to determine the extent of Orthobullets use by orthopaedic residents in academic and clinical settings. We also wanted to determine whether its widespread use is the same in various training programs around the world and so we chose to survey two distinct programs without any academic or institutional ties. An electronic 9 question survey created using SurveyMonkey was sent to residents in two distinct Orthopaedic
Milestone-based outcome oriented training is now an important framework for
Purpose: Despite increasing numbers of women entering surgical fields, orthopaedic surgery
There has been a widespread adoption of training programs or “boot-camps” targeting new surgical residents prior to entrance to the hospital environment. A plethora of studies have shown positive reactions to implementations of “boot camps”. Reaction surveys, however, lack the ability to provide a deeper level of understanding into how and why “boot camps” are seen as effective. The purpose of this study was to develop a rich perspective on the role “boot camps” are perceived to play in resident education. A constructivist approach to qualitative grounded theory methodology, employing iterative semi-structured, in-person, interviews was used to explore the construct of a “boot camp” through the eyes of key stakeholders, including junior surgical residents (n=10), senior surgical residents (n=5), and faculty members (n=5) at a major academic centre. Interviews were coded and analysed thematically using NVIVO software. Three members of the research team coded data independently and compared themes until consensus was reached. A method of constant comparative analysis was utilised throughout the iterative process. Emerging themes were revisited with stakeholders as a measure of rigor. Axial coding of themes was used to discover the overlying purposes embedded in the “boot camp” construct. The overarching themes resonating from participants were ‘anxiety reduction’, ‘cognitive unloading’ and ‘practical logistics’. Resident anxiety was ameliorated through subthemes of ‘social inclusion’, ‘group formation’, ‘confidence building’ and ‘formalisation of expectations’. A resident commented “the nuances of how things work is more stressful than the actual job.” Residents bonded together to create personal and group identities, “forming the identity of who we are as a group”, that shaped ongoing learning throughout training, “right from the beginning we would be able to call on each other.” Junior residents found themselves cognitively unloaded for higher level learning through ‘expectation setting’ and ‘formalised basic skills’; “I knew how the equipment was going to fit together, it allowed me to focus more on what was happening from the operative perspective.” Stakeholders highlighted the importance of positioning “boot camp” at the beginning of
Purpose: Orthopaedic
In March 2020, COVID-19 was declared a pandemic by the World Health Organization. The pandemic imposed drastic changes in our social and professional routine. Professionally at all levels our hospital tasks were changed and prioritized. Surgeons and residents were deployed on rotations to fields other than their expertise in orthopaedics. Health-care education received major changes in these challenging times, and students did face difficulties in receiving education, as well as training due to limited clinical and surgical exposure. In response to the WHO regulations, most of the teaching centres and hospitals worldwide have adopted the web-based teaching and learning model to continue the education and training of orthopaedic residents. These results brought significant changes to the training experience in orthopaedic surgery in combination with the fact that clinical duty hours and case volume were substantially reduced. In what concerns orthopaedic journal publications, the Covid-19 pandemic resulted in a decline in the annual publication rate for the first time in over 20 years. Although not uniform, the reduction was most likely due to multifactorial causes. Regarding the appraisal at the end of training, at the Orthopaedic European Board Examination we were able to verify that the outcome at the written part 1 exam was good, equivalent to the outcome prior to the pandemic. However the oral viva was much worse, probably due to the fact that residents skipped much of the clinical and surgical teaching and exposure during 2020 and 2021. At the end of training, theoretical/factual knowledge was good but poor from the clinical practical experience.
As
The number of complex revision total hip arthroplasties (THA) is predicted to rise. The identification of acetabular bone defects prior to revision THA has important implications on technique and complexity of acetabular reconstruction. Paprosky et al. proposed a classification system including 3 main types with up to 3 subtypes focused on the integrity of the superior rim of the acetabulum and medial wall. However, the classification system is complex and its reliability has been questioned. The purpose of this study was to evaluate the effectiveness of different radiologic imaging modalities (plain radiographs, 2-D CT, 3-D CT reconstructions) in classifying acetabular defects in revision hip arthroplasty cases and their value of at different levels of orthopaedic training. Patients treated with revision total hip arthroplasty for acetabular bone defects between 2002–2012 were identified and 22 cases selected that had plain radiographs, 2-D CT and 3-D reconstructions available. Bone defects were classified independently by two fellowship-trained adult reconstruction surgeons. Representative sections were chosen and compiled into a timed presentation. Thirty-five residents from PGY-1 to PGY-5 and 4 attending orthopaedic surgeons were recruited for this study and received a 15-minute introduction to the classification system. Chi square analysis was utilized to examine the influence of image modality and level of training on the correct classification of acetabular bone loss using the Paprosky classification system with alpha=0.05.Introduction
Methods
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). Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines.Aims
Methods
Musculoskeletal (MSK) disorders continue to be a major cause of pain and disability worldwide. The mission statement of the Canadian Orthopaedic Association (COA) is to “promote excellence in orthopaedic and musculoskeletal health for Canadians,” and orthopaedic surgeons serve as leaders in addressing and improving musculoskeletal health. However, patients with MSK complaints most commonly present first to a primary care physician. According to a survey of family physicians in British Columbia, 13.7-27.8% of patients present with a chief complaint that is MSK-related (Pinney et Regan, 2001). Therefore, providing excellent MSK care to Canadians requires that all physicians, especially those involved in primary care, be adequately trained to diagnose and treat common MSK conditions. To date, there has been no assessment of the total mandatory MSK training Canadian family medicine residents receive. It is also unclear, despite the prevalence of MSK complaints among Canadian patients, if current family physicians are competent or confident in their ability to provide fundamental MSK care. The purpose of this study is to determine the amount of mandatory MSK training Canadian family medicine residents are currently receiving. Web-based research was used to determine how many weeks of mandatory MSK training was incorporated into current Canadian family medicine
The 2020-2021 Canadian
Three dimensional printing is an emerging new technology in medicine and the current educational value of 3D printed fracture models is unknown. The delayed surgery and need for CT imaging make calcaneal fractures an ideal scenario for preoperative 3D printed (3Dp) fracture models. The goal of this study is to assess if improvements in fracture understanding and surgical planning can be realized by trainees when they are given standard CT imaging and a 3Dp model compared to standard CT imaging and a virtual 3D rendering (3D CT). Ethics approval was granted for a selection of calcaneal fracture imaging studies to be collected through a practice audit of a senior orthopaedic trauma surgeon. 3Dp models were created in house. Digital Imaging and Communications in Medicine (DICOM) files of patient CT scans were obtained from local servers in an anonymized fashion. DICOM files were then converted to .STL models using the Mimics inPrint 2.0 (Materialise NV, Leuven, Belgium) software. Models were converted into a .gcode file through a slicer program (Simplify3D, Blue Ash, OH USA). The .gcode files were printed on a TEVO Little Monster Delta FDM printer (TEVO USA, CO USA) using 1.75mm polylactic acid (PLA) filament. Study participants rotated through 10 workstations viewing CT images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. A questionnaire at each workstation assessed fracture classification, proposed method of treatment, confidence with fracture understanding and satisfaction with the accuracy of the 3Dp model or 3D volume rendering. Participants included current orthopaedic surgery trainees and staff surgeons. A total of 16 residents and five staff completed the study. Ten fracture cases were included in the analysis for time, confidence of fracture understanding, perceived model accuracy and treatment method. Eight fracture cases were included for assessment of diagnosis. There were no cases that obtained universal agreement on either Sanders classification or treatment method from staff participants. Residents in their final year of studies had the quickest mean time of assessment (60 +/− 24 sec.) and highest percentage of correct diagnoses (83%) although these did not reach significance compared to the other
Advances in orthopaedic surgery have led to minimally invasive techniques to decrease patient morbidity by minimizing surgical exposure, but also limits direct visualization. This has led to the increased use of intraoperative fluoroscopy for fracture management. Unfortunately, these procedures require the operating surgeon to stay in close proximity to the patient, thus being exposed to radiation scatter. The current National Council on Radiation Protection recommends no more than 50 mSv of radiation exposure to avoid ill-effects. Risks associated with radiation exposure include cataracts, skin, breast and thyroid cancer, and leukemia. Despite radiation protection measures, there is overwhelming evidence of radiation-related diseases in orthopaedic surgeons. The risk of developing cancer (e.g. thyroid carcinoma and breast cancer) is approximately eight times higher than in unexposed workers. Despite this knowledge, there is a paucity of evidence on radiation exposure in orthopaedic surgery residents, therefore the goal of this study is to quantify radiation exposure in orthopaedic surgery residents. We hypothesize that orthopaedic surgery residents are exposed to a significant amount of radiation throughout their training. We specifically aim to: 1) quantify the amount of radiation exposure throughout a Canadian orthopaedic
Surgical reattachment of torn rotator cuff tendons can lead to satisfactory clinical outcome but failures remain common. Ortho-R product is a freeze-dried formulation of chitosan (CS) that is solubilized in platelet-rich plasma (PRP) to form injectable implants. The purpose of the current pilot study was to determine Ortho-R implant acute
Purpose.
Aims. To establish whether there was a consensus among the members of the Hip Society (HS) on the role of direct anterior approach (DAA) contemporary primary total hip arthroplasty (THA). Methods. An online survey was sent to all 112 active and senior members of the HS, to which 71 members responded. The survey was constructed to determine whether they believed that evidence-based medicine proves, in modern clinical practice, that the DAA has significant benefits compared to risks when contrasted with other approaches. In addition, they were asked if they currently used the DAA. Results. While only 16.9% (12/71) of respondents had been trained in a generic anterior approach during
Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine
Purpose: Uncertainty around back pain management results in large volumes of patients with back related complaints being referred to orthopaedic surgeons for direction. The vast majority of these referrals are non surgical leading to unacceptable wait times (T1) across Canada. This reservoir delays not only those who are disabled with problems requiring a surgical remedy but also those who only require direction to appropriate conservative care. Physiotherapists with advanced training in orthopaedics possess skills in musculoskeletal interview, exam and Orthopaedic residents on the other hand must acquire spine specific skills in interview and exam, interpretation of radiographic exams, surgical decision making as well as surgical technique in a 2–3 month
Introduction. The direct anterior approach (DAA) total hip arthroplasty (THA) is now widely used. A recent unpublished survey of 1000 AAHKS members found that over half currently used a DAA technique and that most users felt the DAA was financially beneficial to their practice. Conversely, non-DAA users felt that their surgical volume had decreased. An online survey of Hip Society (HS) members was done to determine member's preference for a surgical approach and opinions regarding the DAA. Methods. 71 of 112 active and senior HS members (63%) responded to this 20-question survey. Results. The survey found that only 17% of respondents had trained in an anterior approach during
Trainees experience significant stress in the operating room, with potentially adverse effects on performance and learning. Psychological resilience explains why some individuals excel despite significant stress, meeting challenges with optimism and flexibility. The purpose of this study was to explore the relationships between trainee resilience, intraoperative stress, and desire to leave
Purpose: Currently, approximately 90% of the 620 graduating orthopaedic residents are planning on entering a post-graduate fellowship. Since January of 2005, two of the largest orthopaedic fellowship match programs, Sports Medicine and Spine Surgery, were dissolved by the NRMP due to gradual decline and reduced participation leaving approximately 70% of applicants in a non-match, decentralized system. Method: An on-line survey was designed by orthopaedic leadership of the AOA with the help of two Harvard business school “match” economists. The survey was administered to PGY-4 orthopaedic residents participating in the AOA Resident Leadership Forum (RLF) of 2007. This data was used as the cornerstone of the RLF for 2007, where the residents deliberated the results of the survey and formulated a brief recommendation list. The survey responses were then tabulated electronically and subjected to market analysis. Results: Sixty-five out of 112 (58%) RLF Residents answered the on-line survey, while 93 (83%) answered audience response questions at the RLF. Thirty percent of residents (19/64) did not have enough time and exposure in their
The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different. In the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group. Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success. The author's personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups. The author's current indication for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection. Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component. The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is an extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000. A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems, unfortunately, may continue to go down as it is uncommonly taught in
As an increasing number of female surgeons are choosing orthopaedics, it is important to recognize the impact of pregnancy within this cohort. The aim of this review was to examine common themes and data surrounding pregnancy, parenthood, and fertility within orthopaedics. A systematic review was conducted by searching Medline, Emcare, Embase, PsycINFO, OrthoSearch, and the Cochrane Library in November 2022. The Preferred Reporting Items for Systematic Reviews and Meta Analysis were adhered to. Original research papers that focused on pregnancy and/or parenthood within orthopaedic surgery were included for review.Aims
Methods
The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery. An electronic survey was conducted of practising female orthopaedic surgeons based in the USA through both the Ruth Jackson Society and the online Facebook group “Women of Orthopaedics”.Aims
Methods
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. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration.Aims
Methods
Femoroacetabular impingement (FAI) is a common cause of hip pain in the young adult. Uncertainty regarding surgical indications, outcome assessment, management preferences and perceptions of the literature exist. We conducted a large international survey assessing the perceptions and demographics of orthopaedic surgeons regarding FAI. A survey was developed using previous literature, focus groups and a sample-to-redundancy strategy. The survey contained forty-six questions and was emailed to national orthopaedic associations and orthopaedic sports medicine societies for member responses. Members were contacted on multiple occasions to increase response rates. Nine hundred orthopaedic surgeons from twenty national and international organisations completed the survey. Surgeons responded across 6 continents, 58.2 % from developed nations with 35.4 % having sports fellowship training. North American and European surgeons reported significantly greater exposure to hip arthroscopy during
The high and ever increasing cost of medical care worldwide has driven a trend toward new payment models. Event based models (such as bundled payment for surgical events) have shown a greater potential for care and cost improvement than population-based models (such as accountable care organizations). Since joint replacement is among the most frequent and costly surgical events in medicine, bundled payments for joint replacement episodes have been at the forefront of evolution from fee-for-service to value-based care models and episode-based healthcare reform in general. Our education as surgeons in medical school,
The number of cemented femoral stems implanted in the United States continues to slowly decrease over time. Approximately 10% of all femoral components implanted today are cemented, and the majority are in patients undergoing hip arthroplasty for femoral neck fractures. The European experience is quite different, in the UK, cemented femoral stems account for approximately 50% of all implants, while in the Swedish registry, cemented stems still account for the majority of implanted femoral components. Recent data demonstrating some limitations of uncemented fixation in the elderly for primary THA, may suggest that a cemented femoral component may be an attractive alternative in such a group. Two general philosophies exist with regards to the cemented femoral stem: Taper slip and Composite Beam. There are flagship implants representing both philosophies and select designs have shown excellent results past 30 years. A good femoral component design and cementing technique, however, is crucial for long-term clinical success. The authors' personal preference is that of a “taper slip” design. The cemented Exeter stem has shown excellent results past 30 years with rare cases of loosening. The characteristic behavior of such a stem is to allow slight subsidence of the stem within the cement mantle through the process of cement creep. One or two millimeters of subsidence in the long-term have been observed with no detrimental clinical consequences. There have been ample results in the literature showing the excellent results at mid- and long-term in all patient groups. The authors' current indications for a cemented stem include the elderly with no clear and definitive cutoff for age, most likely in females, THA for femoral neck fracture, small femoral canals such as those patients with DDH, and occasionally in patients with history of previous hip infection. Modern and impeccable cement technique is paramount for durable cemented fixation. It is important to remember that the goal is interdigitation of the cement with cancellous bone, so preparing the femur should not remove cancellous bone. Modern technique includes distal plugging of the femoral canal, pulsatile lavage, drying of the femoral canal with epinephrine or hydrogen peroxide, retrograde fill of the femoral canal with cement with appropriate suction and pressurization of the femoral cement into the canal prior to implantation of the femoral component. The dreaded “cement implantation syndrome” leading to sudden death can be avoided by appropriate fluid resuscitation prior to implanting the femoral component. This is a extremely rare occurrence today with reported mortality for the Exeter stem of 1 in 10,000. A cemented femoral component has been shown to be clinically successful at long term. Unfortunately, the art of cementing a femoral component has been lost and is rarely performed in the US. The number of cemented stems unfortunately may continue to go down as it is uncommonly taught in
The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. Every surgeon who performs primary hip arthroplasties will expound the particular virtues of his or her particular routine surgical approach. Usually this approach will be the one to which the surgeon was most widely exposed to during
The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the ‘French paradox’ principles through the Hueter anterior approach (HAA) in patients older than 70 years. From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance.Aims
Methods
Background. Tapered cementless femoral components have been used in total hip arthroplasty (THA) constructs for more than 20 years. The Synergy femoral component was introduced in 1996 as a second generation titanium proximally porous-coated tapered stem with dual offsets to better restore femoral offset at THA (Figure 1). The purpose of this study was to evaluate the outcome of the authors' experience using the Synergy stem at minimum 15 years of follow-up. Material and methods. We retrospectively reviewed a consecutive series of 102 patients (112 hips) who underwent surgery between November 1996 and October 1998 for primary THA using cementless Synergy stem with a minimum 15-years follow-up. The mean age at the time of surgery was 61 years, and the mean duration of follow-up was 16.3 years. Seventeen patients were lost at FU (8 died before the 15 years mark, 8 changed
Periacetabular osteotomy (PAO) is the preferred treatment for symptomatic acetabular dysplasia in adolescents and young adults. There remains a lack of consensus regarding whether intra-articular procedures such as labral repair or improvement of femoral offset should be performed at the time of PAO or addressed subsequent to PAO if symptoms warrant. The purpose was to determine the rate of subsequent hip arthroscopy (HA) in a contemporary cohort of patients, who underwent PAO in isolation without any intra-articular procedures. From June 2012 to March 2022, 349 rectus-sparing PAOs were performed and followed for a minimum of one year (mean 6.2 years (1 to 11)). The mean age was 24 years (14 to 46) and 88.8% were female (n = 310). Patients were evaluated at final follow-up for patient-reported outcome measures (PROMs). Clinical records were reviewed for complications or subsequent surgery. Radiographs were reviewed for the following acetabular parameters: lateral centre-edge angle, anterior centre-edge angle, acetabular index, and the alpha-angle (AA). Patients were cross-referenced from the two largest hospital systems in our area to determine if subsequent HA was performed. Descriptive statistics were used to analyze risk factors for HA.Aims
Methods
The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard. We randomized feet from children aged below 36 months with idiopathic clubfoot on a 1:1 basis in either the blade or needle group. Follow-up was conducted at three weeks and three months postoperatively, where dorsiflexion range, Pirani scores, and complications were recorded. The noninferiority margin was set at 4° difference in dorsiflexion range at three months postoperatively.Aims
Methods
This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons? A total of 15 orthopaedic trauma surgeons (seven juniors, eight seniors) evaluated 20 complex elbow fractures for their overall pattern (i.e. varus posterior medial rotational injury, terrible triad injury, radial head fracture with posterolateral dislocation, anterior (trans-)olecranon fracture-dislocation, posterior (trans-)olecranon fracture-dislocation) and their specific characteristics. First, fractures were assessed based on radiographs and 2D and 3D CT scans; and in a subsequent round, one month later, with additional 3D-printed models. Diagnostic accuracy (acc) and inter-surgeon reliability (κ) were determined for each assessment.Aims
Methods
Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs.Aims
Methods
Total knee arthroplasty (TKA) is a successful operation associated with a high rate of clinical success and long-term durability. Cementless technology for TKA was first explored 30 years ago with the hope of simplifying the performance of the procedure and reducing an interface for potential failure by eliminating the use of cement. Poor implant design and the use of first generation biomaterials have been implicated in many early failures of these prostheses due to aseptic loosening and reflected the failure of either the tibial or patellar component. Despite this, many excellent intermediate and long-term series have clearly demonstrated the ability of cementless TKA to perform well with good to excellent survival, comparable to that of cemented designs. Lessons learned from the initial experiences with cementless technology in TKA have led to improvements in prosthetic design and materials development. One of the most innovative biomaterials introduced into orthopaedics for cementless fixation is porous tantalum. Compared to other commonly used materials for cementless fixation, porous tantalum has the highest surface friction against bone, optimizing initial stability at the implant-bone interface as a prerequisite for long-term stability of the reconstruction. At the 2013 AAOS Annual Meeting, Abdel presented the 5-year Mayo Clinic experience with cementless TKA utilizing a highly porous monoblock tibial component in 117 knees and found NO difference in survivorship compared to cemented fixation with a re-operation rate of 3.5% in both groups. They had no revisions for aseptic loosening. These early to intermediate results reflect our own experience with all cementless TKA utilizing a cobalt-chromium fibermesh femoral component, as well as monoblock porous tantalum tibial and patellar components with up to 11-year follow up. In that series of 115 patients, there was a 95.7% survival of implants, with no revisions of any components for aseptic loosening. Further advantages to using cementless fixation include the elimination of concerns with regard to monomer-induced hypotension, thermal necrosis from PMMA polymerization, and third body wear secondary to retained or fragmented cement. Savings are also realised from elimination of the costs of cement, a PMMA mixing system, cement gun, pulse lavage system, and irrigation solution. Perhaps the greatest cost savings is derived from the reduction in operating room time. At our institution–a Level 1 county trauma center with an orthopaedic
To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty).Aims
Methods
Purpose. The ability to correctly interpret quantitative results is a crucial skill developed in medical school and surgical
We aimed to examine the influence of nursing home
The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury. Population-based cohort study with manual review of radiographs and charts. The primary outcome measure was incidence of paediatric distal forearm fractures. The study was based on an average at-risk population of 116,950. A total number of 4,316 patients sustained a distal forearm fracture in the study period. Females accounted for 1,910 of the fractures (44%) and males accounted for 2,406 (56%).Aims
Methods
Purpose: The current study examines the impact of the 80-hour work week on the number of surgical cases performed by PGY2 – PGY5 Orthopedic residents. We also evaluated Orthopaedic In-training Exam (OITE) scores during the same time period. Method: Data were collected from the ACGME national database for 3 academic years prior to and 5 years after July 1, 2003. CPT surgical procedure codes logged by all residents three years prior to and five years following implementation of the 80-hour work week were compared. The average raw OITE scores for each class obtained during the same time period were also evaluated. Data were reported as the mean ± standard deviation (SD) and group means were compared using independent t-tests. Results: No statistical difference was noted in the number of surgical procedure codes logged prior to or after institution of the 80-hour week during any single year of training. However, an increase in the number of CPT codes logged in the PGY-3 year after 2003 did approach significance (457.7 vs. 551.9, p=0.057). There was a statistically significant increase in total number of cases performed (464.4 vs. 515.5 p=0.048). No statistically significant difference was noted in the raw OITE scores before or after work hour restrictions for our residents or nationally. Conclusion: We found no statistical difference for each
Gender bias and sexual discrimination (GBSD) have been widely recognized across a range of fields and are now part of the wider social consciousness. Such conduct can occur in the medical workplace, with detrimental effects on recipients. The aim of this review was to identify the prevalence and impact of GBSD in orthopaedic surgery, and to investigate interventions countering such behaviours. A systematic review was conducted by searching Medline, EMCARE, CINAHL, PsycINFO, and the Cochrane Library Database in April 2020, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to which we adhered. Original research papers pertaining to the prevalence and impact of GBSD, or mitigating strategies, within orthopaedics were included for review.Aims
Methods
Purpose: To evaluate fellowship trainee and supervisor perceptions on the relative importance of core cognitive and procedural competencies in spine subspecialty fellowship training. Method: A questionnaire was designed through synthesis and amalgamation of two previous surveys designed by other authors. This questionnaire was reviewed for content by spine surgery experts (Canadian Spine Society Education Committee). The questionnaire was administered (online and paper) to fellow trainees and supervisors across Canada and data was collected over a 3-month period. It consisted of 40 MCQ items grouped into 13 broad cognitive skills categories, as well as 29 technical/procedural items. Data was analyzed using qualitative and descriptive statistics (e.g. average mean scores, standard deviations, t-tests). Results: The response rate was 91%, with 15 of 17 fellow trainees and 47 of 51 supervisors completing the survey. Twelve of the 13 core cognitive skill categories were rated as being important to acquire by the end of fellowship. Trainees were not comfortable performing, and requested additional training in 8 of 29 spine surgery technical skill items. Specifically, additional training was believed to be required for intradural procedures (e.g. syringomyelia, intradural neoplasms) and other less common, technically demanding, procedures (e.g. transoral odontoidectomy, anterior thoracic discectomy). Significant differences (p<
0.05) existed in perceptions of importance for specific cognitive and technical skills based on previous
Purpose: The RCPSC Orthopaedic Specialty Committee for
Purpose: Although more than half of all medical graduates are now female, orthopaedics has experienced the least growth of all primary surgical fields in attracting female
Cervical spine disorders represent a good proportion of the daily practice of many neurosurgeons. The rapidly increasing knowledge base on spinal conditions and the progressive complexity of surgical interventions appear to be generating a renewed interest in this evolving subspecialty among neurosurgical trainees. In order to assess the current level of spinal surgery training and conveyed competence in dealing with spinal disorders, a self assessment questionnaire was devised and distributed to the neurosurgical trainees attending the EANS (European Association of Neurosurgical Society) training courses. 126 questionnaires were returned with a return rate of 32%. The majority of trainees responding to the questionnaire were in their final (6th) year of training or had completed their training (60,3% of total) representing 25 European nations. A separate analysis of the data pertaining to cervical spine disorders revealed 80% of the trainees completing their training in University hospitals with cervical spine injuries predominantly managed by neurosurgeons (75%). In their practical skill assessment, 78% of the senior trainees were competent in the treatment of cervical disc herniation and cervical spinal stenosis in their anterior microsurgical techniques. In emergency management of cervical spinal trauma, 45% of the senior trainees were competent in being able to perform procedures without direct supervision. Regarding skills in anterior and posterior cervical stabilisation techniques, 33% and 15% respectively were competent in performing as well as dealing with complications &
difficulties that may arise. Spinal surgery training in European
Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective. Cite this article:
Purpose: Given recent evolving guidelines regarding maximum allowable work hours and emphasis on resident quality of life, novel strategies are required for implementing call schedules. The night float system has been used by some institutions as a strategy to decrease the burden of call on resident quality of life in level one trauma centres. The purpose of this study was to determine whether there are differences in quality of life, work-related stressors, and educational experience between orthopaedic surgery residents in the night float and standard call systems at two level one trauma centres. Method: This was a prospective cohort study at two level one trauma hospitals comprised of a standard call (1 in 4) group and a night float (5pm-7am, Sunday to Friday) group for each hospital, respectively. Residents completed the Short Form 36 (SF-36) general quality-of-life questionnaire, as well as, questionnaires on stress level and educational experience before the rotation (baseline), at two, four and subsequently at six months. An analysis of covariance (ANCOVA) approach was used to compare between-group differences using the baseline scores as covariates. Wilcoxon Signed-Rank tests (non-parametric) were used to determine if the residents’ SF-36 scores were different from the age and sex matched Canadian norms. Predictors of resident quality of life were analyzed using multivariable mixed models. Results: Seven residents were in the standard call group and nine in the night float group for a total of 16 residents (all males, mean age=35.1 yrs). Controlling for between-group differences at baseline, residents on the night float rotation had significantly lower role physical (RP), bodily pain (BP), social function (SF) subscale scores (p<
0.05). Conclusion: Our study suggests that the residents in the standard call group had better health related quality of life in comparison with the night float group. No differences existed in subjective educational benefits and stress level between the groups. The study findings may be limited due to the small sample size. However, this sample size is substantial given the size of most orthopaedic
Abstract. This project was funded by “start-up” funds by the Department of Surgery, Division of Orthopaedics, University of Toronto. Purpose. The purpose of this study was to determine the impact of an interactive workshop pertaining to optimizing learning in orthopaedics, on academic performance and changed behaviour towards learning during orthopaedic
This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant.Aims
Methods
Introduction: Since the first meeting in 1875, and the subsequent introduction of the concept of evidence based medicine in the 1990s, the journal club has become an integral part of keeping abreast with current literature. There is no study assessing orthopaedic journal clubs amongst training programs across the UK. This study had two aims: the first was to determine whether journal clubs still play an important part in orthopaedic training programs, the second was to evaluate the frequency, format and goals of journal clubs conducted in orthopaedic training programs in the UK. Method: We surveyed fifty seven hospitals across the UK. This included hospitals from all the orthopaedic teaching regions of which twelve were teaching hospitals and forty five district general hospitals. Results: A total of 57 hospitals were surveyed. Of these hospitals 28/57(49%) had a journal club programme in place. On average journals clubs were undertaken once a month and lasted about 1 hour. Most occurred during the working day and were chaired by a consultant. Specialist registrars presented the vast majority of papers (average of 1.9 each per session), with the JBJS Br being the most widely used journal (100% of journal clubs). Of the twelve teaching hospitals questioned, five (42%) had journal clubs, and twenty three of the forty five (51%) district general hospitals had journal clubs. The average number of articles critically appraised by trainees who attended journal clubs was 5 (0–15) compared to 3 (0–18) in those not attending a journal club. When asked whether there was any alternative way in which a trainee might otherwise learn how to critically appraise an article, fourteen suggested online journal forums and eighteen suggested self-directed learning or personal study. Although only 49% of hospital had journal clubs, 88% of trainees believed that it formed a valuable part of training and 56% thought it should be compulsory. Discussion: This study shows that journal clubs occur in around half of the orthopaedic departments surveyed across the country. This is despite the importance trainees’ associate with journal clubs being part of their training. In contrast, studies from North America show that a regular journal club occurs in 99% of
The aim of this study was to determine whether national standards of best practice are associated with improved health-related quality of life (HRQoL) outcomes in hip fracture patients. This was a multicentre cohort study conducted in 20 acute UK NHS hospitals treating hip fracture patients. Patients aged ≥ 60 years treated operatively for a hip fracture were eligible for inclusion. Regression models were fitted to each of the “Best Practice Tariff” indicators and overall attainment. The impact of attainment on HRQoL was assessed by quantifying improvement in EuroQol five-dimension five-level questionnaire (EQ-5D-5L) from estimated regression model coefficients.Aims
Methods
Background: Poor results were observed at medium term follow-up (FU) after first and second generation cementless stems implantation in total hip arthroplasty (THA). Revision rate up to 24% is reported with anatomic stems; stress-shielding rate up to 50%, thigh pain rate up to 21%, loosening rate up to 20% and osteolysis rate up to 29% were reported with cylindrical stems. A third generation tapered stem, the Synergy stem, was introduced in 1996 to rise such weakness points. Material and methods: A retrospective, cohort study was carried out in two academic centers (London, Toronto, Canada &
Rome, Italy) on 232 primary THA in 215 patients with a 10 to 12 yrs FU. Mean age at surgery was 60 yrs (18–82), 95 patients were males and 120 females. Thirty-six patients were lost at FU (13 died before the 10 yrs mark, 22 changed
To assess the variation in pre-fracture quality of life (QoL) within the UK hip fracture population, and quantify the nature and strength of associations between QoL and other routinely collected patient characteristics and treatment choices. The World Hip Trauma Evaluation (WHiTE) study, an observational cohort study of UK hip fracture patients, collects a range of routine data and a health-related QoL score (EuroQol five-dimension questionnaire (EQ-5D)). Pre-fracture QoL data are summarized and statistical models fitted to understand associations between QoL, patient characteristics, fracture types, and operations.Aims
Methods
The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe.
We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires. During the first four weeks of the nationwide lockdown due to COVID-19, the objective impact of the pandemic on each trainee’s surgical caseload exposure was assessed using data from individual trainee logbook profiles in the deanery of the Republic of Ireland. Independent predictor variables included the trainee grade (ST 3 to 8), the individual trainee, the unit that the logbook was reported from, and the year in which the logbook was recorded. We used the analysis of variance (ANOVA) test to assess for any statistically significant predictor variables. The subjective experience of each trainee was captured using an electronic questionnaire.Aims
Methods
There is no consensus on the treatment of proximal humeral fractures. Hemiarthroplasty has been widely used in patients when non-surgical treatment is not possible. There is, despite extensive use, limited information about the long-term outcome. Our primary aim was to report ten-year patient-reported outcome after hemiarthroplasty for acute proximal humeral fractures. The secondary aims were to report the cumulative revision rate and risk factors for an inferior patient-reported outcome. We obtained data on 1,371 hemiarthroplasties for acute proximal humeral fractures from the Danish Shoulder Arthroplasty Registry between 2006 and 2010. Of these, 549 patients (40%) were alive and available for follow-up. The Western Ontario Osteoarthritis of the Shoulder (WOOS) questionnaire was sent to all patients at nine to 14 years after primary surgery. Revision rates were calculated using the Kaplan-Meier method. Risk factors for an inferior WOOS score were analyzed using the linear regression model.Aims
Methods
Hip fracture is a common condition of the older, frailer person. This population is also at risk from SARS-CoV-2 infection. It is important to understand the impact of coexistent hip fracture and SARS-CoV-2 for informed decision-making at patient and service levels. We undertook a systematic review and meta-analysis of observational studies of older (> 60 years) people with fragility hip fractures and outcomes with and without SARS-CoV-2 infection during the first wave of the COVID-19 pandemic. The primary outcome was early (30-day or in-hospital) mortality. Secondary outcomes included length of hospital stay and key clinical characteristics known to be associated with outcomes after hip fracture.Aims
Methods
The COVID-19 pandemic led to a swift adoption of telehealth in orthopaedic surgery. This study aimed to analyze the satisfaction of patients and surgeons with the rapid expansion of telehealth at this time within the division of adult reconstructive surgery at a major urban academic tertiary hospital. A total of 334 patients underging arthroplasty of the hip or knee who completed a telemedicine visit between 30 March and 30 April 2020 were sent a 14-question survey, scored on a five-point Likert scale. Eight adult reconstructive surgeons who used telemedicine during this time were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate and multivariate ordinal logistic regression modelling.Aims
Methods
Synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells (%PMN) are elevated at periprosthetic joint infection (PJI). Leucocytes produce different interleukins (IL), including IL-6, so we hypothesized that synovial fluid IL-6 could be a more accurate predictor of PJI than synovial fluid WBC count and %PMN. The main aim of our study was to compare the predictive performance of all three diagnostic tests in the detection of PJI. Patients undergoing total hip or knee revision surgery were included. In the perioperative assessment phase, synovial fluid WBC count, %PMN, and IL-6 concentration were measured. Patients were labeled as positive or negative according to the predefined cut-off values for IL-6 and WBC count with %PMN. Intraoperative samples for microbiological and histopathological analysis were obtained. PJI was defined as the presence of sinus tract, inflammation in histopathological samples, and growth of the same microorganism in a minimum of two or more samples out of at least four taken.Aims
Methods
This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases. We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed.Aims
Methods
Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients. All NOF fracture patients presenting between March 2020 and May 2020 were included. Patients were divided into two subgroup: those with or without clinical and/or laboratory diagnosis of COVID-19. Data were collected on patient demographics, pattern of injury, complications, length of stay, and mortality.Aims
Methods
This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google. A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google.Aims
Methods
Orthopaedics like all other branches of medicine is likely make tremendous scientific progress in the new millennium. The extent of this progress will depend on how we have done in last 1000 years. I feel it is important in a discussion of this nature to separate orthopaedic surgery from orthopaedic surgeons. Progress in orthopaedic surgery need not necessarily mean progress of the orthopaedic surgeon or for that matter the medical profession. As an orthopaedic surgeon we have to deal with many issues such as taking care of all the patients who come our way; balancing our responsibilities to our patients and our families; fighting with the administration in the interest of good patient care and for our own economic well-being; and trying to keep up with advances in orthopaedics in order to stay, both competent as well as competitive. Unlike my generation you must deal with a host of health-care delivery systems, need to have a business acumen that rivals that of a corporate CEO and increasingly you require knowledge of coding that should qualify you as medical-records librarian. Before long you may become convinced unfortunately that medicine is really a business and not a profession. The essence of professionalism in medicine is the willingness of the physician to value the patient’s welfare above his or her own and to provide care when necessary without remuneration or at personal inconvenience. It is unselfish attention to the welfare of others and advancement of our patient interests that earns the public’s respect and trust. These in turn have caused the public to support the autonomy of medical practice, including the privilege of self-regulation. However, this trust has begun to erode. Financial return and economic security are important to all of us. But if and when the commercial ethic in medicine becomes so predominant that it is perceived by the society as greed replacing altruism, we will certainly face loss of autonomy and the ability to self-regulate. I believe that we are nearing that point when society will view medicine as a trade rather than as a profession and we will be treated accordingly. Looking to the roots of western medicine, Hippocrates (466 to 370 BC) is recognized as the father of modern medicine. However the earliest mention seems to be in the Indian literature, the Rig Veda, the oldest book of Veda period (1500–99 BC) when the use of artificial leg as well as artificial eyes and teeth were recorded. Before the 20th Century, the practice of medicine employed little science and was mostly an art. Yet despite this its practitioners were held in the highest esteem. 100 years ago, a physician had few tools with which to work except those of compassion and caring. However, during this century a technological explosion has led to spectacular advances in medicine and as a consequence physicians are infinitely better equipped to bring good health-care to their patients. Our orthopaedic roots date back to 1743 when Nicholas Andre unveiled his splinted crooked tree. However, it was not until the use of plaster of Paris 100 years later that we moved out of the splint age. Modern fracture management rapidly accelerated during and after World War I with Sir Robert Jones espousing the principles of Hugh Owen Thomas. This was followed by the impact of World War II and subsequent war has led great advance in the management of musculoskeletal trauma. Operative practice however came into its own with the introduction of modern anesthesia by William Morton a dentist in 1846, sterility by courtesy of Joseph Lister in 1876 and antibiotics from Alexander Fleming in 1945. These advances made the outcome of surgery more predictable and the practice of orthopaedics, in particular expanded exponentially as operative risks decreased substantially. New methodologies involving joint replacement, arthroscopy, spinal instrumentation and reconstruction following trauma were all developed in the latter part of this century. Last 30 years has sen the rapid changes in technology and it may be a good time to pause and think where all are going and take an account of our games and losses. The Future: Developments in physics and engineering have rewarded our specialty with spectacular advances, but the changes in biotechnology by means of the DNA molecular genetic engineering and stem-cell transformation will be even more profound. This new area of biology has the potential to conquer cancer, grow new blood vessels in cardiac patients, create new organs from the stem-cells and possibly even reset the genetic code that causes our cartilage to age. Very soon we will be able to transplant virtually any tissue without fear of rejection. In the next century, when computer technology merges with biotechnology, we may be able to map the ten billion or so neurons in our brain and replace our minds with a machine. Changes: Some of these changes in medical science and particularly in orthopaedics is already hear. It is important for orthopaedic surgeons to realise this and to prepare themselves so that they are not left behind. Most important thing is “orthopaedic education” both at undergraduate and postgraduate level and continuing education. We must re emphasize that orthopaedic surgery means total care of the musculoskeletal system both conservative and operative. Most of us are interested in operative care because it is lucrative, and as Graham Apley use to say “Surgery in Fun” but 80% of our patients need conservative treatment. Scientific basis of our conservative treatment is appealing and is no better than the alternatives medicine providers. No wonders so many of our patients are now moving to “sinseh” and other providers, with dubious repetition. Emphasizes in our
Patient-specific instrumentation has been shown to increase a surgeon’s precision and accuracy in placing the glenoid component in shoulder arthroplasty. There is, however, little available information about the use of patient-specific planning (PSP) tools for this operation. It is not known how these tools alter the decision-making patterns of shoulder surgeons. The aim of this study was to investigate whether PSP, when compared with the use of plain radiographs or select static CT images, influences the understanding of glenoid pathology and surgical planning. A case-based survey presented surgeons with a patient’s history, physical examination, and, sequentially, radiographs, select static CT images, and PSP with a 3D imaging program. For each imaging modality, the surgeons were asked to identify the Walch classification of the glenoid and to propose the surgical treatment. The participating surgeons were grouped according to the annual volume of shoulder arthroplasties that they undertook, and responses were compared with the recommendations of two experts.Aims
Methods
There are significant differences in the methods and styles of orthopaedic surgical training between continents, all with the aim to produce competent consultant surgeons, but the differences in training content and pathway are vast. We review and contrast the key differences between three continents.
We aimed to determine quality of life and burnout
among Dutch orthopaedic trainees following a modern orthopaedic
curriculum, with strict compliance to a 48-hour working week. We
also evaluated the effect of the clinical climate of learning on
their emotional well-being. We assessed burnout, quality of life and the clinical climate
of learning in 105 orthopaedic trainees using the Maslach Burnout
Inventory, linear analogue scale self-assessments, and Dutch Residency
Educational Climate Test (D-RECT), respectively. A total of 19 trainees (18%) had poor quality of life and 49
(47%) were dissatisfied with the balance between their personal
and professional life. Some symptoms of burnout were found in 29
trainees (28%). Higher D-RECT scores (indicating a better climate
of learning) were associated with a better quality of life (r =
0.31, p = 0.001), more work-life balance satisfaction (r = 0.31,
p = 0.002), fewer symptoms of emotional exhaustion (r = -0.21, p = 0.028)
and depersonalisation (r = -0,28, p = 0.04). A reduced quality of life with evidence of burnout were still
seen in a significant proportion of orthopaedic trainees despite
following a modern curriculum with strict compliance to a 48-hour
working week. It is vital that further work is undertaken to improve
the quality of life and reduce burnout in this cohort. Cite this article:
Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making. A 29-question electronic survey was distributed to the readership of an established orthopaedic journal with international readership. The survey aimed to analyse the influence of both extrinsic (journal quality, investigator profiles, etc.) and intrinsic characteristics (study design, sample size, etc.) of research studies in relation to their influence on practice patterns.Objectives
Materials and Methods
We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are ‘driven’ by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes.
While the demand for orthopaedic surgical expertise in the developing world is in critically short supply, short-term remedy from visiting doctors cannot solve this long-term healthcare problem. Capacity building by senior and training orthopaedic surgeons from established Western training programmes can offer a significant contribution to the orthopaedic patient in the developing world and the gains for those visiting are extremely valuable. We report on several visits by a UK orthopaedic team to a hospital in Kabul, Afghanistan and discuss the operative and non-operative case mix and the benefits in terms of local capacity building and the unique experience of those visiting.
Valid and reliable techniques for assessing performance
are essential to surgical education, especially with the emergence
of competency-based frameworks. Despite this, there is a paucity
of adequate tools for the evaluation of skills required during joint
replacement surgery. In this scoping review, we examine current
methods for assessing surgeons’ competency in joint replacement
procedures in both simulated and clinical environments. The ability
of many of the tools currently in use to make valid, reliable and
comprehensive assessments of performance is unclear. Furthermore,
many simulation-based assessments have been criticised for a lack
of transferability to the clinical setting. It is imperative that
more effective methods of assessment are developed and implemented
in order to improve our ability to evaluate the performance of skills
relating to total joint replacement. This will enable educators
to provide formative feedback to learners throughout the training
process to ensure that they have attained core competencies upon
completion of their training. This should help ensure positive patient
outcomes as the surgical trainees enter independent practice. Cite this article:
The October 2012 Research Roundup360 looks at: whether you can escape your genes; oral prophylaxis for DVT; non-responders and the internet; metal-on-metal, mice and damaged livers; sleeping on the job; cartilage contact stress in the normal human hip; and a perfect reason to subscribe to
We retrospectively reviewed 2989 consecutive
patients with a mean age of 81 (21 to 105) and a female to male
ratio of 5:2 who were admitted to our hip fracture unit between
July 2009 and February 2013. We compared weekday and weekend admission
and weekday and weekend surgery 30-day mortality rates for hip fractures
treated both surgically and conservatively. After adjusting for
confounders, weekend admission was independently and significantly
associated with a rise in 30-day mortality (odds ratio (OR) 1.4,
95% confidence interval (CI) 1.02 to 1.9; p = 0.039) for patients
undergoing hip fracture surgery. There was no increase in mortality
associated with weekend surgery (OR 1.2, 95% CI 0.8 to 1.7; p =
0.39). All hip fracture patients, whether managed surgically or
conservatively, were more likely to die as an inpatient when admitted
at the weekend (OR 1.4, 95% CI 1.02 to 1.80; p = 0.032), despite
our unit having a comparatively low overall inpatient mortality
(8.7%). Hip fracture patients admitted over the weekend appear to
have a greater risk of death despite having a consultant-led service. Cite this article:
The April 2013 Research Roundup360 looks at: when the ‘residency cake’ is done; steroids, stem cells and tendons; what exactly is osteoarthritis; platelet-rich plasma; CRPS; d-Dimer for DVT; reducing bacterial adhesion; and fin or limb?
The April 2012 Knee Roundup360 looks at the torn ACL, ACL reconstruction, the risk of ACL rupture, the benefit of warm-ups before exercise, glucosamine and tibiofemoral osteoarthritis, sensitisation and sporting tendinopathy, pain relief after TKR, the long-term results of the Genesis I, the gender specific recovery times after TKR, and the accuracy of the orthopaedic eyeball
The use of journal clubs and, more recently,
case-based discussions in order to stimulate debate among orthopaedic
surgeons lies at the heart of orthopaedic training and education. A
virtual learning environment can be used as a platform to host virtual
journal clubs and case-based discussions. This has many advantages
in the current climate of constrained time and diminishing trainee
and consultant participation in such activities. The virtual environment
model opens up participation and improves access to journal clubs
and case-based discussions, provides reusable educational content,
establishes an electronic record of participation for individuals,
makes use of multimedia material (including clinical imaging and
photographs) for discussion, and finally, allows participants to
link case-based discussions with relevant papers in the journal
club. The Leicester experience highlights the many advantages and some
of the potential difficulties in setting up such a virtual system
and provides useful guidance for those considering such a system
in their own training programme. As a result of the virtual learning
environment, trainee participation has increased and there is a
trend for increased consultant input in the virtual journal club
and case-based discussions. It is likely that the use of virtual environments will expand
to encompass newer technological approaches to personal learning
and professional development.
The 2010 Fellows undertook a six-week journey through centres of orthopaedic excellence along the East Coast of Canada and the United States. What we learned and gained from the experience and each other is immeasurable, but five areas particularly stand out; education, research, service delivery, financial insights and professional development.
We conducted a prospective randomised controlled trial to compare the standard Ponseti plaster method with an accelerated method for the treatment of idiopathic congenital talipes equinovarus. The standard weekly plaster-change method was accelerated to three times per week. We hypothesised that both methods would be equally effective in achieving correction. A total of 40 consecutive patients (61 feet) were entered into the trial. The initial median Pirani score was 5.5 (95% confidence interval 4.5 to 6.0) in the accelerated group and 5.0 (95% confidence interval 4.0 to 5.0) in the standard control group. The scores decreased by an average 4.5 in the accelerated group and 4.0 in the control group. There was no significant difference in the final Pirani score between the two groups (chi-squared test, p = 0.308). The median number of treatment days in plaster was 16 in the accelerated group and 42 in the control group (p <
0.001). Of the 19 patients in the accelerated group, three required plaster treatment for more than 21 days and were then assigned to the standard control method. Of the 40 patients, 36 were followed for a minimum of six months. These results suggest that comparable outcomes can be achieved with an accelerated Ponseti method. The ability to complete all necessary manipulations within a three-week period facilitates treatment where patients have to travel long distances.
We have tested the reliability of a recently reported classification system of hip morphology in adolescents with cerebral palsy in whom the triradiate cartilage was closed. The classification is a six-grade ordinal scale, based on the measurement of the migration percentage and an assessment of Shenton’s arch, deformity of the femoral head, acetabular deformity and pelvic obliquity. Four paediatric orthopaedic surgeons and four physiotherapists received training in the use of the classification which they applied to the assessment of 42 hip radiographs, read on two separate occasions. The inter- and intra-observer reliability was assessed using the intraclass correlation coefficient and found to be excellent, with it ranging from 0.88 to 0.94. The classification in our study was shown to be valid (based on migration percentage), and reliable. As a result we believe that it can now be used in studies describing the natural history of hip displacement in cerebral palsy, in outcome studies and in communication between clinicians.
We aimed to document the pre-operative expectations in Korean patients undergoing total knee replacement using an established survey form and to determine whether expectations were influenced by sociodemographic factors or pre-operative functional status. Expectations regarding 17 items in the Knee Replacement Expectation Survey form were investigated in 454 patients scheduled for total knee replacement. The levels and distribution patterns of summated expectation and of five expectation categories (relief from pain, baseline activity, high flexion activity, social activity and psychological well-being) constructed from the 17 items were assessed. Univariate analyses and multivariate logistic regression were performed to examine the associations of expectations with the sociodemographic factors and the functional status. The top three expectations were relief from pain, restoration of walking ability, and psychological well-being. Of the five expectation categories, relief from pain was ranked the highest, followed by psychological well-being, restoration of baseline activity, ability to perform high flexion activities and ability to participate in social activities. An age of <
65 years, being employed, a high Western Ontario and McMaster Universities osteoarthritis index function score and a low Short-form 36 social score were found to be significantly associated with higher overall expectations.
The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved.