nine patients followed for osteomyelitis were included in this study. These patients were given antibiotics in a continuous infusion using a portable diffuser connected to an implanted chamber. Mean duration of treatment was four months, range 1.5–12 months. The follow-up team included the primary care physician, an infectious diseases specialist, and a nurse with special training in prolonged ambulatory antibiotic treatments. Results of weekly blood tests were transmitted to the referral hospital physician. Adverse effects and cost of prolonged ambulatory antibiotic therapy were recorded. Cost included costs for nurses, physical therapists, and physicians as well as drugs, supplies and laboratory tests. The cost of hospitalisation was determined on the basis of the standard cost for one day of hospitalisation in France. Results: There were three cases of thrombophlebitis and one case of allergic reaction, both required re-hospitalisation. Cure was achieved in 93% of the patients. Mean follow-up since cure with discontinuation of the antibiotics was 18 months (14–22). Home care was possible in 100% of the patients and 23% of the patients were able to resume their occupational activity; 25% resumed their schooling. Self-administered schemes were possible in 23% of the patients. Compared with conventional hospitalisation, ambulatory parenteral antibiotic therapy enabled a cost savings of 1352 euros per patient. Discussion: These results demonstrate that ambulatory antibiotic therapy is a very good alternative to classical hospitalisation enabling low morbidity, early resumption of social activities without loss of efficacy

Aims

The worldwide COVID-19 pandemic is directly impacting the field of orthopaedic surgery and traumatology with postponed operations, changed status of planned elective surgeries and acute emergencies in patients with unknown infection status. To this point, Germany's COVID-19 infection numbers and death rate have been lower than those of many other nations.

Introduction: Necrotizing Fasciitis (NF) is a potentially lethal deep soft tissue infection. Correlation between prompt diagnosis and adequate surgical treatment and favorable outcome is well documented, however scarcity of specific cutaneous signs and the potential of evolution from otherwise simple infections may contribute to delay in diagnosis and treatment. Few clues may assist the physician to avoid overlooking this surgical emergency. Patients and Methods: Sixty-eight patients were treated in our hospital for necrotizing fasciitis since 1990. In twenty-five of them the major involvement was peripheral, sparing the head, neck and torso. We reviewed these 25 cases for patterns of presentation and alarming signs for the first encountered physician, as well as for kinetics of treatment and outcome. Results: Eight female and seventeen male patients aged 1–83 (average 53.6) years were treated. Only eight of them (32%) were free of comorbidities associated with reduced immunity. Majority of patients referred to the emergency department complaining of local pain/tenderness and erythema for few days accompanied by excruciating pain. Vital signs were often within normal limits, although leucocytosis on admission was common and gas was evident in the soft tissue by imaging. Surgical debridement was usually carried out on the day of diagnosis that was established immediately on admission in 10 cases (40%) but was delayed beyond 72 hours in seven patients (28%). CT scans showed severe edema and muscle liquefaction when taken. Thighs and gluteal region was the most common site of infection (56%) and cultures grew gram positive cocci (64%) and enteral flora (68%) in mono- and poly-microbial cultures. Only three cultures grew unaerobes, of which only one was clostridium. Accordingly, imaging studies showing gas in the soft tissue were uncommon. Eight patients (32%) have expired, and the average hospitalization period was over 38 days for the survivors. Conclusions: NF is one of the surgical emergencies encountered by orthopedic surgeons. It is there, knocking at our door and will not go away… even a minor delay in diagnosis may be catastrophic to the patient, who often present with common signs and symptoms of mild to moderate skin infection. It should therefore be noted that pain inadequate for a minor infection was characteristic to most patients diagnosed with NF, and that CT findings may establish the diagnosis. Although considered pathognomonic, both crepitus and imaging finding of gas in the soft tissue are uncommon. Special attention to patients at risk and careful physical examination may lead to rapid diagnosis and treatment, and eventually lower the significant morbidity and mortality associated with this condition

Fluoroscopic guidance is common in interventional pain procedures. In spine surgery, injections are used for differential diagnosis and determination of indication for surgical treatment as well. Fluoroscopy ensures correct needle placement and accurate delivery of the drug. Also, exact documentation of the intervention performed is possible. However, besides the patient, interventional pain physicians, surgeons and other medical staff are chronically exposed to low dose scatter radiation. The long-term adverse consequences of low dose radiation exposure to the medical staff are still unclear. Especially in university hospital settings, where education of trainees is performed, fluoroscopy time and total radiation exposure are significantly higher than in private practice settings. It remains a challenge for university hospitals to reduce the fluoroscopic time while maintaining the quality of education. Multiple approaches have been made to reduce radiation exposure in fluoroscopy, including the wide spread use of pulsed fluoroscopy, or rarely used techniques like laser guided needle placement systems. The Zero-Dose-C-Arm-Navigation (ZDCAN) allows an optimal positioning of the c-arm without exposure to radiation. For training purposes, relevant anatomical structures can be highlighted for each interventional procedure, so injection needles can be best positioned next to the target area. The Zero-Dose-C-Arm-Navigation (ZDCAN) module was developed to display a radiation free preview of the expected fluoroscopic image of the spine. Using an optical tracking system and a registered 3D-spine model, the expected x-ray image is displayed in real-time as a projection of the model. Additionally, selected anatomical structures including nerve roots, facet joints, vertebral discs and the epidural space, can be displayed. A seamless integration of the ZDCAN in a c-arm system already used in clinical practice for years could be achieved. For easy use, a tool was developed allowing the admission and use of regular single-use syringes and spinal needles. Accordingly, these can be used as pointers in the sterile area, a sterilization of the whole tool after every single injection is not required. We evaluated the efficiency and accuracy of this procedure compared to conventional fluoroscopically guided interventional procedures. In sawbones of the lumbar spine, facet joint injections (N = 50), perineural injections (N = 46) and epidural injections (N = 20) were performed. Highlighting the target area in the radiation free preview model, an optimal positioning of the c-arm could be achieved even by unskilled medical staff. The desired anatomical structures could be identified easily in the x-rays taken, as they were displayed in the 3D model aside. As already seen evaluating a previous version of the ZDCAN module for the lower limb, the total number of x-ray images taken could be reduced significantly. Compared to the conventional group, the number of x-ray images required for facet joint injections could be reduced from 12.5 (±1.1) to 5.7 (±1.1), from 5.4 (±1.8) to 3.8 (±1.3) for perineural injections and from 4.1 (±0.9) to 2.1 (±0.3) for epidural injections. Total radiation time was reduced accordingly. Likewise, the mean time needed for the interventional procedure could be reduced from 168.3 s (±19.1) to 131.4 s (±16.8) for facet joint injections, was unchanged from 97.7 s (±26.0) to 104.7 s (±31.0) for perineural injections and from 60 s (±14.9) to 52 s (±7.1) for epidural injections. The ZDCAN is a powerful tool advancing conventional fluoroscopy to another level. Using the radiation free preview model, the c-arm can easily be positioned to show the desired area. The accentuated display of the target structures in the preview model makes the introduction to fluoroscopy guided interventional procedures easier. This feature might reduce the learning curve to achieve better clinical results with lower radiation dose exposure. Thus, the ZDCAN can be a tool to improve education in university hospital settings for physicians as well as for medical staff while reducing radiation dose exposure in general use