Introduction. The transition from resident to registrar constitutes a steep learning curve in most medical practitioners’ careers, regardless of speciality. We aimed to determine whether a six-week orthopaedic surgical skills course could increase resident skills and confidence prior to transitioning to orthopaedic registrar within the Gold Coast University Hospital, Queensland, Australia. Materials. Unaccredited registrars, orthopaedic trainees, and orthopaedic consultants, through a departmental peer reviewed process and survey, developed a six-session course (“Registrar Academy”) that included basic knowledge and essential practical skills training for residents with an interest in becoming orthopaedic registrars. This course was implemented over a 3-month period and assessed. Mixed method quantitative and qualitative evidence was sought via a 14-item and 18-item Likert scale questionnaire coupled with open-ended questions. Ethical approval was granted by our institutions Human Research and Ethics Comittee, reference no.: HREC/16/QGC336. Results/Discussion. Results were qualitatively synthesised using quantitative and qualitative data. Thirteen residents participated in the course. All residents agreed to statements indicating they felt unprepared to work as an orthopaedic registrar and were not confident in performing various core tasks required. After completing the course, residents indicated greater confidence or comfort in all these areas and felt better prepared for the transition to registrar. There was broad approval of the course among participants. Every participant who completed the final questionnaire agreed or strongly agreed that they enjoyed the course and that it taught usable, reproducible practical skills and increased their orthopaedic knowledge. This group also uniformly agreed or strongly agreed that the course improved their patient care and patient safety. Conclusion. Residents feel unprepared for their transition to orthopaedic registrar and lack confidence in several core competencies. A supplemental “Registrar Academy” within an institution is an effective way to improve knowledge, confidence, and practical skills for residents wishing to transition to a registrar position

Derriford Hospital gained Major Trauma Centre (MTC) status in April 2012, this led to a significant increase in the trauma case load. Our aim was to review registrar exposure to theatre and clinic in the elective and trauma setting. This was then compared to audits performed pre-MTC status and shortly following MTC changes to see if training standards were being maintained. Improvements in registrar rota planning were made following the previous assessment of training. Training was assessed with respect to national recommendations for registrar training. Data was collected for 8 weeks in February and March 2014 for all 12 registrars, and cross-referenced with the on-call and daily rota. The data was divided into training and non -training registrars. Elective exposure had improved in both theatres and clinic along with trauma theatre exposure whilst fracture clinic exposure had reduced since the previous audit. The reduction may be a result of the on-call registrar no longer being present in fracture clinic when on-call in compliance with MTC guidance. Rota management requires a fine balance between service and training commitments. Recent improvements to the management of the registrar rota appear to provide satisfactory training despite the pressures of MTC changes at Derriford Hospital

The process of training orthopaedic registrars in the technique of lower limb arthroplasty (hip & knee) requires a long learning curve. The practice of consultant supervised operating should not compromise the final outcome and patient care. The aim of this study was to compare complication rates of lower limb arthroplasties performed by orthopaedic trainees with the national average. We reviewed specialist registrar operating over a one year period between January 2003–January 2004 with reference to lower limb arthroplasty surgery (hip and knee replacements). A postal questionnaire was sent to 24 specialist registrars on The Welsh Orthopaedic Higher Training Programme in confidence. Complications enquired about were:. infection;. deep vein thrombosis and pulmonary embolism;. dislocation. Data obtained was analysed and individual complication rates were compared with the national United Kingdom average. Complication rates for registrar operated patients were comparable if not lower than the national average. Outcomes after lower limb arthroplasty did not differ between consultants and trainees with regards to complications. The authors conclude that consultant supervised lower limb arthroplasties performed by trainee orthopaedic surgeons is safe and not associated with higher complication rates as one would believe

Aim: To audit the accuracy and efficacy of injections for subacromial impingement administered by our medical staff and specialist role physiotherapist. Methods: 49 patients presenting to the outpatient clinic with subacromial impingement agreed to take part in the study. They were allocated according to date of referral to either the consultant, the physiotherapist or registrar grade for injection via an anterior approach into the subacromial bursa. The therapeutic injection contained a specified volume of radiocontrast as well as depomedrone and lignocaine. Antero-posterior and scapula-Y radiographs were performed immediately after injection. The Constant shoulder score was evaluated before and at six weeks after injection and all radiographs were reviewed by an independent, blinded radiologist recording the position of contrast. Results: Accuracy rates of 67% through an anterior approach were obtained by both the consultant and the physiotherapist. At registrar level 48% accuracy was achieved. Improvement in shoulder score was obtained in 70% of patients with accurate injections, but additionally in 59% of patients with inaccurate injections. Only 7% of cases had contrast confined to the subacromial space; in the remainder, contrast tracked medially around the rotator cuff muscle bellies in 59%, gleno-humeral joint in 20% and within the cuff tendon in 16%. Conclusions: In our practice, the specialist physiotherapist already has an established role in administering therapeutic subacromial injections. Our audit demonstrates acceptable and equal accuracy to the consultant which we feel justifies this particular part of their role. However, at registrar grade the level of accuracy is reduced and most likely reflects inexperience, as over time accuracy improved. Interestingly, shoulder function scores have improved in over half of impingement patients with inaccurate injections which may reflect a generalised ‘field’ effect of steroid on the shoulder

Aims

The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O).

Introduction

Following the publication of our original survey in 2000 (Eur. Sp. J. 11(6):515-8 2002) we have sought to re-evaluate the perceptions and attitudes towards spinal surgery of the current UK orthopaedic Specialist Registrars (SpRs), and to identify factors influencing an interest in spinal surgery. At that time 175 orthopaedic spinal surgeons in the UK needed to increase by 25% to satisfy parity with other European countries.

Introduction: In order to improve the provision of Spinal Surgery in the United Kingdom, the number of Specialist Spinal Surgeons and Surgeons with an Interest in Spinal Surgery needs to increase by 25% from the existing 175 surgeons. There is an expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery not only to maintain the status quo, with one third of Specialist Spinal Surgeons due to retire in the next three years, but also to provide the needed expansion in numbers.

Methods and results: A postal survey of the 528 SpRs was performed with a response rate fo 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery.

Sixty-nine per cent indicated that they intended to avoid all Spinal Surgery. Thirty-five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only nine (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first two years of training, to 70% in the middle two years, and to 75% in the final two years and post C.C.S.T. fellowships. There should be 24 newly accredited Specialist Spinal Surgeons based on a projection of the 4.3% response intending to become Specialist Spinal Surgeons. This leaves a shortfall of 34 Specialist Spinal Surgeons by 2005.

The survey has revealed three main features of Spinal Surgery which appear to have a negative effect on the attitude of the SpRs to Spinal Surgery and overwhelm the potentially attractive features. These are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to Spinal Surgery during their training.

Conclusion: It is clear from the response of SpRs that there are important misconceptions concerning Spinal Surgery, together with the shortcomings of training and of the provision of services within the NHS. These have to be addressed urgently if the speciality is to become more attractive to them. Areas where positive action can be taken include the modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and above all the need for Spinal Surgeons to be encouraging and enthusiastic about a field of surgery which provides some of the exciting challenges in Orthopaedic Surgery.

To quantify the expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery with one third of Specialist Spinal Surgeons due to retire in the next 3 years and to provide the needed expansion of 25% in the existing number of 175 surgeons.

A postal survey of the 528 SpRs was performed with a response rate of 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery.

Sixty nine percent indicated that they intended to avoid all Spinal Surgery. Thirty five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only 9 (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first 2 years of training, to 70% in the middle 2 years, and to 75% in the final 2 years and post CCST fellowships. Based on a projection of the 4. 3% response intending to become Specialist Spinal Surgeons there will be a shortfall of 34 Specialist Spinal Surgeons by 2005.

The features of Spinal Surgery which appear to have a negative affect and overwhelm the potentially attractive features are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to spinal surgery during SpR training.

The modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and a need for Spinal Surgeons to be encouraging and enthusiastic about this field of surgery are essential.

Objectives: To surgery the UK Specialist Orthopaedic Registrars (SpRs) to assess their perceptions of and attitudes towards spinal surgery, and to identify factors discouraging interest in spinal surgery.

Introduction: In order to improve the provision of spinal surgery in the UK, the existing 175 Orthopaedic Surgeons with an interest in Spinal Surgery needs to increase by 25%. There is a predicted shortfall in the number of orthopaedic trainees intending to practise spinal surgery.

Methods: A postal questionnaire was sent to all 578 SpRs

Results: Three hundred and seventy-four replied (71%). Sixty-nine percent intend to avoid spinal surgery. Thirtyfive (9%) intend becoming either Specialist Spinal Surgeons or Surgeons with a Spinal interest. Their perceptions will be discussed; the intellectual challenge and opportunities for research are widely recognised but are outweighed by poor perceptions of outcomes of surgery, psychological complications, and of badly organised clinics. There is also inadequate exposure to spinal surgery during training.

Conclusions: Training in spinal surgery could be improved by exposure to spinal surgery at an earlier stage of training, and the development of more specialised units with properly structured spinal clinics to include triage systems to assess referrals and close liaison between the specialities required to treat these patients.

Introduction: Following the publication of our original survey in 2000 (Eur. Sp. J.11(6):515–8 2002) we have sought to re-evaluate the perceptions and attitudes towards spinal surgery of the current UK orthopaedic Specialist Registrars (SpR’s), and to identify factors influencing an interest in spinal surgery. At that time 175 orthopaedic spinal surgeons in the UK needed to increase by 25% to satisfy parity with other European countries.

Methods: A postal questionnaire was sent to all 950 SpR’s. The questionnaire sought to identify perceptions in spinal surgery, levels of current training and practice, and intentions to pursue a career in spinal surgery.

Results: As before, a 70% response rate has confirmed that 74% of trainees intend to avoid spinal surgery (69% in 2000). However 10% are committed to become a Specialist Spinal Surgeon (9% in 2000). Their perceptions were wide ranging but most concluded that the intellectual challenge and opportunities for research are widely recognised. However enthusiasm is dampened by poor perceptions of outcomes from surgery, negative somatization and depression associations, complications and the fear of litigation. In some areas there is inadequate exposure to spinal surgery during the first 4 years of training.

Conclusions: Spinal surgery remains a career choice for 10% of surgical trainees (up 1% since 2000). With a large SpR expansion (578 to 950 SpRs in the last 5 years) an average of 16 new spinal surgeons annually will be produced over the next six years. This has improved on the figure of 8.6 per year from 2000 and represents a 200% increase in numbers per year. These figures suggest that by 2011 and allowing for retirement, there should be enough spinal surgeons to meet the desired UK/Europe ratio.

Aims. Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research. Methods. A literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had ‘suspected CES’; ‘early CES’; ‘incomplete CES’; or ‘CES with urinary retention’. Inter-rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss’s kappa. Results. Each of the 100 participants were rated by four medical students, five neurosurgical registrars, and four consultant spinal surgeons. No groups achieved reasonable inter-rater agreement for any of the categories. CES with retention versus all other categories had the highest inter-rater agreement (kappa 0.34 (95% confidence interval 0.27 to 0.31); minimal agreement). There was no improvement in inter-rater agreement with clinical experience. Across all categories, registrars agreed with each other most often (kappa 0.41), followed by medical students (kappa 0.39). Consultant spinal surgeons had the lowest inter-rater agreement (kappa 0.17). Conclusion. Inter-rater agreement for categorizing CES is low among clinicians who regularly manage these patients. CES categories should be used with caution in clinical practice and research studies, as groups may be heterogenous and not comparable. Cite this article: Bone Joint J 2023;105-B(9):1007–1012

Orthopaedic surgery is a practical surgical specialization field, the exit exam for registrars remains written and oral. Despite logbook evaluation and surgical work-based assessments, the question remains: can registrars perform elective surgery upon qualification? In South Africa, obstacles to elective surgical training include the trauma workload, financial constraints, fellowships and the Covid pandemic. In hip and knee arthroplasty, new approaches like the direct anterior approach (DAA) and robotic-assisted knee surgery also contributed to the dilution of cases available for registrar training. There are concerns that orthopaedic registrars do not perform enough cases to achieve surgical proficiency. Review of the last 4 years of registrar logbooks in hip and knee arthroplasty surgery performed in a single tertiary academic hospital in South Africa. We included all primary total hip replacements (THR), total knee replacements (TKR) and hemiarthroplasties (HA) done for neck of femur (NOF) fractures between 1 April 2019 and 30 March 2023. Differentiation between registrar assisting, registrar performing with consultant supervision and registrar performing independent surgery was done. 990 hip arthroplasties (472 Primary THR, 216 NOF THR, 302 NOF HA) and 316 Primary TKR were performed during the study period. In primary elective THR the posterior approach was dominant and used in 76% of cases. In NOF THA the DAA was dominant used in 98% of cases. Primary TKR robotic-assisted technologies was used in 27% (n=94) cases. Registrars as the primary surgeon were the highest in NOF THA at 70% of cases and the lowest performing TKR at 25%. During 3-month rotations, an average registrar performed 12 (2 TKR and 10 THR) and assisted in 35 (10 TKR and 25 THR) cases. Despite the large number of arthroplasties operations being performed over the last 4-year period, the surgical cases done by registrars are below, the proposed minimal cases to provide surgical proficiency during their training period

Distal radius fractures are common in South Africa. Accurate, decisive radiographic parameter interpretation is key in appropriate management. Digital radiographic facilities are rare in the public setting and goniometer usage is known to be low, thus, visual estimates are the primary form of radiographic assessment. Previous research associated orthopaedic experience with accuracy of distal radius fracture parameter estimation but, oftentimes, doctors treating orthopaedic patients are not experienced in orthopaedics. A cross-sectional questionnaire including four distal radius fracture radiographs administered to 149 orthopaedic doctors at three Johannesburg teaching hospitals. Participants grouped into ranks of: consultants (n=36), registrars (n=41), medical officers (n=20) and interns (n=52). Participants visually estimated values of distal radius fracture parameters, stated whether they would accept the position of the fractures and stated their percentage of routine usage of goniometers in real practice. The registrar group was most accurate in visually estimating radial height, whilst the interns were least accurate (p=0.0237). The consultant, registrar and medical officer groups were equally accurate in estimating radial inclination whilst the intern group was the least accurate (p<0.0001). The consultant and registrar group were equally accurate at estimating volar tilt, whilst the medical officer and intern groups were least accurate (p<0.0001). The Gwet's AC agreement was 0.1612 (p=0.047) for acceptance of position of the first radiograph, 0.8768 (p<0.0001) for the second, 0.8884 (p<0.0001) for the third and 0.8064 (p<0.0001) for the fourth. All groups showed no difference in goniometer usage, using them largely 0–25% of practice (p=0.1937). The study found that accuracy in visual estimations of distal radius fracture parameters was linked to orthopaedic experience but not linked to routine practice goniometer usage, which was minimal across all groups. Inter-rater agreement on acceptability of fracture position is potentially dependent on severity of deviation from acceptable parameters

Aims. Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for the purpose of guiding clinicians’ management of PFI. There are also concerns about the validity of the Dejour Classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol Classification (OBC) is a recently proposed system of classification of TD, and the authors report a fair-to-good interobserver agreement and good-to-excellent intraobserver agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications. Methods. In all, six assessors (four consultants and two registrars) independently evaluated 100 axial MRIs of the patellofemoral joint (PFJ) for TD and classified them according to OBC and DJC. These assessments were again repeated by all raters after four weeks. The inter- and intraobserver reliability scores were calculated using Cohen’s kappa and Cronbach’s α. Results. Both classifications showed good to excellent interobserver reliability with high α scores. The OBC classification showed a substantial intraobserver agreement (mean kappa 0.628; p < 0.005) whereas the DJC showed a moderate agreement (mean kappa 0.572; p < 0.005). There was no significant difference in the kappa values when comparing the assessments by consultants with those by registrars, in either classification system. Conclusion. This large study from a non-founding institute shows both classification systems to be reliable for classifying TD based on axial MRIs of the PFJ, with the simple-to-use OBC having a higher intraobserver reliability score than that of the DJC. Cite this article: Bone Jt Open 2023;4(7):532–538

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for this purpose to guide clinicians in order to treat PFI. There are also concerns about validity of the Dejour classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol classification (OBC) is a recently proposed system of classification of TD and the authors report a fair-to-good interobserver agreement and good-to-excellent intra-observer agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications. 6 assessors (4 consultants and 2 registrars) independently evaluated 100 magnetic resonance axial images of the patella-femoral joint for TD and classified them according to OBC and DJC. These assessments were again repeated by all raters after 4 weeks. The inter and intra-observer reliability scores were calculated using Cohen's kappa and Cronbach's alpha. Both classifications showed good to excellent interobserver reliability with high alpha scores. The OBC classification showed a substantial intra-observer agreement (mean kappa 0.628)[p<0.005] whereas the DJC showed a moderate agreement (mean kappa 0.572) [p<0.005]. There was no significant difference in the kappa values when comparing the assessments by consultants to those by registrars, in either classification systems. This large study from a non-founding institute shows both classification systems to be reliable for classifying TD based on magnetic resonance axial images of the patella-femoral joint, with the simple to use OBC having a higher intra-observer reliability score compared to the DJC

Conventional fracture courses utilise prefabricated sawbones that are not realistic or patient specific. The aim of this study is to determine the feasibility of creating 3D fracture models and utilising them in fracture courses to teach surgical technique. We selected an AO type 2R3C2 fracture that underwent open reduction internal fixation. De-identified CT scan images were converted to a stereolithography (STL) format. This was then processed using Computer Aided Design (CAD) to create a virtual 3D model. The model was 3D printed using a combination of standard thermoplastic polymer (STP) and a porous filler to create a realistic cortical and cancellous bone. A case-based sawbone workshop was organised for residents, unaccredited registrars, and orthopaedic trainees comparing the fracture model with a prefabricated T-split distal radius fracture. Pre-operative images aided discussion of fixation, and post-operative x-rays allowed comparison between the participants fixation. Participants were provided with identical reduction tools. We created a questionnaire for participants to rate their satisfaction and experience using a Likert scale. The 3D printed fracture model aided understanding and appreciation of the fracture pattern and key fragments amongst residents and unaccredited trainees. Real case-based models provided a superior learning experience and environment to aid teaching. The generic sawbone provided easier drilling and inserting of screws. Preliminary results show that the cost of 3D printing can be comparable to generic sawbones. It is feasible to create a fracture model with a real bone feel. Further research and development is required to determine the optimum material to use for a more realistic feel. The use of 3D printed fracture models is feasible and provides an alternative to generic sawbone fracture models in providing surgical training to residents

Distal radius fractures (DRFs) are one of the most common types of fracture and one which is often treated surgically. Standard X-rays are obtained for DRFs, and in most cases that have an intra-articular component, a routine CT is also performed. However, it is estimated that CT is only required in 20% of cases and therefore routine CT's results in the overutilisation of resources burdening radiology and emergency departments. In this study, we explore the feasibility of using deep learning to differentiate intra- and extra-articular DRFs automatically and help streamline which fractures require a CT. Retrospectively x-ray images were retrieved from 615 DRF patients who were treated with an ORIF at the Royal Brisbane and Women's Hospital. The images were classified into AO Type A, B or C fractures by three training registrars supervised by a consultant. Deep learning was utilised in a two-stage process: 1) localise and focus the region of interest around the wrist using the YOLOv5 object detection network and 2) classify the fracture using a EfficientNet-B3 network to differentiate intra- and extra-articular fractures. The distal radius region of interest (ROI) detection stage using the ensemble model of YOLO networks detected all ROIs on the test set with no false positives. The average intersection over union between the YOLO detections and the ROI ground truth was Error! Digit expected.. The DRF classification stage using the EfficientNet-B3 ensemble achieved an area under the receiver operating characteristic curve of 0.82 for differentiating intra-articular fractures. The proposed DRF classification framework using ensemble models of YOLO and EfficientNet achieved satisfactory performance in intra- and extra-articular fracture classification. This work demonstrates the potential in automatic fracture characterization using deep learning and can serve to streamline decision making for axial imaging helping to reduce unnecessary CT scans

Classification systems for tibial plateau fractures suffer from poor interobserver agreement, and their value in preoperative assessment to guide surgical fixation strategies is limited. For tibial plateau fractures four major characteristics are identified: lateral split fragment, posteromedial fragment, anterior tubercle fragment, and central zone of comminution. These fracture characteristics support preoperative assessment of fractures and guide surgical decision-making as each specific component requires a respective fixation strategy. We aimed to evaluate the additional value of 3D-printed models for the identification of tibial plateau fracture characteristics in terms of the interobserver agreement on different fracture characteristics. Preoperative images of 40 patients were randomly selected. Nine trauma surgeons, eight senior and eight junior registrars indicated the presence or absence of four fracture characteristics with and without 3D-printed models. The Fleiss kappa was used to determine interobserver agreement for fracture classification and for interpretation, the Landis and Koch criteria were used. 3D-printed models lead to a categorical improvement in interobserver agreement for three of four fracture characteristics: lateral split (Kconv = 0.445 versus K3Dprint = 0.620; P < 0.001), anterior tubercle fragment (Kconv = 0.288 versus K3Dprint = 0.449; P < 0.001) and zone of comminution (Kconv = 0.535 versus K3Dprint = 0.652; P < 0.001). The overall interobserver agreement improved for three of four fracture characteristics after the addition of 3D printed models. For two fracture characteristics, lateral split and zone of comminution, a substantial interobserver agreement was achieved. Fracture characteristics seem to be a more reliable way to assess tibial plateau fractures and one should consider including these in the preoperative assessment of tibial plateau fractures compared to the commonly used classification systems

The Revision Hip Complexity Classification (RHCC) was developed by modified Delphi system in 2022 to provide a comprehensive, reproducible framework for the multidisciplinary discussion of complex revision hip surgery. The aim of this study was to assess the validity, intra-relater and inter-relater reliability of the RHCC. Radiographs and clinical vignettes of 20 consecutive patients who had undergone revision of Total Hip Arthroplasty (THA) at our unit during the previous 12-month period were provided to observers. Five observers, comprising 3 revision hip consultants, 1 hip fellow and 1 ST3-8 registrar were familiarised with the RHCC. Each revision THA case was classified on two separate occasions by each observer, with a mean time between assessments of 42.6 days (24–57). Inter-observer reliability was assessed using the Fleiss™ Kappa statistic and percentage agreement. Intra-observer reliability was assessed using the Cohen Kappa statistic. Validity was assessed using percentage agreement and Cohen Kappa comparing observers to the RHCC web-based application result. All observers were blinded to patient notes, operation notes and post-operative radiographs throughout the process. Inter-observer reliability showed fair agreement in both rounds 1 and 2 of the survey (0.296 and 0.353 respectively), with a percentage agreement of 69% and 75%. Inter-observer reliability was highest in H3-type revisions with kappa values of 0.577 and 0.441. Mean intra-observer reliability showed moderate agreement with a kappa value of 0.446 (0.369 to 0.773). Validity percentage agreement was 44% and 39% respectively, with mean kappa values of 0.125 and 0.046 representing only slight agreement. This study demonstrates that classification using the RHCC without utilisation of the web-based application is unsatisfactory, showing low validity and reliability. Reliability was higher for more complex H3-type cases. The use of the RHCC web app is recommended to ensure the accurate and reliable classification of revision THA cases

Alcohol hand rubs, endorsed by WHO and NICE guidelines, are integral to modern surgical practices. Our objective was to assess how different scrubbing methods impact overall water usage by the surgical team, shedding light on variations among team members and their environmental implications. Over three consecutive arthroplasty lists spanning a week, water usage during scrubbing was observed for the operating team. Blinding all team members, including the anesthetist, consultant surgeon, orthopaedic registrar, orthopaedic SHO, and scrub nurse, during water usage calculations was implemented. Automated taps, using motion sensors, posed a challenge due to variable water quantity, necessitating water flow calculations per sensor movement. The senior surgeon, with over 20 years of experience, follows a traditional approach, starting with a morning prescrub and using an alcohol tub for each case, except when hands are soiled. We observed a total of 14 cases of lower limb primary arthroplasty. The cumulative water usage for scrubbing by the entire team was 193 liters, yielding a mean of 13.8 liters (±1.85) per case. The anaesthetist demonstrated the most conservative water usage, utilizing a total of 11.85 liters with a mean of 0.84 liters per case. Notably, alcohol rub was employed for half of the observed time, contributing to this efficient use. The senior operating surgeon used a total of 15.6 liters, averaging 1.1 liters per case. In contrast, the SHO and the registrar exhibited the highest water consumption, totaling 121.6 liters and yielding a mean of 5.7 liters per case. The nurses’ collective water usage for scrubbing amounted to 44.8 liters. Adopting alcohol rub, as endorsed by WHO, results in a remarkable 10-fold reduction in water usage, aligning with global health guidelines. This highlights significant potential for resource conservation in surgical procedures, presenting a practical and environmentally conscious approach to surgical scrubbing practices

Aims. COVID-19 has changed the practice of orthopaedics across the globe. The medical workforce has dealt with this outbreak with varying strategies and adaptations, which are relevant to its field and to the region. As one of the ‘hotspots’ in the UK , the surgical branch of trauma and orthopaedics need strategies to adapt to the ever-changing landscape of COVID-19. Methods. Adapting to the crisis locally involved five operational elements: 1) triaging and workflow of orthopaedic patients; 2) operation theatre feasibility and functioning; 3) conservation of human resources and management of workforce in the department; 4) speciality training and progression; and 5) developing an exit strategy to resume elective work. Two hospitals under our trust were redesignated based on the treatment of COVID-19 patients. Registrar/consultant led telehealth reviews were carried out for early postoperative patients. Workflows for the management of outpatient care and inpatient care were created. We looked into the development of a dedicated operating space to perform the emergency orthopaedic surgeries without symptoms of COVID-19. Between March 23 and April 23, 2020, we have surgically treated 133 patients across both our hospitals in our trust. This mainly included hip fractures and fractures/infection affecting the hand. Conclusion. The COVID-19 pandemic is not the first disease outbreak affecting the UK, nor will it be the last. The current crisis has necessitated rapid development of new hospital guidelines and early adaptive strategies in our services. Protocols and directives need to be formalized keeping in mind that COVID-19 will have a long and protracted course until a definitive cure is discovered

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. Methods. A 42-point questionnaire was designed, validated, and disseminated via e-mail and an instant-messaging platform. Results. A total of 101 orthopaedic trainees, representing the four nations (Wales, England, Scotland, and Northern Ireland), completed the questionnaire. Overall, 23.1% (23/101) of trainees were redeployed to non-surgical roles. Of these, 73% (17/23) were redeployed to intensive treatment units (ITUs), 13% (3/23) to A/E, and 13%(3/23%) to general medicine. Of the trainees redeployed to ITU 100%, (17/17) received formal induction. Non-deployed or returning trainees had a significant reduction in sessions. In total, 42.9% (42/101) % of trainees were not timetabled into fracture clinic, 53% (53/101) of trainees had one allocated theatre list per week, and 63.8%(64/101) of trainees did not feel they obtained enough experience in the attached subspecialty and preferred repeating this. Overall, 93% (93/101) of respondents attended at least one weekly online webinar, with 79% (79/101) of trainees rating these as useful or very useful, while 95% (95/101) trainees attended online deanery teaching which was rated as more useful than online webinars (p = 0.005). Conclusion. Orthopaedic specialist trainees occupied an important role during the COVID-19 pandemic. COVID-19 has had a significant impact on orthopaedic training. It is imperative this is properly understood to ensure orthopaedic specialist trainees achieve competencies set out in the training curriculum. Cite this article: Bone Joint Open 2020;1-11:676–682

Time at the surgical ‘coal-face’ has been reduced by introduction of the European Working Time Directive (EWTD) significantly impacting training opportunity. Our null hypothesis was that duration of surgery is significantly longer if a trainee were performing the operation despite supervision or level of trainee experience. Cemented hip hemiarthroplasty was chosen as our index procedure as complexity is largely comparable between cases. 461 patients were identified on the hospital trauma database. Data were augmented by information regarding level of surgeon, assistant and time of surgery from the hospital theatre database. There was no significant difference in registrar and consultant operative times, mean time 69 and 72 minutes respectively. SHOs were significantly slower (mean 80 minutes, p=0.0006). Junior (ST5 or less) registrars were significantly slower (mean 81minutes, p=0.0002) whereas senior registrars were not. Supervision level had no effect on duration of senior registrar operations but when junior registrars were consultant supervised they were not significantly slower (mean 75 minutes, p=0.09). Supervised operating therefore reduces time variability and should be promoted within a climate of training. Increase in mean operative time in registrars and SHOs is insignificant within a day's operating and is unlikely to lead to cancellations of cases

Introduction. Post-traumatic arthritis is the commonest cause of arthritis of the ankle. Development of arthritis is dependent on the restoration of pre-injury anatomy. To assess the effect of grade of lead surgeon on the accuracy of surgical reduction, we performed a retrospective radiographic analysis of all ankle fractures undergoing open reduction and internal fixation, in a single institution. Method. All patients treated by surgical intervention in an 11 month period (January to November 2011) were included, with the grade of lead surgeon performing the operation recorded.105 patients, 48 males and 53 females, were included with a mean age of 41 years (range: 17–89). Standard antero-posterior (AP) and mortise views were analysed for tibiofibular overlap, ankle clear space and talocrural angle and compared to standardised values from the literature. Lead surgeon grade was stratified as either, trauma consultant, senior registrar (years 4+) or junior registrar (years 1–3). Results. Radiographic reduction within accepted margins was achieved in 78% of ankles on the AP radiograph and 81% on the mortise view. Trauma consultants achieved the highest rate of anatomical reduction, followed by senior registrars, with junior registrars achieving the lowest rate; the rates of anatomical reduction on the mortise view were 83.3%, 79.2% and 75%, respectively. However, senior registrars performed the majority of cases (70%). Conclusion. Radiographic reduction in this institute is comparable to that in the literature. The majority of cases are performed by senior trainees who are able to restore to anatomical reduction radiographically. Junior registrars achieved the lowest rate of anatomical reduction, which may reflect their level of experience and a greater need for supervision in the early years of specialty training

We describe the results at five years of a prospective study of a new tri-tapered polished, cannulated, cemented femoral stem implanted in 51 patients (54 hips) with osteoarthritis. The mean age and body mass index of the patients was 74 years and 27.9, respectively. Using the anterolateral approach, half of the stems were implanted by a consultant orthopaedic surgeon and half by six different registrars. There were three withdrawals from the study because of psychiatric illness, a deep infection and a recurrent dislocation. Five deaths occurred prior to five-year follow-up and one patient withdrew from clinical review. In the remaining 51 hips the mean pre-operative Oxford hip score was 47 points which decreased to 19 points at five years (45 hips). Of the stems 49 (98%) were implanted within 1° of neutral in the femoral canal. The mean migration of the stem at five years was 1.9 mm and the survivorship for aseptic loosening was 100%. There was no significant difference in outcome between the consultant and registrar groups. At five years, the results were comparable with those of other polished, tapered, cemented stems. Long-term surveillance continues

Background and Aims:. Forearm fractures are common in the paediatric population and most are treated in a moulded plaster of Paris (POP) cast. It is our concern that many casts applied by our registrars are sub-optimal and that we need to improve our training process. The aim of our study was to review the adequacy of forearm cast application in paediatric patients at our institution and to identify if there is a need for a more formal training program with regard to plaster cast application. Methods:. A retrospective review of control x-rays of forearm fractures treated at our institution was undertaken. X-rays that were reviewed were done as part of the routine treatment protocol. X-ray measurements to assess POP application were the cast index and the gap index. A cast index of > 0.81 and Gap index of > 0.15 were regarded as an indication of poor cast application. Results:. Adequate control X-rays of twenty eight patients with a forearm fracture were available. The average patient age range was 5–12 years. There were thirteen distal metaphyseal fractures, nine diaphyseal fractures and six Salter-Harris type fractures. Of the 28 patients, 20 patients had a poor cast index and 17 patients had poor gap index. In 12 patients both the gap and the cast index were unacceptable. Conclusion:. Our study suggests that paediatric forearm plaster cast application by registrars at our institution is inadequate. This indicates a need for a strategy to improve the training in plaster cast application amongst our registrars

Aim: To determine if extended scope physiotherapists perform to the same standards as their orthopaedic colleagues with regards to diagnosing knee pathology and making appropriate referrals for arthroscopy. Method: Data was collected prospectively from Aug 2005. Patients were seen in a consultant led orthopaedic clinic by an Extended Scope Physiotherapist (ESP), a registrar or the consultant. All patients placed onto the waiting list for knee arthroscopy were considered for the study. The outpatient diagnosis and demographic data were recorded and compared against the arthroscopy findings. A single consultant surgeon performed the arthroscopies. Results: 300 patients were included in the study (100 in each group). Each group was similar in terms of presenting complaint and demographics. There was no significant difference between the ESP’s and registrars in their ability to diagnose intraarticular pathology (CHI squared test: X 2.031, df 1, p=0.15). When only cruciate and meniscal pathology were considered there was also no significant difference between the ESP’s and the registrars (Fishers test p=0.12 and p=0.22 respectively, 2-tail test) The ESPs performed particularly well in their ability to diagnose cruciate injuries (sensitivity 100%, specificity 100% and PPV 100%). Both ESPs and registrars had high sensitivity but low specificity with regards to diagnosing meniscal pathology suggesting a low threshold for a positive diagnosis and a poor ability to correctly diagnose those patients who did not have a meniscal injury. Of the 300 patients only 9 unnecessary arthroscopies were requested. None were requested by the ESPs. Conclusions: Extended scope physiotherapists perform a useful role in orthopaedic outpatients. They perform as well as orthopaedic registrars with regards to making the correct diagnosis and the selection of patients for arthroscopy

To determine if extended scope physiotherapists perform to the same standards as their orthopaedic colleagues with regards to diagnosing knee pathology and making appropriate referrals for arthroscopy. Data was collected prospectively from Aug 2005. Patients were seen in a consultant led orthopaedic clinic by an Extended Scope Physiotherapist (ESP), a registrar or the consultant. All patients placed onto the waiting list for knee arthroscopy were considered for the study. The outpatient diagnosis and demographic data were recorded and compared against the arthroscopy findings. A single consultant surgeon performed the arthroscopies. 300 patients were included in the study (100 in each group). Each group was similar in terms of presenting complaint and demographics. There was no significant difference between the ESP’s and registrars in their ability to diagnose intraarticular pathology (CHI squared test: X 2.031, df 1, p=0.15). When only cruciate and meniscal pathology were considered there was also no significant difference between the ESP’s and the registrars (Fishers test p=0.12 and p=0.22 respectively, 2-tail test) The ESPs performed particularly well in their ability to diagnose cruciate injuries (sensitivity 100%, specificity 100% and PPV 100%). Both ESPs and registrars had high sensitivity but low specificity with regards to diagnosing meniscal pathology suggesting a low threshold for a positive diagnosis and a poor ability to correctly diagnose those patients who did not have a meniscal injury. Of the 300 patients only 9 unnecessary arthroscopies were requested. None were requested by the ESPs. Extended scope physiotherapists perform a useful role in orthopaedic outpatients. They perform as well as orthopaedic registrars with regards to making the correct diagnosis and the selection of patients for arthroscopy

Background: Medial plica syndrome is the most common symptomatic plica. The size and shape of the plica have an important impact on impingement on the femoral condyle and hence, symptoms. The validity of the classification systems of such injuries is essential for prospective studies. The study was designed to assess the reproducibility and reliability of Iino and Jee classification systems of medial plica syndrome. The agreement among multiple surgeons for medial plica syndrome has not been established before. Methods: We validated both classification systems independently from the original authors at our institution. Arthroscopic videos from 30 patients were reviewed by 6 consultant surgeons, 6 registrars and 6 house officers. Intra- and inter-observer reliability and reproducibility were assessed. Each observer scored the videos on two separate occasions and classified the medial plica according to its type (A, B, C and D) for Iino classification and (1, 2, 3 and 4) for Jee classification system. Results: The results were subjected to weighted kappa analysis. Intra-observer agreements were 0.76 for consultants, 0.64 for registrars and 0.60 for house officers for Iino classification system. They were 0.81 for consultants, 0.75 for registrars and 0.71 for house officers for Jee classification system. Total unanimity (18 observers assigned same grade for medial plica) was achieved in 23% (7 of 30) with Iino system and 40%(12 of 30) for Jee system. Inter-observer agreement was 0.63 for the first reading and 0.68 for the second reading for Iino system. They were 0.72 for the first reading and 0.80 for the second reading for Jee system. Validity analysis showed a kappa value of 0.78 (substantial agreement). Conclusions: Jee classification system showed a better inter and intra-observer agreement compared to Iino’s system. Consultants had a better intra-observer agreement compared to their registrars. We have shown that substantial agreement can be found between individuals with no specialist training. Such reliability is crucial for multi-centre clinical research studies involving arthroscopic knee surgery. Jee’s classification system did not consider femoral condyle impingment which has an important effect on symptoms. Both systems should be used in prospective studies to evaluate the state of the medial plica

Current orthopaedic practice involves an increasing use of operative fluoroscopic screening and radiation exposure. The AOA produces a booklet entitled “Radiation safety for orthopaedic surgeons” outlining the risks. There is a disparity between guidelines and actual clinical practice for trainee registrars. Aims:. To measure trainee fluoroscopy usage with and without consultants present. To audit trainees and hospitals adherence to the guidelines. All procedures in a 6 month period using II were analysed. Data for Procedure, Operating Surgeon, First Assistant and if Consultant Surgeon was present or absent was collected. Fluoroscopic Exposure Time was also recorded. Procedures were grouped and times compared depending on the staff present. There were 121 cases included in the study. 44 cases were performed by the trainee with the consultant assisting and 76 were performed in the absence of the consultant. A questionnaire based on the AOA guidelines was produced. All NSW advanced trainees in Orthopaedic surgery were asked to complete the anonymous questionnaire. There was a significant difference of 32.18 seconds in mean exposure time per case with a p-value 0.0069 where the consultant was present or not. There was also a significant difference between consultants doing the same cases. Other very significant findings were:. 97% of trainees were not aware of the maintenance and inspection schedules equipment. 97% of trainees have practiced the incorrect technique of using the image receptor of the II machine as an operating table which maximizes scatter to the head and neck. 65% regularly use continuous screening of II. 65% admit to taking unnecessary II shots to ensure the perfect xray. 32% of trainees wore no thyroid protection, 87% no eye protection and 100% used no head and hand protection. One registrar was exposed to 8131 seconds of II exposure during his 6 month rotation. Without the use of lead protection, the trainee registrar will have exceeded the annual limit of whole body exposure (20mSv/year) by more than 2-fold. Dramatic decreases in exposure can be achieved by better discipline with the usage of II. This needs to be a fundamental part of registrar training. The survey shows trainees are not aware, or fail to adhere to current guidelines and that hospitals are not providing appropriate safety equipment and not insisting that staff exercise safe practices

Introduction. The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison. Methods. Patients over the age of 16 years undergoing an elbow CT scan within one week of a documented elbow dislocation between 1st June 2010 and 1st June 2014 were included in the study. Three orthopaedic registrars independently reviewed both the initial dislocation and immediate post reduction plain radiographs to identify any associated bony injuries. This radiograph review was repeated by each registrar after two weeks. The incidence of associated injuries as well as the inter- and intra-observer variability was calculated. Results. 28 patients were included in the study. 54% of the patients were female and the mean age was 45 years (range 16 to 90 years). The incidence of a radial head fracture was 54%, coronoid fracture 43% and epicondyle avulsion 18% on CT. The inter-observer reliability was only shown to be fair amongst registrars and the intra-observer variability moderate. Conclusions. Computerised tomography is a useful adjunct in the assessment of associated osseous injuries following an elbow dislocation due to the presence of a high number of injuries. Plain radiographs alone have been shown to have only a fair and moderate inter and intra-observer variability respectively, therefore a low threshold to obtain further 3D imaging should be practised. Level of Evidence. IV

Parallel operating lists are a contentious subject. Many people feel that supervision, training and quality of patient care is negatively affected and consider this an outdated model in modern practice. Dual and parallel lists have been largely abandoned due to training committees' opinions that standards of orthopaedic training were being negatively affected. A new model of dual lists was implemented in a district general hospital as part of an arthroplasty service. The training impact was evaluated. Adjacent theatres were utilised for a single session. Two joint replacement surgeries were undertaken in each theatre. The sequential timing of the lists allowed the consultant to perform or supervise all of the operations in a consecutive manor. Staggering the start times allowed the consultant to approach and implant the first joint replacement, leaving the junior doctor or nurse practitioner to close the first operation and get the patient off the table while the consultant transferred to the adjoining theatre where the registrar had positioned, painted and draped the second patient, allowing the consultant to perform or supervise the second surgery. The process was then repeated until all four cases were performed. Evaluation of two registrar's elogbooks was undertaken and compared to the national average. During a twelve month period the trainees was involved in a mean of 72 joint replacement surgeries compared to a national average of 49. The trainees were the primary surgeon in a significantly higher number of operations compared to the national average. This model of sequential operating lists facilitated a service of high volume arthroplasty surgeries and significantly increased the exposure of the training registrar to joint replacements. Supervision of trainees was not significantly impacted. The model requires effective support services and a dedicated team of theatre staff, but can be very rewarding for consultant surgeon and trainee alike

Background. Positioning of the acetabular component in total hip arthroplasty has profound effects on the biomechanics, stability and wear of the prosthesis. Normal anatomical position in females is 57 degrees (50 – 67 degrees) inclination with 19 degrees (9 – 32 degrees) of anteversion, whilst in males 56 degrees of inclination (48 – 66 degrees) with 19 degrees (9 – 32 degrees) is normal. In total hip arthroplasty, inclination recommendation ranges from 30 – 50 degrees. The aim of this study was to radiographically measure acetabular component position in total hip arthroplasty and compare to normal values. Method. The Widmer method was used by two independent observers to radiographically measure inclination in 522 patients using standard AP radiographs. Primary measures and variables were statistically analysed as was inter and intra observer reliability. All patients included within the study received total hip arthroplasty for age related degenerative changes to the hip. Operations were undertaken by 17 separate consultants or senior registrars under their care. Results. Overall mean inclination was measured at 45.27 degrees with a range of 26 – 68 degrees. Statistically significant differences were observed between cemented 45.9o and non-cemented hips 43.9 degrees (p= 0.018), Simple 45.5 degrees vs complex 42.1 degrees (p=0.003) and Male 44.3 degrees vs Female 46.2 degrees (p=0.0198). No statistical difference was seen between consultant and registrar (p=0.211) and right vs left (p=0.768). Inter observer reliability was seen to be 0.91 whilst intra observer reliability 0.96. Conclusion. Although a large range of outcomes were observed, 95% of radiographs reviewed fell within a range of 33.6 – 56.9 degrees Variables such as surgical positioning, patient anatomy/body habitus, surgical technique, instrumentation likely influenced abnormal results. Abnormal positioning may have effects such as eccentric wear and dislocation, however, and such findings are yet to be observed in the study group

Introduction. Ankle fractures are common injuries presenting to trauma departments and ankle open reduction and internal fixation (ORIF) is one of the first procedures targeted in early orthopaedic training. Failure to address the fracture pattern with the appropriate surgical technique and hardware may lead to early failure resulting in revision procedures or premature degenerative change. Patients undergoing revision ORIF are known to be at much greater risk of complications, and many of these secondary procedures may be preventable. Method. A retrospective analysis of all patients attending our unit for ankle ORIF over a two year period was undertaken. Patients were identified from our Bluespier database and a review of X rays was undertaken. All patients undergoing re-operation within eight weeks of the primary procedure were studied. The cause of primary failure was established and potential contributing patient and surgical factors were recorded. Results. 236 patients undergoing ankle ORIF were identified. 13 patients (5.5%) returned to theatre for a secondary procedure within eight weeks. Within this group, 7 (54%) patients returned for treatment of a neglected or under treated syndesmotic injury, 3 (23%) for complete failure of fixation, 2 (15%) with wound problems and 1 (8%) for medial malleoulus mal-reduction. Of the patient group, 5 (38%) were known type 2 diabetics. Consultants performed 2 (15%) of procedures, supervised registrars 5 (39%) and unsupervised registrars 6 (46%) operations. Conclusion. Errors are being made at all levels of training in applying basic principles such as restoring fibula length and screening the syndesmosis intra-operatively. Appropriate placement and selection of hardware is not always being deployed in osteopenic bone resulting in premature failure of fixation and fracture patterns are not being fully appreciated. Patients are undergoing preventable secondary procedures in the operative treatment of ankle fractures

We propose a model of care where by Regular scheduled outreach visits by a Single team provides more dependability of care and understanding of the local needs and cultural practises. Thereby titrating the care to meet local needs rather than enforcing the Western model of care to a very different cultural background. I have been fortunate as a SET 4 Registrar to be involved with an Outreach team to Latouka Hospital. Spear headed by Dr M McAuliffe over the last 3 years the annual visit has taken shape as a dependable way of providing care to the community of Latouka. The team has evolved over the years to involve Dr Brazel, Dr Tetsworth, Dr Bansi, and our scrub staff. The team consists of 2 teams which visit Latouka every 6 months and help institute a multimodal care plan. 1) Regularity of visits helps build confidence locally and engraves the foundations of dependability of care. 2) Difficult and complex cases are discussed in specially earmarked clinics held every 6 months providing a brain storming sessions to the local clinicians and helping them achieve the best care for the patients under the restrictions of the local infrastructure. 3) Regular teaching sessions / practical workshops are held for the registrars and junior doctors empowering them to carry the baton once the visiting team leaves. 4) Regular follow up of the patients operated upon is attained to titrate care to the locals based upon the local needs and cultural practises. 5) Helping the surgical teams, nurses, radiographers, physiotherapists formulate protocols of care and comparing them to the protocols used in Australia/NZ. 6) Creating an educational fund for the local registrars enabling them to attend observer ships and courses in Australia/New Zealand. We think that this model of care provides a much more organised and long term benefit to the local community compared to erratic visits by volunteer teams. A similar model of care, if instituted over many divisional hospitals of the South Pacific, will be vital in improving the health care needs of the locals and provide the local staff with the much needed support they deserve

Aims. The Wrightington classification system of fracture-dislocations of the elbow divides these injuries into six subtypes depending on the involvement of the coronoid and the radial head. The aim of this study was to assess the reliability and reproducibility of this classification system. Methods. This was a blinded study using radiographs and CT scans of 48 consecutive patients managed according to the Wrightington classification system between 2010 and 2018. Four trauma and orthopaedic consultants, two post CCT fellows, and one speciality registrar based in the UK classified the injuries. The seven observers reviewed preoperative radiographs and CT scans twice, with a minimum four-week interval. Radiographs and CT scans were reviewed separately. Inter- and intraobserver reliability were calculated using Fleiss and Cohen kappa coefficients. The Landis and Koch criteria were used to interpret the strength of the kappa values. Validity was assessed by calculating the percentage agreement against intraoperative findings. Results. Of the 48 patients, three (6%) had type A injury, 11 (23%) type B, 16 (33%) type B+, 16 (33%) Type C, two (4%) type D+, and none had a type D injury. All 48 patients had anteroposterior (AP) and lateral radiographs, 44 had 2D CT scans, and 39 had 3D reconstructions. The interobserver reliability kappa value was 0.52 for radiographs, 0.71 for 2D CT scans, and 0.73 for a combination of 2D and 3D reconstruction CT scans. The median intraobserver reliability was 0.75 (interquartile range (IQR) 0.62 to 0.79) for radiographs, 0.77 (IQR 0.73 to 0.94) for 2D CT scans, and 0.89 (IQR 0.77 to 0.93) for the combination of 2D and 3D reconstruction. Validity analysis showed that accuracy significantly improved when using CT scans (p = 0.018 and p = 0.028 respectively). Conclusion. The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. CT scans are significantly more accurate than radiographs when identifying the pattern of injury, with good intra- and interobserver reproducibility. Cite this article: Bone Joint J 2020;102-B(8):1041–1047

Introduction. Surgical complications are common and most of them are preventable. Up to 70 % of surgical errors originate outside theatre and recent studies have shown that pre-op checklists can reduce such problems. We hypothesized that in our institution outcomes could be improved by introducing a safety checklist. Method. A modified multidisciplinary WHO safety checklist was introduced at our institution on the 1st March 2011. The primary focus was for elective patients admitted in all the units of the division. Prior to that all involved personnel (Consultants in Orthopaedics and Anaesthesia, Registrars in both departments, nursing staff in the wards and theatre and clerical staff) were fully oriented. To further ensure that everyone was familiar with the new checklist the whole month of March 2011 was used as a training month. We prospectively collected data from daily Mortality and Morbidity (MM) meetings by units from 1/1/2011 to 29/2/2011 (2 months). A pre-induction survey was completed by all Registrars. The same survey was given to the same registrars for comparison at the end of the 2 month implementation period in June 2011. Results. Only 77% of registrars acknowledged doing pre-op planning prior to implementation of the check list compared to 87.5% post implementation. There was also an increase from 50 to 71% of those who had heard of the surgical check list pre-implementation compared to post implementation. There were 35 cancellations before and 36 after implementation. However if one breaks them into unavoidable and avoidable groups there was 70% reduction of avoidable cancellations (from 10 to 3 patients). There was a 25% reduction of mortality and a 25% reduction of avoidable morbidity. Discussion. In our study there was significant increase in the percentage of registrars who were doing pre-op planning after the implementation of the modified WHO safety check list. The avoidable theatre case cancellations were significantly reduced. It is very hard to attribute the reduction of mortality in our studies to our checklist as the documented causes of death were unavoidable. Compared to published studies our numbers were relatively small but comparable to the SURPASS study which showed reduction of complications from 27.7 % to 16.7 %. The time for getting acquainted to the safety checklist was also very short (1 month) compared to other published studies. Conclusion. The implementation of the modified WHO safety check list was associated with reduction in cancellations, avoidable morbidity and mortality. It should be regarded as a standard practice for all orthopaedic procedures to decrease complications especially in high operation volume and training centres. NO DISCLOSURES

Frequently, radiological data is transferred verbally between ED/GP/LMO to the Orthopaedic registrar. Given the different medical backgrounds and presentation skills there is often a limit to the verbal description of the radiographs. The aim of this study is to determine the feasibility and benefits of concurrently using picture messaging of X-rays to enhance communication between ED and Orthopaedic Registrars to optimise patient care. The X-rays of 40 patients referred to orthopaedics OPD or admitted from the ED were photographed and retrospectively reviewed on a mobile phone screen (240 × 320) by an orthopaedic registrar along with a printout of the patient history and verbal description of the x-ray as interpreted by the ED staff. No further information was provided to the registrar. A questionnaire was completed to subjectively and objectively evaluate the therapeutic benefit of the image review. Patient(tm)s management was compared to management plans after image review and differences were attributed to the visual inspection of the x-rays on the mobile phone. Concurrent to the retrospective review, the ED is currently trialling this with a Sony-Erickson K750i. After hours orthopaedic cases are sent via MMS to the registrar prior to consultation. In the emergency department, 10% of patients who presented with a fracture were reviewed in person by an orthopaedics registrar and none were admitted straight from ED whilst two were admitted following review at the OPD. X-rays of 40 patients were reviewed in this study. Twenty-seven patients presented with a fracture and four with islocations. When the clinical data was reviewed alongside images of x-rays by an orthopaedic registrar, a difference in management plans were observed in 25% of cases and 7.5% where surgical intervention would yield a better result. Twenty-six of the twenty-seven fractures and four dislocations were successfully visualised on the MMS. In 18 cases, picture messaging provided additional information compared to verbal report alone. The limiting factor in picture messaging was the resolution and size of the radiograph. Ease of operation and portability was found to be satisfactory by both ED and Orthopaedic staff. Equipping the ED with the phone has enhanced communication with the orthopaedics department and increased the potential for optimising patient care. This will be formally assessed through questionnaires after 12 months trial of the phone. Picture messaging is an inexpensive way of utilising technical advancements to improve patient care. Consistent with current literature, the quality of images was not sufficient as a diagnostic tool but rather a screening tool. Picture messaging is valuable practically and educationally and enhances the consultation and teaching process whilst encompassing medical staff who have limited skills in radiological description

Clinical investigations and tests need to be validated by studying their inter-observer and intra-observer errors, but there has been no documentation of such verification in diagnostic knee arthroscopy. We performed a prospective study to find out to what extent the findings in knee arthroscopy differ between two different surgeons. Two senior specialist registrars (M.S. and A.J.) who took part in this study worked with the senior author (ACW) for a period of eight and seven months respectively. A total of 78 knee arthroscopies admitted from routine waiting list were studied. The specialist registrar first performed arthroscopy when the supervising consultant stayed away from the operating room. His findings were recorded on a proforma by an independent third person before the consultant returned to the operating room and repeated the EUA and arthroscopy without prior knowledge of the trainee findings. Findings from the consultant arthroscopy were then recorded separately on the same proforma. The following findings were recorded:. Examination under anaesthesia. Meniscal pathology. ACL pathology. Articular surface pathology (more than 1 Outer-bridge grade). The inter-observer variations in diagnostic knee arthroscopy were found to be high. Given the seniority and experience of the two trainee senior registrars involved in the study, and allowing for the Hawthorne effect, the results of the study cast doubt on this procedure being performed un-supervised. It also questions the validity of any therapeutic intervention based on the findings of un-supervised arthroscopies

Recent reports observe that orthopaedic surgeons lack essential knowledge about ionising radiation. We aim to demonstrate perceived use of image-intensifiers by surgeons and awareness of radiation doses used during fractured neck of femur surgery. Surgeons at a regional trauma centre were sent an online questionnaire. They were shown two neck of femur fracture radiographs and asked the total number of images they would use to reduce and fix the fracture with a dynamic-hip-screw / inter-medullary nail respectively. They were asked the maximum safe radiation dose, and that of ‘hip pining’ compared to CXR as outlined by the Ionising Radiation Regulations 1999. For a DHS, consultants and registrars estimate their image use similarly. For IM nailing, consultants estimated higher image use than registrars, and double the number of X-rays taken for IM nailing compared to DHS. Knowledge levels regarding radiation doses during orthopaedic hip procedures are very low. There is an expectation that more images will be used in IM nailing procedures. We plan to educate orthopaedic surgeons about radiation dose and safety. Correlating our findings with actual use of image in theatre when performing hip fracture surgery would extend the use of this study

The International Commission on Radiological Protection has established standards for radiation protection. This study aims to determine actual and perceived radiation dose and audit safe practice when using image-intensifiers in theatre. Between September 2012 and March 2013, 50 surgeons were surveyed during 39 procedures. Information collected by radiographers included the number of images the surgeons thought they used, actual number used, dose, screening time, number of people scrubbed, wearing thyroid collars and standing within 1m of the image-intensifier when in use. The primary surgeon was more likely to estimate the number of images used correctly compared to the assistant. Supervising consultants were most accurate, followed by registrars as primary surgeons, consultants as primary surgeons then assisting registrars, and lastly SHOs. Most surgeons underestimated the number of images used. 87.5% of scrubbed staff were standing within 1m of the image-intensifier during screening and 36.5% were wearing thyroid protection. Three surgeons stated they were not wearing collars as they were unavailable. We conclude that surgeons have a reasonable estimation of the x-rays used but are not undertaking simple steps to protect themselves from radiation. We plan to initiate an education program within the department and have ordered new, lightweight thyroid collars

Background. The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. Purpose of Study. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics. Methods. Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis. Results. 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers. Conclusion. Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics. NO DISCLOSURES

Randomised controlled trials (RCT) published in the British volume of the JBJS from United Kingdom based institutes have been analysed to review the level of involvement of junior doctors over the past 25 years (1988 to 2012) which included three different training eras: Pre-Calman (1988 to 1995), Calman (1996 to 2006), and MMC (2007 to 2012). Authors were divided into: Senior doctors, Registrars, Fellows, Senior House Officers/ Foundation Doctors, and Others. The level of involvement has been identified as being first author, senior author or co-author. One hundred and fifty nine RCTs have been identified with a total of 705 authors. Eighty eight registrars, 32 fellows and 19 SHO/ Foundation doctors have been involved in RCT published over the last 25 years (19.7%). Registrars constituted 15% of all authors in the pre-Calman, 12% in the Calman and 11% in the MMC periods. They constituted 33% of all first authors in the pre-Calman, 21% in the Calman, and 12% in the MMC periods. With regards to SHO/ Foundation doctors, they were only 2% of all authors in the pre-Calman, 3% in the Calman, and 4% in the MMC periods. They were not the first author in any RCT in the pre-Calman period, rising to 7% in both the Calman and MMC periods. Our study shows that registrars involvement was at its highest in the pre-Calman era with gradual decline in their involvement in the subsequent training eras. SHO/Foundation doctors involvement remains very low, however showing increasing rate in the MMC era

Introduction. Hallux valgus is a common orthopaedic complaint with multiple surgical options. There are many methods available for assessing whether sufficient translation of the first metatarsal can be achieved with a metatarsal translational osteotomy alone. None of the current methods take into account the breadth of the metatarsal. With current PACS technology a radiograph can be zoomed to any size and we postulate that by using the surgeon's thumb (or any suitable digit), as a sizing tool, a safe clinical decision can be made concerning whether a translational metatarsal osteotomy alone will provide sufficient correction. Method. We reviewed the preoperative radiographs (weightbearing AP) of twenty patients who had scarf and akin osteotomies and twenty patients with a deformity too great for scarf and akin osteotomies. The senior author (CC) taught the rule of thumb to one consultant and two registrars (total two registrars and two consultants). The radiographs were blindly randomised and the participants assessed each radiograph and decided whether sufficient translation could be achieved with a translational metatarsal osteotomy alone. The process was repeated three months later. Twenty patients were deemed sufficient for intra-user variability and significance based on a recent JBJS(A) article concerning radiographic measurements post proximal crescentic osteotomy (Shima et al. 2009). Results. Good inter- and intra- user variability was demonstrated and using the rule of thumb is a safe way of determining whether a distal osteotomy alone will provide sufficient correction

Introduction: An audit was undertaken to quantify patient satisfaction in the Orthopaedic Outpatient setting. Materials and Methods: A 16 point questionnaire on a Likert scale of 1 to 5 was used. 216 consecutive questionnaires were distributed to patients attending the elective orthopaedic clinic during a three week period. The questionnaire collected details of sex, age, the grade of the health professional primarily assessing the patient in the clinic, administration of the appointment, welcome by reception staff, waiting room facilities, 7 questions pertaining to the care provided by the health professional primarily assessing the patient, 1 question regarding nurses and 2 regarding the overall service. Results: Completed data was available only from 178 respondents (82.4%). There were 109 females and 69 males. 13 patients were under 20, 34 between 20 to 39, 61 between 40 to 60 and 70 over 60. 105 patients were seen by the Consultant, 49 by the Registrar, 14 by the Senior House Officer, 8 by a Physio Practitioner and 2 by an Associate Specialist. The mean score for questions 7 to 13 that pertained to the consultation with the health professional showed the following results. Associate Specialist 5.00, SHO 4.74, Consultant 4.70, Physio 4.68 and Registrar 4.63. The differences were not significant (P=0.017). Conclusions: Our results show that patients are satisfied by being assessed even by Senior House Officers as long as normal NHS work practices are complied with. Conflicts of Interest: None. Source of Funding: None

It is well recognised that there is a requirement for military surgeons to treat the victims of penetrating trauma while on operations. Casualty templates from recent and past conflicts demonstrate that a high proportion of survivable injuries affect the limbs; expertise in the management of penetrating trauma to the limbs is clearly important. While it is widely agreed that a combined specialities approach to limb injuries is necessary, debate has been ongoing for some time in the UK military as to the most appropriate means to gain the necessary experience for treating the wounds encountered on operations. This study examines the operational requirement, looking at data and individual cases from Iraq, and considers the relevance of a training placement at The Johannesburg General Hospital, a level 1 trauma centre in South Africa. Surgeon Lt Cdr Mercer RN is currently a Specialist Registrar in Vascular Surgery at MDHU Portsmouth and Surgeon Lt Cdr Ayers is a Specialist Registrar in Plastic Surgery at Frenchay Hospital in Bristol

There is widespread appreciation amongst orthopaedic surgeons of the importance of thromboprophylaxis. However much of the evidence is based on surrogate outcomes of clinical end-points. This population-based study aims to identify the incidence and trends in venous thromboembolic disease (VTE) following total hip (THR) and knee arthroplasty (TKR) with death or readmission for VTE up to two years following surgery for all patients in Scotland as the primary outcome. We used the Scottish Morbidity Record (SMR01) system to identify all patients undergoing hip or knee arthroplasty over the ten-year period from 1992 to 2001. Patients undergoing cataract surgery over the same period were identified as a control group. Record linkage for all patients to subsequent SMR01 and Registrar General records provided details of further admissions due to DVT or non-fatal PE and deaths within Scotland up to two years after the operation. The cause of death was determined from the Registrar General Records. The incidence of VTE (including fatal pulmonary embolism (PE)) three months following primary THR was 2.27% and primary TKR was 1.79%. The incidence of fatal PE within three months of THR was 0.22% and TKR was 0.15%. The majority of events occurred in the interval from hospital discharge to six weeks after surgery. There was no apparent trend over the period. An apparent reduction in the overall mortality within 365 days of surgery appears to be due to a reduction in the incidence of acute myocardial infarct. The data support the current advice that prophylaxis should be continued for at least six weeks following surgery. Despite increased uptake of prophylaxis regimens and earlier mobilisation, there has been no apparent change in the incidence of symptomatic VTE over the ten-years from 1992 to 2001

The treatment of massive chronic tears is problematic. The re-tear rate following surgery for extensive cuff tears remains high, and there is little consensus regarding optimum treatment. To investigate the outcome of a cohort of patients who had open repair of an extensive cuff tear using the Leeds Kuff patch as an augment. A retrospective cohort study of consecutive patients with a massive cuff tear who had surgery in our regional elective orthopaedic centre over a two year period from January 2015 to Dec 2016. All patients followed identical rehabilitation protocols, supervised by physiotherapists with an interest in the shoulder. Outcomes assessment was undertaken at a minimum of 12 months by a registrar or physiotherapist who was not part of the treating team. Pre-op data collection included; range of motion, pain score, Oxford shoulder score (OSS), assessment of muscle atrophy on MRI. Data collection was completed in 15 patients. The mean age was 62 yrs (56 – 75). The mean pre-op OSS was 22, improving to a mean of 43. The range of motion and pain score improved. There were no intra-operative complications. One patient required a second surgery for evacuation of a haematoma at 10 days post op. One patient had an obvious re-tear at 4 months. Open rotator cuff repair with synthetic Kuff patch augmentation for chronic degenerative tears appears worthwhile when assessed at 12 months and they continuous to improve even at 18 months. This treatment method may be a useful option for patients > 70 years old

Introduction: Knee arthroscopy is a common orthopaedic procedure. Growing demand on orthopaedic services has led to the introduction of new initiatives to reduce waiting lists and streamline services. Recently extended scope physiotherapists have placed patients directly on arthroscopy waiting lists without prior assessment by an orthopaedic surgeon. Aim: To determine if extended scope physiotherapists perform to the same standards as their orthopaedic colleagues with regards to diagnosing knee pathology and making appropriate referrals for arthroscopy. Method: Data was collected prospectively from Aug 2005. Patients were seen either in the physiotherapy led acute knee clinic or in orthopaedic outpatients by a consultant or registrar. Any patient placed onto a waiting list for knee arthroscopy was considered for the study. The clinical indications and diagnoses were recorded as well as demographic data. The arthroscopies were performed by one surgeon. The arthroscopic findings were compared with the clinical findings. Results: 300 patients were included in the study – 100 in each of the groups. The physiotherapists saw fewer patients per clinic and had longer time-slots per patient. All three groups had similar presenting complaints, indications for surgery and demographics. The Consultant performed best with 87% agreement with his initial diagnosis. The physiotherapists had 77% agreement and the registrars 68% agreement. No unnecessary arthroscopies were performed in any group. Conclusions: Extended scope physiotherapists perform a useful role in orthopaedic outpatients. They perform as well as their orthopaedic colleagues with regards to the selection of patients for arthroscopy and making appropriate diagnoses

We present an objective method for predicting the redisplacement of paediatric forearm and wrist fractures. Novel radiographic measurements were defined and their value assessed for clinical decision making. In Phase I of the study we defined the cast index and padding index and correlated these measurements with the incidence of fracture redisplacement. Phase II assessed these indices for their value in clinical decision making. Cast Index (a/b) is the ratio of cast width in lateral view (a) and the width of the cast in AP view (b). Padding Index (x/y) isthe ratio of padding thickness in the plane of maximum deformity correction (x) and the greatest interosseous distance (y) in AP view. The sum of cast index and padding index was defined as the Canterbury Index. In Phase I, 142 children's radiographs were analysed and a statistically significant difference was identified between redisplacement and initial complete off-ending of the bones, cast index > 0.8 and padding index of > 0.3. There was no significant association with age, fracture location, seniority of surgeon or angulation. In Phase II, radiographs of 5 randomly selected cases were presented to 40 surgeons (20 consultants & 20 registrars). Following an eyeball assessment they were asked to measure the cast index and padding index (after instruction). With eyeballing the consultants predicted 33% and registrars 25% of the cases that redisplaced. After learning to measure the indices the accuracy increased to 72% for consultants and 81% for registrars (p<0.001). We conclude that the cast index, padding index and Canterbury Index are validated tools to assess plaster cast quality and can be used to predict redisplacement of paediatric forearm fractures after manipulation. They can easily be taught to orthopaedic surgeons and are more accurate than eyeballing radiographs in the clinical setting. Redisplacement can be predicted if cast index > 0.8, padding index > 0.3 and Canterbury Index > 1.1

Aims

The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

There has been limited research examining the effect training of orthopaedic trainees may have on patient outcomes. This paper aims to determine if there is a difference in revision rate and functional outcomes of total hip joint replacement performed by consultants compared to those performed by supervised and unsupervised trainees. We reviewed all patient data since 2000 from the New Zealand National Joint Registry in patients undergoing total hip joint replacement (THJR) comparing the outcomes with the experience of the primary surgeon. The outcome measures were revision hip replacement and the Oxford Hip score at six months. We compared the reason for revision controlling for factors such as ASA, age and the index diagnosis. We also compared the six-month Oxford scores with the experience of the primary surgeon. There were 35415 patients who underwent elective THJR, 30344 of which were performed by a consultant, 2982 by a supervised registrar and 1067 by an unsupervised registrar. There was an overall revision rate (RR) of 0.77 per 100 component years. The RR was 0.75 (95% CI 0.67–0.82) for consultants, 0.97 (95% CI 0.72 – 1.28) for supervised trainees and 0.70 (95% CI 0.36 – 1.22) for unsupervised trainees. There was no significant difference in revision rates between consultants and supervised trainees (p<0.077) or unsupervised trainees (p< 0.30). The most common cause for revision surgery was dislocation, occurring in 39% of cases. This was more common in supervised and unsupervised trainees (48% and 50%) however there was no significant difference between the three groups (p-value 0.24). The other causes for revision were; loosening of the acetabular or femoral component, deep infection, pain and fracture with no significant difference between the three groups. The mean OHS was higher for consultants at 40.7 compared to 38.95 and 38.23 for supervised and unsupervised trainees respectively (p <0.001). The results of this study show no significant difference in the revision rate of THJR performed by trainees when compared to their consultants. Orthopaedic consultants do appear to have slightly better (1–2 points) OHS. These results are reassuring and show orthopaedic training does not adversely compromise patient outcomes

Introduction. We implemented an exhaustive operative and supervision algorithm for surgical treatment of hip fractures primarily based on own previously published literature. The purpose was to improve supervision and reduce the rate of reoperations. Materials and methods. 2000 consecutive unselected patients above 50 years admitted with a hip fracture were included, 1000 of these prospectively after implementation of the algorithm. Demographic parameters, hospital treatment and reoperations within the first postoperative year were assessed from patient records. The algorithm dictated the surgical treatment based on three objective patient parameters: age, new mobility score and fracture classification on pre-operative anterior-posterior and axial radiographs. Intra capsular fractures were treated with two parallel implants, a sliding hip screw, an arthroplasty or resection of the femoral head. Extra capsular fractures were treated with a sliding hip screw or an intramedullary nail. Supervision of junior registrars was mandatory for the prosthesis and intramedullary nail procedures. Results. 931/1000 operative procedures were operated according to the algorithm, compared to only 726/1000 prior to its introduction (p<0.001). Retrospectively we found that 13% (208/1657) of operative procedures performed as the algorithm dictated were reoperated compared to 28% (96/343) of operative procedures performed with other methods (p<0.001). In logistic regression analysis combining sex, age, ASA score, cognitive function, new mobility score and level of surgeon's experience, not following the algorithm was a predictor for re-operation (p<0.001 log. reg.). After implementing the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192/1000 to 105/1000 (p=0.039). The rate of reoperations declined from 18% to 12% (p<0.001, log. reg.), with a 24% (112/467) to 18% (87/482) decline for intra capsular fractures (p=0.025) and a 13% (68/533) to 7% (37/518) decline for extra capsular fractures (p=0.002). The extra bed-days caused by reoperations were hereby reduced from 24% to 18% of total hospitalization. Conclusion. An exhaustive algorithm for hip fracture treatment can be implemented. In our case, the algorithm both raised the rate of supervision and reduced the rate of reoperations, the latter saving many hospital bed-days

Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum. Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant

Aim: It is widely accepted that surgical skills improve with experience. Part of this experience comes from operating on patients while honing new skills. Total hip arthroplasty is one such procedure. This paper examines outcomes in relation to the primary surgeon. Methodology: All patients who had an Exeter femoral component implanted and 2 years follow-up in the hospital joint register had their X-Ray, outcome scores and complications reviewed. Complications are routinely recorded as part of the joint register and hospital computer discharge system. Radiological outcome measures were taken as recommended by Johnston et al. Procedures were recorded as either performed by consultant surgeon or registrar supervised by consultant surgeon. Results: Post operative WOMAC scores at six months and 2 years were similar in both groups (Consultant 19.6, registrar 22.32 at 6 months) SF-36 figures were similar at six months (Consultant performed 78.56, consultant supervised 75.39). There was a difference in SF-36 at 2 years (72.77 vs 63.11) but this was not statistically significant. Average abduction angle was lower in consultant supervised than consultant performed procedure. (36.75 vs 47 deg) Barrack cement grading was similar in both groups. Consultant inserted stems were more likely to be in neutral position compared to consultant supervised stems (84% vs 56%). Conclusion: In both goups the quality of life indexes do show a difference in outcome which relates to the primary surgeon.. However decreased abduction angle may lead to decreased range of motion post operatively and should be addressed intraoperatively

Aim: It is widely accepted that surgical skills improve with experience. Part of this experience comes from operating on patients while honing new skills. Total hip arthroplasty is one such procedure. This paper examines outcomes in relation to the primary surgeon. Methodology: All patients who had an Exeter femoral component implanted and 2 years follow-up in the hospital joint register had their X-Ray, outcome scores and complications reviewed. Complications are routinely recorded as part of the joint register and hospital computer discharge system. Radiological outcome measures were taken as recommended by Johnston et al. Procedures were recorded as either performed by consultant surgeon or registrar supervised by consultant surgeon. Results: Post operative WOMAC scores at six months and 2 years were similar in both groups (Consultant 19.6, registrar 22.32 at 6 months) SF-36 figures were similar at six months (Consultant performed 78.56, consultant supervised 75.39). There was a difference in SF-36 at 2 years (72.77 vs 63.11) but this was not statistically significant. Average abduction angle was lower in consultant supervised than consultant performed procedure. (36.75 vs 47 deg) Barrack cement grading was similar in both groups. Consultant inserted stems were more likely to be in neutral position compared to consultant supervised stems (84% vs 56%). Conclusion: In both goups the quality of life indexes do show a difference in outcome which relates to the primary surgeon. However decreased abduction angle may lead to decreased range of motion post operatively and should be addressed intraoperatively

Introduction: We undertook an audit study to find out patient perception of being seen by a nurse practitioner in the clinic for a follow up appointment instead of a consultant and satisfaction with the joint clinic. Methods and materials: 100 patients were surveyed following their post-operation review with the nurse. Data was collected prospectively over a period of 6 months. Patients were asked to complete the questionnaire on the day of their appointment and to hand the survey prior to leaving. Hence we had 100% response rate. Results: Majority of the respondents were female (61%) with 50 % having had total hip replacements and the rest had knee replacements. 99% of respondents (94/95) felt that enough time was spent with them during the appointment. All respondents (100%) reported that they were able to ask questions and were answered satisfactorily. The consultant saw 26% of respondents; further 6% was seen by a registrar and the rest 68% were seen by the nurse specialist. Reasons for being seen by a doctor included check up or assessment, reviewing stitches and infection. 42% of respondents (33/79) were referred for further treatment either by the consultant (33%), nurse (64%) or registrar (3%). Reasons for further treatment included physiotherapy, plaster room, and further follow up (check up) appointment at 3–6 months to review the patient following surgery. 100% of respondents (97/97) were satisfied with the combined consultant/nurse clinic. 3 did not record their response. The vast majority of respondents (80%, 79/99) reported that they ‘don’t mind’ who they would have been seen by in the clinic. Discussion: The results indicate that patients are satisfied with the current clinic arrangements i.e. nurse-led clinic with the consultant being available. Hence there is a definite role for nurse led clinics for joint replacement surgery follow-ups

Introduction and Aims: Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that a detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. Method: A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually, to reach the diagnosis and plan the management. Sixty consecutive lower back pain and/or radiculopathy patients were included in the study. All the patients were seen by two orthopaedic registrars. Detailed history was taken by one and clinical examination was performed by the other registrar. A provisional diagnosis was made by both registrars based on their information. A consultant also took history and examined these patients. MRI scan was done as per clinical indication. Results: The gathered information was analysed using standard statistics software. The data indicates that clinical examination on its own was non-contributory in reaching diagnosis and plan the management. All information obtained by history alone correlated well with MRI results. The full results and cost implications will be discussed. Conclusion: Routine clinical examination of spine can be omitted without compromising the patient care, where clear history is available to reach diagnosis and plan the management. Clinical examination should be performed on those patients who need surgery to document the pre-operative neurology

Femoral shaft fractures are usually the result of high energy trauma and are often associated with poly-trauma. Inappropriate treatment results in prolonged morbidity and disability. The treatment of choice for fixation is an interlocking intramedullary nail inserted by closed technique. This study reviewed the perioperative difficulties associated with late nailing of femoral fractures at a busy trauma unit. Thirty four consecutive femoral nails were reviewed retrospectively. Delay to surgery, operative time and peri-operative morbidity was assessed. There were 27 males and 7 females. The average age was 30.5 years. Eleven patients were referred from a peripheral hospital. Motor vehicle collisions accounted for 22 fractures, and gun shot wounds for 7. There were 29 mid shaft injuries, 2 subtrochanteric and 3 distal femurs (Retrograde nails). Preoperative immobilization was by Thomas splint or skin traction. Six operations were done by a consultant, 17 by a senior registrar and 10 by a junior registrar. The average delay to theatre was 32 days (range 10–63). Nineteen femurs required open reduction. Open reduction resulted in increased operating time: 117 minutes versus 82 minutes for closed reduction. Nine patients required perioperative blood transfusion and 2 patients were admitted to high care post operatively. Leg length discrepancy post operatively ranged from 0 to 4cm. Early knee range of motion was limited. Delay to surgery was due to insufficient theatre availability, and delay in referral from peripheral hospitals. We found that the delay to surgery resulted in increased operative difficulty, operative time and perioperative morbidity. Late nailing of fractures requires meticulous preoperative planning by the entire theatre team, and careful, experienced surgical technique

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.

Cite this article: Bone Joint J 2024;106-B(3):227–231.

Aims

Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK.

Introduction and Aims Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. The aim of the study was to look at 1) Contributions from History and Examination. 2) Does Clinical Examination add any further information not identified from history?. Method A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually to reach the diagnosis and plan the management. 75 consecutive lower back pain and/or radiculopathy patients were included in the study. Two orthopaedic registrars saw all the patients. One took detailed history and the other registrar performed clinical examination. Both registrars based on their information arrived at a provisional diagnosis. A consultant also took history and examined these patients. MRI scan was done as per clinical indication. Results The data was analysed using standard statistics software. In all patients history suggested the possible diagnosis. Clinical examination did not add any further information to alter the course of management, which was planned for the patient. Clinical examination did not show any further information that was not identified in the MRI scan. Conclusion Clinical examination does not add to the body of information available from history. Clinical examination does not add any further information not available on the scan. Clinical examination should be performed for patients considered for surgery to document the findings; here both subjective and objective assessment should be performed. Examination is not a useful screening tool

This study was designed to assess the standard of orthopaedic training of Senior House Officers in the U.K. and to determine the optimum time that should be spent in these posts before registrar training. Two MCQ papers were constructed. One for the pre test and one for the post test. Questions covered all aspects of orthopaedics and trauma including operative surgery. The paper was firstly tested on controls including medical students, house officers, registrars of various grades and consultants. There was no statistical difference in the results for the two papers within the groups indicating that pre and post test papers were of similar standard. In addition the average scores in the tests increased proportionately to the experience and grade of the control. 129 SHOs from 25 hospitals in 10 different regions were tested by MCQ examination at the beginning of their 6-month post. They were again tested at the end of the job. The differences in score were compared. This difference was then correlated with the experience and career intention of the SHO. There was no statistical difference between pre and post test results in all groups of SHOs in the study (student t test). The best improvement in scores during this six month period were seen in SHOs of 1–1.5 years orthopaedic experience. SHOs of more than 3 years experience demonstrated the smallest improvement in their score. There was a net loss of seven trainees with a career intention of orthopaedics to other disciplines. In the vast majority of Senior House Officer posts in this country, very little seems to be learnt during a six-month attachment. This is especially so for those who are doing orthopaedics for the first time as well as very experienced SHOs

Aims

To assess the cost-effectiveness of a two-layer compression bandage versus a standard wool and crepe bandage following total knee arthroplasty, using patient-level data from the Knee Replacement Bandage Study (KReBS).

Aim: Our aim was to find the effect of implementation of European working time directive on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum. Methods: The audit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. We have analysed the results of the this and have identified a potential area of concern. Results: An orthopaedic trainee of registrar level(Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. Overall, a trust grade surgeon (non-training grade) was the lead surgeon in 24% of cases. Comparing with the previous audits performed in the same hospitals, the number of hip fracture operations performed by trainees have reduced drastically. In 2003 and 2005 audits, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. There is a definite trend suggesting decrease in number of operations by trainees since the implementation of European working time directive as it has been introduced in a phased manner since 2004. In NHS, Current target is to achieve it fully by next year which may make the situation even worse from training point of view. Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. On the other hand, the modernising medical curriculum (MMC) emphasises demonstration and record keeping of core competencies of surgical skills. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in England are mirrored elsewhere in Europe, the implications for orthopaedic training are significant. We are setting very high standards for training on one side but on practical grounds, not able to achieve the requirements set by educational bodies like OCAP and ISCP

Aim: We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease. Methods: Fifty patients with history of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy. Results: The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons: 100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears. Conclusion: The Neer’s and Hawkins’ signs were the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear

We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease. Fifty patients with history suggestive of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of commonly used clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs of impingement syndrome we evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy. The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons:100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears. Our findings echoed the conclusions of other papers in that the Neer’s and Hawkins’ signs are the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear

We report a three year Medical Devices Agency and Local Ethical Committee approved prospective study for a new tri-tapered polished cannulated cemented femoral component. Our stem was implanted in 53 primary total hip replacements. Eleven male patients (11 hips) and 39 female patients (39 hips). The mean age at surgery was 73 (range 65 to 84). The mean weight was 71.76 kg (range 49.3 kg to 94.6 kg) with a mean BMI of 28 (range 20.20 to 40.26). All patients had a pre operative diagnosis of osteoarthritis. All the hips were implanted via the anterolateral approach. Twenty-six (51%) hips were implanted by a single consultant and 24 (49%) were implanted by six different registrars. Pre-operative and sequential post-operative clinical and radiological evaluations were undertaken. The mean pre-operative Oxford hip score was 47 points.which declined 19 points at three years. Radiological analysis, using the Johnston criteria, did not reveal any untoward features. Prosthetic stem migration was measured using a technique developed in our unit and validated as accurate to 0.61 mm; as previously reported. Stem migration measured averaged 1.38 mm (n=52; sd ±1.38) 6 months post implantation. This progressed to 1.71 mm (n=50; SD=1.18) at one year; 1.61mm (n=48; sd ±1.17) at 2 years. and 1.55 mm (n=28; SD 1.13). At 3 years average stem migration for hips implanted by the registrar group and the consultant group was not sig-nificantly different (p=0.2048) and the migration curve, against time was similar for both groups. Our study has demonstrated initial component migration, comparable to that of other polished tapered cemented stem designs. The improvement in Oxford hip score parallels other reported series and no adverse radiological signs have been observed. Long-term surveillance of our cohort will provide further data to compare the new design with substantial equivalents. More sophisticated studies, such as RSA analysis would provide further data on early femoral component migration

The European Working Time Directive is a directive from the Council of Europe to protect the health and safety of workers in the European Union. The working time directive currently ensures a 56 working hour week and by August 2009 a 48 hour maximum working week. To accommodate such a reduction in working hours, the on call rotas for institutions have had to change. Has this had an affect on trauma exposure for current specialist registrars?. Materials and Methods: Data collection was from electronic logbooks of orthopaedic specialist registrars and locum appointment trainees on the Southwest Thames rotation. From the elogbooks indexed trauma procedures were audited, this included: dynamic hip screw, hemiarthroplasty, open reduction and internal fixation ankle, intramedullary nail femur, intramedullary nail tibia, and intramedullary nail humerus. The data was divided into year groups and then the data was subdivided into on call rotas. Obtained from the data collection was the number of indexed linked operations carried out per 6 months per year group. Results: The data collection was over an 18 month period October 2006 – April 2008. The total number of trainee logbooks who had the complete data from the logbook available was 90. The number of trainees for each year = n, the total number of operations =x and mean number of operations for each year of training =μ. The results for year groups are as follows:Year 1 n=18, x=4897, μ= 272:Year 2 n=12, x=2853, μ= 238: Year 3 n=22, x=4106, μ= 187:Year 4 n=19, x=3176, μ= 167:Year 5 n=4, x=658, μ=165:Year 6 n=15, x=3249, μ=217.Data for on call rotas were subdivided into the following groups: 1in13, 1in9, 1in8 and 1in7. The number of trainees for each on type of on call rota =n, the total number of operations = x, the mean number of operations for each on call rota group = μ.The results were as follows:1in13 on call: n=12, x=2215, μ=185; 1in9 on call: n=11, x=3195, μ=290. 1in8 on call: n=20, x=3754, μ=188; 1in7 on call: n=47, x=9775, μ=208. The results for the number of indexed linked operations carried out per 6 months per year group are as follows:YEAR 1 257.73:YEAR 2 228.24:YEAR 3 173.49: YEAR 4 173.23:YEAR 5 164.50: YEAR 6 208.49. Conclusion: The results show that year groups 1, 2 and 6 have carried out the highest number of procedures. The data also shows that trainees on the lowest frequency of on call rota call have the lowest number of indexed operations. The results for the number of indexed linked operations carried out per 6 months per year group shows that as the year groups progress the number of procedures carried out continues to decrease from year 1 to 5 and then increases again at year 6. The structure of orthopaedic training is being overhauled. The need for effective training has intensified. This audit aims to demonstrate some of the effects of the changes made in higher speciality training in orthopaedics

Background. The Fracture Fixation Assessment Tool score (FFATs) was developed as an objective evaluation of post-operative fracture fixation radiographs as a means of appraisal and education. The tool has proven validity, simple to use and based upon AO principles of fracture fixation. This study has been designed to assess how FFATs changes throughout the training program in the UK. Methods. The local trauma database of a district general hospital, with trauma unit status was used to identify cases. Although FFATs is designed to apply to any fracture fixation, Weber B ankle fractures were selected as common injuries, which constitute indicative cases in T&O training. Grade of the primary surgeon and supervision level were both stratified. The initial and intraoperative radiographs were anonymised and presented to the assessor who had been blinded to the identity and grade of the surgeon, for scoring using FFATs. Results. 293 fractures around the ankle were identified from the Database between 2013 and 2016. After applying the inclusion criteria of Weber B fractures operatively fixed, Specialist training registrars and consultants, there were 99 cases for evaluation. These were grouped by training experience into 4 groups. (ST3-4, ST5-6, ST7-8, Consultants) and demonstrated a trend of increasing scores with experience level with a dip in consultant scores, albeit not statistically significant due to low numbers of cases at higher training grades. Conclusions. We present our first experience of using FFATs in a uniform series of fractures in surgeons of different training grades. There is a trend to increasing scores throughout training with a dip in consultant scores likely reflecting increased complexity of cases. Implications. FFATs could prove to be an invaluable appraisal tool for teaching and mentoring surgeons in training both locally in the United Kingdom and remotely overseas

Aims

The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement.

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Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK.

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Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA), and has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA.

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This study aims to identify the top unanswered research priorities in the field of knee surgery using consensus-based methodology.

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Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.

Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children. Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%). A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of growth arrest, but corrective surgery for functional limitation was required in only three (1%) patients

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We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

Aim. This study aimed to evaluate the impact on length of hospital stay from dedicated infectious diseases input for orthopaedic infection patients compared to sporadic infection specialist input. Method. We conducted an observational cohort study of 157 adults with orthopaedic infections at a teaching hospital in the UK. The orthopaedic infections included were: osteomyelitis, septic arthritis, infected metalwork and prosthetic joint infections, and adults were aged 18 years or more. Prior to August 2016, advice on orthopaedic infection patients was adhoc with input principally from the on-call infectious diseases registrar and phone calls to microbiology whereas after August 2016 these patients received regular input from dedicated infectious diseases doctor(s). The dedicated input involved bedside reviews, medical management, correct antimicrobial prescribing, managing adverse drug reactions, increased use of outpatient parenteral antimicrobial therapy (OPAT) services especially self-administration of intravenous antibiotics and shared decision-making for treatment failure, whilst remaining under orthopaedic team care. Orthopaedic patients operated on for management of their infection between 29/8/16 and 15/3/17 were prospectively identified and orthopaedic operation records were used to retrospectively identified patients between 29/8/15 and 15/3/16. The length of stay was compared between the 2 groups. Results. There were 83 patients in the dedicated infectious diseases input group (dedicated group) and 74 patients in the sporadic infection specialist input group (sporadic group). The dedicated group were significantly younger: median 58 years versus 69years (p<0.001), and there was a trend to significant differences in the breakdown of diagnosis (p=0.06), but no significant sex difference. The median length of stay for the sporadic group was 20 days (interquartile range (IQR) 13–29 days) compared to 14 days (IQR 9–27 days) for the dedicated group, with a trend to significance (p=0.06) but no effect from age or diagnosis. Our hospital values one day in hospital at £864, therefore over the 6.5 months trial period of the dedicated infectious diseases input there was a cost saving of £430,272 (£864 × 6 days × 83 patients). Conclusions. Dedicated infectious diseases input would be expected to improve patient care but by additionally reducing median length of stay for orthopaedic infection patients, this encourages investment to achieve both. In this era of increased scrutiny of health budgets demonstrating value for money, not just improved quality of patient care, is essential

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The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

The undergraduate curricula in the UK have no designated modules on sarcomas. Lumps and bumps are commonly presented to surgeons, hence awareness of sarcoma is important. The aim of this study was to identify the awareness and knowledge of orthopaedic and surgical trainees relating to the presentation, referral and management of sarcomas. Participants were invited to take part and complete an online questionnaire. Sarcoma knowledge was assessed using a variety of questions. Key resources were provided to improve knowledge at the end of the questionnaire. There were 250 respondents, which included medical students (n=49), foundation doctors (n=37), core surgical trainees (n=58), registrars (n=73), post-CCT surgeons (n=9) and academic fellows (n=4). Both UK and international trainees were included. 45% did not recall receiving sarcoma teaching at undergraduate level, with 61% stating they did not have adequate training to identify sarcoma “red flags”. 58% did not have sufficient background knowledge of sarcomas whilst 38% were unable to identify sarcoma red flags. 64% and 25% of trainees had insufficient knowledge of the correct referral process and management for sarcomas respectively. There appears to be a deficiency in training regarding sarcoma identification and management within trainees. “Red flags” for lumps are not widely known who may be asked to review these patients. Many trainees are not aware of the national guidelines for referral and management. The large sample of respondents is likely to be representative of the larger trend and may lead to inappropriate management, poor outcomes and litigation

By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants. This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively. There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921). This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively

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Evidence exists of a consistent decline in the value and time that medical schools place upon their undergraduate orthopaedic placements. This limited exposure to trauma and orthopaedics (T&O) during medical school will be the only experience in the speciality for the majority of doctors. This review aims to provide an overview of undergraduate orthopaedic training in the UK.

Aims

Nearly 99,000 total knee arthroplasties (TKAs) are performed in UK annually. Despite plenty of research, the satisfaction rate of this surgery is around 80%. One of the important intraoperative factors affecting the outcome is alignment. The relationship between joint obliquity and functional outcomes is not well understood. Therefore, a study is required to investigate and compare the effects of two types of alignment (mechanical and kinematic) on functional outcomes and range of motion.

Introduction. Orthopaedic theatres can be noisy. Noise exposure is known to be related to reduced cognition, reduced manual dexterity and increased rates of post-operative wound infection. Up to 50% of orthopaedic theatre staff have features of Noise-Induced Hearing Loss (NIHL) with higher levels in consultants compared to registrars. Exposure to noise levels of 90dB(A) at work for a career of 40 years, equates to a 51% risk of hearing loss. Materials & methods. A Casella CEL-242 meter was positioned in the corner of the theatre tent. Recordings were taken for 17 Total Knee Replacements (TKRs) and 11 Total Hip Replacements (THRs). This meter recorded the decibel level once per second (whereas EU Regulation requires equivalent continuous level measurement). Results. Noise levels reached 105.6dB(A) using a hammer during a TKR and 97.9dB(A) with an oscillating saw. Decibel levels exceeded 90dB(A) in every operation within the sample. Percentages of readings at 80.0dB(A) or above, per case, were calculated to estimate the proportion of our data above the EU regulation Lower Action Level; the maximum was 12.6% and they appeared to be greater in TKRs. Discussion. The small percentage of values at 80.0dB(A) or above indicates that the equivalent continuous decibel level for an average 8 hour day would be below the EU Lower Action Level. It was expected that TKRs would have higher percentages of decibels at 80.0dB(A) or above, given the greater time spent sawing in this procedure. Exposure to levels above 90dB (which occurred in every case) for short time periods is proven to cause irreversible loss of hearing. Minor damage accumulates throughout a career of 40 years, and can result in NIHL. Conclusion. Tools used in orthopaedic theatre produce impulse noises that can cause NIHL. Average daily exposure can be assumed to be acceptable. Further investigation is required

The imminent introduction of the new Trauma & Orthopaedic (T&O) curriculum, and the implementation of the Improving Surgical Training initiative, reflect yet another paradigm shift in the recent history of trauma and orthopaedic training. The move to outcome-based training without time constraints is a radical departure from the traditional time-based structure and represents an exciting new training frontier. This paper summarizes the history of T&O training reform, explains the rationale for change, and reflects on lessons learnt from the past.

Cite this article: Bone Jt Open 2021;2-3:181–190.

Postgraduate training in orthopaedics has traditionally been delivered through an apprenticeship model. However, junior doctor working patterns have more recently moved away from a team based structure, potentially affecting training experience. We aimed to compare the perceived quality of training between medical students, junior non-orthopaedic trainees and orthopaedic specialty trainees. We conducted an anonymous questionnaire of all medical students and trainees rotating through our unit over 24 months. The questionnaire contained 6, 10-point Likert rating scale questions and free text responses. Results were collated and analysed according to training stage. Of 82 questionnaires distributed, 60 (73%) were completed (18 specialty registrars, 22 junior trainees and 20 medical students). Junior trainees consisted of 8 GPSTs and 14 Foundation Year (FY2) doctors, only one of whom had specifically chosen an orthopaedic placement. Median Likert rating of training experience was (1 = very poor, 10 = excellent): ST4-ST8 = 8 (range 7–9), ST1-ST3 = 7 (6–9), GPSTs/FY2s = 4 (2–5) and medical students = 8 (7–10). Further analysis of junior non-orthopaedic doctors' training experience showed that placement induction, organisation of formal teaching and opportunities for training out with formal sessions were rated as poor. However, content of delivered teaching was rated highly. Free text responses identified several barriers to training including being too busy on wards and no opportunity for protected teaching. Our study shows that junior non-orthopaedic trainees feel their training experience during orthopaedic placements is much poorer than orthopaedic trainees and medical students. Time constraints and less team based working patterns may detract from their teaching opportunities. In addition, junior doctors rotating through orthopaedic units now have a wider spectrum of career interests with heterogeneous training needs. Therefore, orthopaedic departments may need to adopt a more targeted training programme that recognises individual training needs if junior doctor training is to improve

In February 2007 an Electronic Emergency Board was introduced into the Orthopaedic Department at Musgrove Park Hospital. The aims of this system were to replace the often disorganized handwritten trauma white-board and improve multidisciplinary communication. The electronic board can be accessed from any computer terminal in the hospital and a large plasma screen is kept permanently on display in the orthopaedic theatre corridor. Emergency admissions are added by the on-call registrar before the morning trauma meeting and during the day the board is managed by our Trauma Coordinator. We performed an informal survey of orthopaedic trauma departments in the South West region to ascertain current practices for organizing the trauma workload. In summary we have introduced an electronic system for the organising and recording of all our trauma cases. We have found this system extremely beneficial to the smooth running of the orthopaedic trauma service

Introduction:. South Africa has a very sports orientated population and a high blunt trauma prevalence. In August 2008, we re-established the soft tissue knee service at our academic hospital. Our clinic is staffed by a sessional Consultant, a Registrar, and is overseen by a senior honorary Consultant. Here we present a review of our first 2 years experience. Methods:. The clinic operates on a referral basis. All patients have all their clinical and demographic data and referral data entered into a Soft Tissue Database. The Data for 2009 and 2010 data were collated and analysed. Results:. A total of 346 patients were assessed and treated, of which 162 received surgery during this period. Patient referrals originated from both the state and independent sectors, and were made by hospital specialists, physiotherapists, and general practitioners. The mean delay from referral to first consultation was 9 days, and the mean wait from first consultation to surgery was 6 weeks. Our 162 procedures comprised of ACL reconstructions (52), PCL reconstructions (5), multiple ligament reconstructions (10), and osteotomies (4), as well as other procedures (91). There were 6 recorded major complications. Discussion:. A referral based specialist clinic can be successfully operated in a government hospital, and deliver both high quality clinical care, and valuable training opportunities to our trainees. Although currently staffed by part-time staff we believe that we have the capacity for many more patients and believe that we are only treating a small percentage of those in need. We want to increase awareness and referrals