Aims

The aim of this study was to explore differences in operative autonomy by trainee gender during orthopaedic training in Ireland and the UK, and to explore differences in operative autonomy by trainee gender with regard to training year, case complexity, index procedures, and speciality area.

Aims

Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons.

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

The February 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.

Aims

The COVID-19 pandemic has had a significant impact on the provision of orthopaedic care across the UK. During the pandemic orthopaedic specialist registrars were redeployed to “frontline” specialties occupying non-surgical roles. The impact of the COVID-19 pandemic on orthopaedic training in the UK is unknown. This paper sought to examine the role of orthopaedic trainees during the COVID-19 and the impact of COVID-19 pandemic on postgraduate orthopaedic education.

The coronavirus 2019 (COVID-19) global pandemic has had a significant impact on trauma and orthopaedic (T&O) departments worldwide. To manage the peak of the epidemic, orthopaedic staff were redeployed to frontline medical care; these roles included managing minor injury units, forming a “proning” team, and assisting in the intensive care unit (ICU). In addition, outpatient clinics were restructured to facilitate virtual consultations, elective procedures were cancelled, and inpatient hospital admissions minimized to reduce nosocomial COVID-19 infections. Urgent operations for fractures, infection and tumours went ahead but required strict planning to ensure patient safety. Orthopaedic training has also been significantly impacted during this period. This article discusses the impact of COVID-19 on T&O in the UK and highlights key lessons learned that may help to proactively prepare for the next global pandemic.

Cite this article: Bone Joint Open 2020;1-7:420–423.

Aims. Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). Patients and Methods. A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration. Results. VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (. sd. 3) vs 12 (. sd. 3)), were 12° more accurate in component orientation (mean error 4° (. sd. 6°) vs 16° (. sd. 17°)), and were 18% faster (mean 42 minutes (. sd. 7) vs 51 minutes (. sd. 9)). Conclusion. Procedural knowledge and psychomotor skills for THA learned in VR were transferred to cadaveric performance. Basic preparatory materials had limited value for trainees learning a new technique. VR training advanced trainees further up the learning curve, enabling highly precise component orientation and more efficient surgery. VR could augment traditional surgical training to improve how surgeons learn complex open procedures. Cite this article: Bone Joint J 2019;101-B:1585–1592

Aims

There are many guidelines that help direct the management of patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken a study to compare the management of patients with MOM hip arthroplasties in different countries.

In June 2012 the Orthopaedic Speciality Advisory of the Joint Committee on Surgical Training defined ‘minimum indicative numbers’ that trainees would have to meet before completion of specialist training. It has been speculated that regions have varied in their ability to provide operative opportunities to their trainees. This study aims to test the hypothesis that there are regional differences in operative training experience. The eLogbook database was interrogated for cases over a 12 month period from 7 August 2013 to 5 August 2015. Within each region, the mean of the cases registered by orthopaedic trainees in each year of training during the study period was calculated and summed to give a representative surgical experience for the years ST3-8. First surgeon only cases were analysed for 11 index procedures in 30 T&O rotations. Considerable variation in training existed across rotations. In three index procedures, including DHS, no rotation achieved the minimum indicative number required. All rotations achieved the minimum indicative number of external fixator applications. This study proves the extent of the significant regional variation in surgical training in Trauma and Orthopaedics in the UK and raises concerns regarding the volume of operative training currently achieved

There are significant differences in the methods and styles of orthopaedic surgical training between continents, all with the aim to produce competent consultant surgeons, but the differences in training content and pathway are vast. We review and contrast the key differences between three continents.

Objectives

Acetabular retractors have been implicated in damage to the femoral and obturator nerves during total hip replacement. The aim of this study was to determine the anatomical relationship between retractor placement and these nerves.

Introduction. Malpositioning of the tibial component is a common error in TKR. In theory, placement of the tibial tray could be improved by optimization of its design to more closely match anatomic features of the proximal tibia with the motion axis of the knee joint. However, the inherent variability of tibial anatomy and the size increments required for a non-custom implant system may lead to minimal benefit, despite the increased cost and size of inventory. This study was undertaken to test the hypotheses: . 1. That correct placement of the tibial component is influenced by the design of the implant. 2. The operative experience of the surgeon influences the likelihood of correct placement of contemporary designs of tibial trays. Materials and Methods. CAD models were generated of all sizes of 7 widely used designs of tibial trays, including symmetric (4) and asymmetric (3) designs. Solid models of 10 tibias were selected from a large anatomic collection and verified to ensure that they encompassed the anatomic range of shapes and sizes of Caucasian tibias. Each computer model was resected perpendicular to the canal axis with a posterior slope of 5 degrees at a depth of 5 mm distal to the medial plateau. Fifteen joint surgeons and fourteen experienced trainees individually determined the ideal size and placement of each tray on each resected tibia, corresponding to a total of 2030 implantations. For each implantation we calculated: (i) the rotational alignment of the tray; (ii) its coverage of the resected bony surface, and (iii) the extent of any overhang of the tray beyond the cortical boundary. Differences in the parameters defining the implantations of the surgeons and trainees were evaluated statistically. Results. On average, the tibial tray was placed in 5.5 ± 3.1° of external rotation. The overall incidence of internal rotation was only 4.8%: 10.5% of trainee cases vs. 0.7% of surgeon cases (p < 0.0001). The incidence of internal rotation varied significantly with implant design, ranging from 1.7% to 6.2%. Bony coverage averaged 76.0 ± 4.5%, and was less than 70% in 8.6% of cases. Tibial coverage also varied significantly between designs (73.2 ± 4.3% to 79.2 ± 3.8%; p < .0001). Clinically significant cortical overhang (>1 mm), primarily in the posterior-lateral region, was present in 12.1% of cases, and varied by design, as expressed by the area of the tray overhanging the cortical boundary (min: 2.3 ± 6.7 mm. 2. ; max: 4.7 ± 7.9 mm. 2. ; p < .0001). The surgeons and the trainees also differed in terms of the incidence of sub-optimal tibial coverage (10.0% vs. 14.4%, p < 0.001), and cortical overhang (7.4% vs. 9.7%, p < 0.001). Discussion. 1. Malrotation, bony coverage and cortical overhang are all strongly influenced by the design of the tibial tray selected and the experience of the surgeon. 2. Compared to trainees, experienced surgeons tend to position tibial trays in more external rotation, and with less concern for reduced bony coverage and cortical overhang than trainees. 3. This study supports the hypothesis that improvements in the outcome and reliability of TKR may be achieved through attention to implant design

Valid and reliable techniques for assessing performance are essential to surgical education, especially with the emergence of competency-based frameworks. Despite this, there is a paucity of adequate tools for the evaluation of skills required during joint replacement surgery. In this scoping review, we examine current methods for assessing surgeons’ competency in joint replacement procedures in both simulated and clinical environments. The ability of many of the tools currently in use to make valid, reliable and comprehensive assessments of performance is unclear. Furthermore, many simulation-based assessments have been criticised for a lack of transferability to the clinical setting. It is imperative that more effective methods of assessment are developed and implemented in order to improve our ability to evaluate the performance of skills relating to total joint replacement. This will enable educators to provide formative feedback to learners throughout the training process to ensure that they have attained core competencies upon completion of their training. This should help ensure positive patient outcomes as the surgical trainees enter independent practice.

Cite this article: Bone Joint J 2013;95-B:1445–9.

Purpose

Case logs have been utilized as a means of assessing residents surgical exposure and involvement in cases. It can be argued that the degree of involvement in operative cases is as important as absolute number of cases logged. A log which contains accurate information on actual participation in surgical cases in addition to self reported competency, is a powerful tool in obtaining a true reflection of surgical experience. Thus a prerequisite for a valuable log is the ability to perform an accurate self-assessment. Numerous studies have shown mixed results when examining residents ability to perform self-assessment on varying tasks. The purpose of the study was to examine the correlation between residents self-assessment and staff surgeons evaluation of surgical involvement and competence in performing primary hip and knee arthroplasty surgery.

Surgery for spinal deformity was previously carried out only in teaching hospitals in the United Kingdom. With increasing numbers of patients especially adults, seeking treatment for spinal deformity, the number of centres offering treatment for spinal deformity is going to have to increase. The deformity part of the Spinal Surgical Service in the District General Hospital in Taunton started in 2005. This paper is an audit of this deformity service. It looks at two key areas – that of patient satisfaction and patient reported outcomes of surgery. Patient satisfaction was assessed by a validated questionnaire that evaluated a patient's perception of consultations, consent, preoperative assessment, operative and post operative experience and follows up visits. Patient reported outcomes were evaluated using the SRS 30 questionnaire. 104 patients were contacted and 95 patients (91%) responded. The overall patient satisfaction rate was 96%, with 87% very pleased with the result of surgery, 80% felt that their body shape had improved considerably, 62% had an increased ability to carry out day to day activities to a much higher level and 78% had significantly decreased pain after surgery. The results of the different domains of the SRS questionnaire also supported this. The authors believe that this audit proves that it is possible to provide a spinal deformity service in a District General Hospital in the United Kingdom safely and effectively with a high degree of patient satisfaction. Audits of this kind are required to compare results of treatment between different centres and establish standards

Background. Every trainee in Trauma and Orthopaedics (T&O) in the UK and Ireland records their operative experience via the Faculty of Health Informatics eLogbook. Since August 2009, all doctors were subject to the full European Working Time Directive (EWTD) restrictions of 48 hours of work per week. We have previously shown that the implementation of shift working patterns in some units in preparation for these restrictions reduced training opportunities by 50% (elective surgical exposure). We have now analysed the national data to establish whether operative experience has fallen since August 2009. Methods. All operative data recorded nationally by trainees (all years, all supervision levels) between the 3 months of August to October 2007, 2008 and 2009 were compared. Data were available for 1091 ‘validated’ training grade surgeons (ST3-8 or equivalent) in 2007, 1103 in 2008 and 767 in 2009. Mean operative figures were calculated per trainee for each of the 3-month time periods. Results. During the three study periods trainees performed an average of 63 (2007), 62 (2008) and 65 (2009) operations, and total operative exposure was 102, 101 and 107 respectively. There was an increase in operative exposure of 5% from 2007 to 2009. Trauma represented 44% (2007), 41% (2008) and 42% (2009) of total exposure. Conclusion. This national data shows that, in the 3 months following implementation of the 48-hours EWTD restrictions, the expected decrease in operative exposure did not occur. This may be a result of the introduction of rotas to maximise theatre exposure, whilst minimising other commitments, such as outpatient experience. Alternatively, there may be widespread disregard for shift working and hours restrictions in order to maintain adequate operative exposure. Despite the implementation of the full EWTD restrictions, it appears that T&O trainee operative exposure in the first three months has not fallen

Centre Hospitalo-Universitaire de Lille, Service de Neurochirurgie et Chirurgie du Rachis, Lille, France. Assessment of current thoughts regarding spinal fellowships amongst spinal fellows in the United Kingdom and abroad. Qualitative analysis provides rich and contextual detail that cannot be borne out by quantitative research. We undertook detailed interviews amongst fellows who have varying fellowship experience both in the United Kingdom and abroad. Ten fellows, all of whom were approaching their Certificate of Completion of Training (or equivalent) in Trauma and Orthopaedic surgery, or just awarded the certificate. All undertaking/undertaken at least one 12-month fellowship. Qualitative experiences. A large unit provides a breadth of pathology that may is usually not encountered in smaller units. Fellows who worked in such units felt confident that they would recognise a variety of pathologies, but did not necessarily feel confident in their surgical management. Operative exposure to deformity surgery, whilst not necessarily a future part of practice, was felt useful for the added technical skills it provides. Fellows attending a smaller unit, where they may have been the sole ‘spinal fellow’, reported greater satisfaction in operative experience. Interestingly, there was felt to be a ‘saturation point’, where a fellow perceived no further educational benefit from remaining in one particular unit. A fellowship in spinal surgery is useful in preparing for independent practice as a spinal surgeon. Large units provide skills that are applicable to several aspects of spinal surgery. There appears to be a difference in breadth and complexity of pathology versus operative experience

From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected. A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day, 24hr on call then off next working day, or shifts including nights). 66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced. This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK

Introduction: The assessment of quality in the provision of healthcare is one of the core features of the National Health Service in the 21st Century. From April 2009 Patient Reported Outcome Measure (PROM) data are being collected for the Department of Health for elective hip and knee arthroplasty using generic and disease specific measures of health status. The perceived uses of these data may be for research, assessment of procedural outcome, measures of health inequalities and to aid commissioning groups in selecting their secondary care providers. Foot and ankle surgery covers a wide spectrum of operative procedures with patient responses less predictable than with major joint arthroplasty. We report the use of a sixteen point satisfaction-based questionnaire in order to investigate the nature of patient outcome after the processes of foot and ankle surgery. Methods: A prospective series of 100 two-part Visual Analogue Scale (VAS) questionnaires was distributed to patients undergoing elective foot and ankle surgery at the Northern General Hospital under the care of four foot and ankle surgeons over a three-month period. The questionnaires were numbered to allow patient anonymity. The first part of nine questions enquired about pre-operative preparation and information and was distributed before surgery. The second part of seven questions, distributed at the first post-operative clinic sought to investigate their hospital and operative experience. Free text comments were requested in addition to the VAS responses, which were expressed as percentages. Results: 97% of part one and 85% of part two questionnaires were returned completed. 82% had both parts completed and matched. The day case to inpatient ratio was 55: 45. For part one, all clinically related questions scored more than 90% satisfaction, with only two scores for administration-based questions falling below this level. For part two, satisfaction for clinical questions again scored more than 90% and overall, all scored more than 80% satisfaction. Only 23% of pre-operative and 28% of post-operative questionnaires were returned with free-text comments. Conclusions: A simple patient satisfaction-based questionnaire may be as useful as existing non-validated generic scoring systems used in foot and ankle surgery when assessing quality in the health service, particularly where regional demographics or referral patterns may be important factors influencing patient outcomes. Active dialogue with the surgical colleges and Department of Health should be pursued to avoid inappropriate outcome measures being imposed in foot and ankle surgery

Background: From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected. Methods: A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day [traditional on call], 24hr on call then off next working day, or shifts including nights). Results: 66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced. Discussion: The eLogbook is a powerful resource that provides accurate data for the purpose of supporting orthopaedic training. This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK