Background: Hip fracture is a serious injury mainly affecting the elderly population. The injury has a high mortality of 30% at 1 year and also has a major impact on the quality of life of the survivors. The Scottish Hip Fracture Audit has identified significant difference in the level of care provided in hip fractures between different hospitals and regions. The study aims to assess the impact of the experience of the operating surgeon on the long term outcome of hip fractures taking a cemented bipolar hip arthroplasty as an index procedure.

Materials and Methods: All patients who had the index procedure carried out over an eight year period at the Dumfries and Galloway Royal Infirmary were included in the study. Their preoperative mobility and health status along with the experience of the surgeon performing the procedure were determined. The outcome assessment was carried out using a modified Harris hip score.

Results: 46 patients were followed up at a mean of 45 months (range 16 to 109). One patient required a revision for aseptic loosening. Of the remaining, 18 procedures were carried out by consultant surgeons and 27 by trainees unsupervised. There was no statistical difference in the age, sex, ASA grade, preoperative mobility level or duration of follow up between the two groups of patients. The mean hip score at the time of follow up for the consultant group was 67.2 and 52.6 for the trainee group. This was statistically significant with a P value < 0.05.

Conclusion: The proportion of hip fracture surgeries done by, or under the direct supervision of a consultant orthopaedic surgeon vary widely between various Scottish hospitals (20% to 90%). The significant difference in long term out come of the procedure based on the surgeon’s experience calls for greater supervision and training of juniors.

Orthopaedic training sessions, vital for surgeons to understand post-operative joint function, are primarily based on passive and subjective joint assessment. However, cadaveric knee simulators, commonly used in orthopaedic research,. 1. could potentially benefit surgical training by providing quantitative joint assessment for active functional motions. The integration of cadaveric simulators in orthopaedic training was explored with recipients of the European Knee Society Arthroplasty Travelling Fellowship visiting our institution in 2018 and 2019. The aim of the study was to introduce the fellows to the knee joint simulator to quantify the surgeon-specific impact of total knee arthroplasty (TKA) on the dynamic joint behaviour, thereby identifying potential correlations between surgical competence and post-operative biomechanical parameters. Eight fellows were assigned a fresh-frozen lower limb each to plan and perform posterior-stabilised TKA using MRI-based patient-specific instrumentation. Surgical competence was adjudged using the Objective Structured Assessment of Technical Skills (OSATS) adapted for TKA. 2. All fellows participated in the in vitro specimen testing on a validated knee simulator,. 3. which included motor tasks – passive flexion (0°-120°) and active squatting (35°-100°) – and varus-valgus laxity tests, in both the native and post-operative conditions. Tibiofemoral kinematics were recorded with an optical motion capture system and compared between native and post-operative conditions using a linear mixed model (p<0.05). The Pearson correlation test was used to assess the relationship between the OSATS scores for each surgeon and post-operative joint kinematics of the corresponding specimen (p<0.05). OSATS scores ranged from 79.6% to 100% (mean=93.1, SD=7.7). A negative correlation was observed between surgical competence and change in post-operative tibial kinematics over the entire range of motion during passive flexion – OSATS score vs. change in tibial abduction (r=−0.87; p=0.003), OSATS score vs. change in tibial rotation (r=−0.76; p=0.02). When compared to the native condition, post-operative tibial internal rotation was higher during passive flexion (p<0.05), but lower during squatting (p<0.033). Post-operative joint stiffness was greater in extension than in flexion, without any correlation with surgical competence. Although trained at different institutions, all fellows followed certain standard intraoperative guidelines during TKA, such as achieving neutral tibial abduction and avoiding internal tibial rotation,. 4. albeit at a static knee flexion angle. However, post-operative joint kinematics for dynamic motions revealed a strong correlation with surgical competence, i.e. kinematic variability over the range of passive flexion post-TKA was lower for more skilful surgeons. Moreover, actively loaded motions exhibited stark differences in post-operative kinematics as compared to those observed in passive motions. In vitro testing on the knee simulator also introduced the fellows to new quantitative parameters for post-operative joint assessment. In conclusion, the inclusion of cadaveric simulators replicating functional joint motions could help quantify training paradigms, thereby enhancing traditional orthopaedic training, as was also the unanimous opinion of all participating fellows in their positive feedback

Introduction. The efficacy of Virtual Reality (VR) as a teaching augment for arthroplasty has not been well examined for unfamiliar multistep procedures such as unicompartmental knee arthroplasty (UKA). This study sought to determine if VR improves surgical competence over traditional procedural preparation when performing a UKA. Methods. 22 Orthopaedic trainees were randomized to training sessions: 1) “VR group” with access to an immersive VR learning module that had been designed in conjunction with the manufacturer or 2) “Guide group” with access to manufacture's technique guide and surgical video. Both groups then performed a full UKA on SawBones models. Surgical competence was assessed via Objective Structures Assessment of Technical Skills (OSATS) validated rating system (max 25 points). Results. Participants equally distributed all training levels between groups. There was no difference in surgical times between VR and Guide groups (VR=43.0 vs Guide=42.4 mins; p=0.9). There was no difference in total OSATS score between groups (VR=14.2 vs Guide=15.7; p=0.59). There was also no difference between groups when sub-analysis was performed by training level. Most felt VR would be a useful tool for resident education (77%) and reported a likeliness to utilize VR for case preparation if available (86.4%). Conclusion. In a randomized controlled trial for trainees performing a complex, unfamiliar procedure (UKA), VR training demonstrated equivalent surgical competence to traditional technique guides and videos. Despite this, the majority of trainees find the technology beneficial and would use it if available. This project suggests as currently constructed, VR should be incorporated as an adjunct, rather than a replacement, to traditional surgical preparation/training methods

Procedure Based Assessments (PBAs) are one type of Workplace Based Assessment (WBA) introduced recently to orthopaedic training in the UK. They play an increasing role in the assessment of a trainee's surgical competence. The study aims to determine the most valuable aspects of a PBA to a trainee, and the changes trainees suggest to improving the use of PBAs. A link to an online questionnaire was sent by email via the eLogbook system to all orthopaedic trainees in the UK with a National Training Number (NTN). The free text responses were coded and categorised. Analysis of results was conducted using the online survey software and Microsoft Excel. Of 668 responses, 616 met the inclusion criteria, making a response rate of 66% of all trainees with a NTN in the UK. There was a broad, representative spread of seniority and of geographical location. Trainees found the verbal feedback gained from their trainer to be most valuable (47%), followed by the assessment of competence (21%). Trainees identified the PBA form itself as the most important area for change (52.4%). This included increased numbers of PBAs (17.5%), more specific to the procedure (8.6%), more user friendly (15%), more levels of competence (4.5%) and a generic PBA (3.4%). Further suggestions included changing the role of PBAs, with 8.2% suggesting discontinuing their use entirely. Improving trainer investment in the use of PBA was also highlighted. Trainees value PBAs to gain formal feedback more than their use as evidence of competence in a procedure. There are a number of changes suggested by trainees that could improve the use and effectiveness of PBAs, and we have incorporated these into recommendations made by the British Orthopaedic Trainees’ Association, which should inform the debate on the further development of this assessment tool, and on WBAs in general

Objective: To investigate the effect of lab based simulator training, on the ability of basic surgical trainees to perform diagnostic knee arthroscopy. Method: 20 orthopaedic SHO’s with minimal arthroscopic experience were randomised to 2 groups. 10 received a fixed protocol of simulator based arthroscopic skills training. This consisted of 3 sessions of 6 simulated arthroscopies using a Sawbones bench-top knee model. Their learning curve was assessed objectively using motion analysis. Time taken, path length and number of movements were recorded. All 20 then spent an operating list with a blinded consultant trainer. They received instruction and demonstration of diagnostic knee arthroscopy before performing the procedure independently. Their performance was assessed using the intra- operative section of the Orthopaedic Competence Assessment Project (OCAP) procedure based assessment (PBA) protocol for diagnostic arthros-copy and further quantified with a global rating assessment scale. Results: In theatre, simulator-trained SHO’s outscored all but one untrained SHO. The simulator trained group were scored as competent on more than 70% of occasions compared to less than 15% for the un-trained group (p< 0.05). The mean global rating score of the trained group was 24.4 out of 45 compared with 12.4 for the untrained group (p< 0.05). Motion analysis demonstrated objective and significant improvement in performance during simulator training. Conclusion: The use of lab based arthroscopic skills training leads to subsequent significant improvement in operating theatre performance. This may suggest that formalised lab based training should be a standardised part of future surgical curricula. OCAP PBA’s appear to provide a useful framework for assessment however potential questions are raised about the ability of OCAP to truly distinguish levels of surgical competence

The August 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Serial MRIs best for pseudotumour surveillance; Is ultrasound good enough for MOM follow-up?; Does weight loss in obese patients help?; Measuring acetabular anteversion on plain films; Two-stage one-stage too many in fungal hip revisions? and 35 is the magic number in arthroplasty.

The June 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.