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 residency programs, either via text message or by email. The two programs surveyed were the McGill University Orthopaedic Surgery residency program located in Montreal, Canada, and the Oman Medical Specialty Board (OMSB) Orthopaedic Surgery residency program located in Muscat, Oman. A total of 36 residents, 20 from McGill and 16 from OMSB, responded to the survey request. In both programs, 89% of all the residents surveyed claimed they use Orthobullets at least 4 times per week, and greater than 95% of them use it during call shifts to obtain information rapidly. Regarding the use of Orthobullets in the context of operating theatre case preparation, over 50% of residents claim to use it often while only 25% claim to rarely use it for this purpose. The use of Orthobullets during clinics seemed to be the least popular among residents as 47% claimed they rarely use it. Cumulatively in both programs, more than 80% of residents indicated that they always use Orthobullets in preparation for an exam especially among senior residents. Approximately two thirds of residents have said they completely trust the information provided on Orthobullets, with the remainder indicating that they trust Orthobullets more than 75% of the time. The proportion of residents who indicated that they completely trust Orthobullets was greater in the OMSB group (75%) and among senior trainees. Over 85% of residents discovered Orthobullets through friends and colleagues, and the rest through the program and faculty members. Our survey results demonstrate the widespread use of Orthobullets, a popular online orthopaedic resource, among orthopaedic residents of all levels. The settings in which Orthobullets was most used were exam preparation and during call shifts. In addition, with the high amount of confidence residence have Orthobullets, it is questionable as to how many are actually aware that its information is not validated. For the time being however, we do not discourage the use of Orthobullets for exam preparation, however, we recommend that programs warn their residents to abstain from using it in their clinical decision-making until it has demonstrated peer-reviewed approval

Milestone-based outcome oriented training is now an important framework for residency education and program accreditation. Analysing 18 months of Orthopaedic Surgery Patient Care Milestone real-time evaluations via a web platform in a single residency program demonstrated significant variability in the rate of assessment and competency level among Milestones. In 614 evaluations, there was a strong, positive linear relationship between postgraduate year and competency level. Chief residents achieved an average competency level of 4.0, the graduation target, as assessed by faculty in real-time. These data may inform ongoing discussions about potential revisions to the Orthopaedic Surgery Milestones, and highlight one potential model for improving resident feedback. The Accreditation Council for Graduate Medical Education (ACGME) now requires the biannual submission of a variety of Milestones by United States residency programs, as part of a move towards competency-based medical training. Our program developed a web-based platform to collect Milestone-based evaluations in real-time, in an effort to improve feedback and facilitate ACGME compliance. After 18 months of use, we assessed how frequently each Milestone is evaluated in real-time, as well as the distribution of competency levels by each Patient Care Milestone and postgraduate year (PGY). These results may inform on relative strengths and weaknesses of a program, or of particular Milestones. At a single academic orthopaedic residency program with 40 residents in total, the use of a web-based trainee-driven evaluation tool (eMTRCS – electronic Milestone Tracking and Competency System) was initiated in 2014. Residents initiate evaluation in real-time, triggering a digital Milestone-based evaluation by a particular faculty member. De-identified data from January 2014 to December 2015 was abstracted. Descriptive statistics on the distribution of evaluations submissions, type of Milestone, faculty evaluation levels, and resident PGY were calculated. As the data was ordinal with evidence of non-normality, nonparametric tests were utilised to analyse differences in the distribution, and assess correlation between planned outcome variables. A total of 614 evaluations were included in the analysis, for an average of 38.4 evaluations per Patient Care Milestone. There was a wide variability in the number of evaluations per Milestone, ranging from only four “Diabetic Foot” submissions to 75 submissions on “Hip and Knee Arthritis” (Figure 1). Faculty-scored competency also varied significantly among the Milestones (Figure 2, p = 0.009 by Kruskal-Wallis rank sum test). Higher levels of competency were seen as resident PGY progressed (mean = 2.1, 2.4, 3.1, 3.7, 4.0 for PGY1–5 respectively, p<0.001). Through 18 months of use and 614 real-time evaluations, a web-based system for assessing Milestone levels showed significant variability in the number of assessments and competency level among the Orthopaedic Surgery Patient Care Milestones. There are multiple possible explanations, ranging from resident and faculty confusion about the Milestones to a lack of clinical volume in specific areas. In contrast to the inter-Milestone variability in assessments and competency levels, the strong stepwise relationship between advancing PGY and increasing levels of competency does provide evidence of validity for Milestone-based evaluations. Graduating residents in this program achieved, on average, the graduation target competency level as assessed by faculty in real-time

Purpose: Despite increasing numbers of women entering surgical fields, orthopaedic surgery residency continues to have the lowest percentage of women (11%) of all primary surgical specialties. In an effort to examine prevailing attitudes, we compared the performance of male and female orthopaedic residents using a variety of measures. We hypothesized that the performance of men and women would not differ significantly. Method: We prospectively gathered data on 81 residents (67 male, 14 female) with graduation years of 1999–2010. Six males and one female dropped out of the program during their training, leaving a group of 74 residents (61 male, 13 female) with data available for analysis. Residents were compared on the basis of their Orthopaedic In-Training Exam (OITE) scores, American Board of Orthopaedic Surgery (ABOS) results, and a comprehensive eight category electronic faculty evaluation measure (E*ValueTM) that rates resident performance in every category on each rotation on a 1–5 scale. Practice profile data was gathered through a survey which looked at fellowship training and current practice patterns. Results: Males and females had no statistically significant differences in their E*ValueTM scores in any of the eight categories measured (medical knowledge, patient care, behaviors, technical, communication, practice-based, systems-based, overall competence). Males and females had no significant difference in their mean OITE scores for year 2 and year 3 of residency; however, men had higher mean scores at year 4 (66.9 vs. 47.0), year 5 (66.8 vs. 45.8) and overall (61.7 vs. 46.5, p < 0.001). All resident graduates that had taken ABOS Parts 1 had passed; however, the percentage of men that took more than one attempt to pass Part 1 was significantly lower statistically than women (7% vs. 43%). No difference was seen in Part 2 pass attempts. For residents that had matched in our program, 9% of males and 7% of females have dropped out due to lifestyle issues (NSD). Conclusion: In our program, male and female residents were seen as equally competent physicians as graded by comprehensive faculty evaluations. However, men outperformed women on both OITE measures and ABOS Part 1 measures. Further study is needed to explain these differences

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 residency training, as it directly influenced the point of transition. This highlights the strength of the “boot camp” construct at targeting the challenges associated with discrete moments of transition in the advancement in practice. While surgical preparatory “boot camps” were initially born out of a competency-based framework focused on technical skill development, our findings demonstrate that the benefits outweigh simple improvement in technical ability. The formation of a learner group identity has downstream effects on resident perceptions of anxiety and confidence, while priming for higher-level learning. “Boot camp” then, is re-imagined as an experience of social professional enculturation

Purpose: Orthopaedic residency training requires intellectual and motor skill development. In this study we aim to develop a model to evaluate junior resident proficiency and efficiency versus senior residents in the placement of a center-center guidewire during fixation of an intertrochanteric proximal femur fracture utilizing a computer-based haptic simulator. We hypothesize the junior residents will utilize more fluoroscopy and require more time to complete the task. Method: Post-graduate year residents (PGY) 3–5s, labeled Group II, placed a single central guide pin into a femoral head utilizing a surgical simulator four times. PGY 1–2s, labeled Group I, completed the same task six times. The residents were then evaluated based on final tip-apex distance (TAD), fluoroscopy time, time to complete the task, total number of distinct attempts at pin placement for each femur construct as well as final three-dimensional location of the pin from the isometric center of the femoral head. This project was approved by the institutional IRB. Conclusion: In this study we displayed that based on our simulator model there was no statistical difference between Group I and II in time to completion, final placement on AP view, and tip-apex distance. There was a statistically significant difference in the anterior/posterior placement of the wire between the two groups, fluoroscopy time, and number of attempts per trial. Our findings suggest a computer based surgical simulator can identify measurable differences in surgical proficiency between junior and senior orthopaedic residents

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 residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees’ performance in managing orthopaedic trauma patients. . This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States. . In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma. Cite this article: Bone Joint J 2016;98-B:1320–5

Introduction

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.

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).

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 residency training programs. This information was gathered from either the Canadian Resident Matching Service website (carms.ca) or the residency program's individual website. If this information was not available on a program's website, a program administrator was contacted via email in order to ascertain this information directly. MSK training was considered to be any rotation in orthopaedic surgery, spine surgery, sports medicine, or physiatry. 156 Canadian family medicine residency training sites were identified. Information pertaining to mandatory MSK education was collected for 150 sites (95.5%). Of the 150 training sites, 102(68 %) did not incorporate any mandatory MSK training into their curriculum. Of the 48 programs that did, the average number of weeks of MSK training was 3.37 weeks. 32/48 programs (66.7%) included 4 weeks of MSK training, which represents 3.8% of a 2-year training program. Current Canadian family medicine residents are not receiving sufficient musculoskeletal training when compared to the overall frequency of musculoskeletal presentations in the primary care setting. Understanding current family medicine physicians’ surveyed confidence and measured competence with respect to diagnosing and treating common musculoskeletal disorders could also prove helpful in demonstrating the need for increased musculoskeletal education. Future orthopaedic initiatives could help enhance family medicine MSK training

The 2020-2021 Canadian Residency Matching Service (CaRMS) match year was altered on an unprecedented scale. Visiting electives were cancelled at a national level, and the CaRMS interview tour was moved to a virtual model. These changes posed a significant challenge to both prospective students and program directors (PDs), requiring each party to employ alternative strategies to distinguish themselves throughout the match process. For a variety of reasons, including a decline in applicant interest secondary to reduced job prospects, the field of orthopaedic surgery was identified as vulnerable to many of these changes, creating a window of opportunity to evaluate their impacts on students and recruiting residency programs. This longitudinal survey study was disseminated to match-year medical students (3rd and 4th year) with an interest in orthopaedic surgery, as well as orthopaedic surgery program directors. Responses to the survey were collected using an electronic form designed in Qualtrics (Qualtrics, 2021, Provo, Utah, USA). Students were contacted through social media posts, as well as by snowball sampling methods through appropriate medical student leadership intermediates. The survey was disseminated to all 17 orthopedic surgery program directors in Canada. A pre-match and post-match iteration of this survey were designed to identify whether expectations differed from reality regarding the effect of the COVID-19 pandemic on the CaRMS match 2020-2021 process. A similar package was disseminated to Canadian orthopaedic surgery program directors pre-match, with an option to opt-in for a post-match survey follow-up. This survey had a focus on program directors’ opinions of various novel communication, recruitment, and assessment strategies, in the wake of the COVID-19 pandemic. Students’ responses to the loss of visiting electives were negative. Despite a reduction in financial stress associated with reduced need to travel (p=0.001), this was identified as a core component of the clerkship experience. In the case of virtual interviews, students’ initial trepidation pre-CaRMS turned into a positive outlook post-CaRMS (significant improvement, p=0.009) indicating an overall satisfaction with the virtual interview format, despite some concerns about a reduction in their capacity to network. Program directors and selection committee faculty also felt positively about the virtual interview format. Both students and program directors were overwhelmingly positive about virtual events put on by both school programs and student-led initiatives to complement the CaRMS tour. CaRMS was initially developed to facilitate the matching process for both students and programs alike. We hope to continue this tradition of student-led and student-informed change by providing three evidence-based recommendations. First, visiting electives should not be discontinued in future iterations of CaRMS if at all possible. Second, virtual interviews should be considered as an alternative approach to the CaRMS interview tour moving forward. And third, ongoing virtual events should be associated with a centralized platform from which programs can easily communicate virtual sessions to their target audience

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 residency years. There was a significant increase in confidence of fracture understanding with increasing residency year. Also, confidence was improved in cases where a 3Dp model was available compared to conventional CT alone although this improvement diminished with increasing residency year. Perceived accuracy of the cases with 3Dp models was significantly higher than cases without models (7 vs 5.5 p < 0.0001). This is the first study to our knowledge to assess trainee confidence as a primary outcome in the assessment of the educational value of 3Dp models. This study was able to show that a 3Dp model aides in the perceived accuracy of fracture assessment and showed an improvement in trainee confidence, although the effect on confidence seems to diminish with increasing residency year. We propose that 3D printed calcaneal fracture models are a beneficial educational tool for junior level trainees and the role of 3Dp models for other complex orthopaedic presentations should be explored

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 residency training program and 2) determine the variability in resident radiation exposure by rotation assignment and year of training. This ongoing prospective cohort study includes all local orthopaedic surgery residents who meet eligibility criteria. Inclusion criteria: 1) adult residents in an orthopaedic surgery residency program. Exclusion criteria: 1) female residents who are pregnant, and 2) residents in a non-surgical year (i.e. leave of absence, research, Masters/PhD). After completion of informed consent, each eligible resident will wear a dosimeter to measure radiation exposure in a standardized fashion. Dosimeters will be worn on standardized lanyards underneath lead protection in their left chest pocket during all surgeries that require radiation protection. Control dosimeters will be worn on the outside of each resident's scrub cap for comparison. Dosimeter readings will then be reported on a monthly and rotational basis. All data will be collected on a pre-developed case report form. All data will be de-identified and stored on a secure electronic database (REDCap). In addition to monthly and rotational dosimeter readings, residents will also report sex, height, level of training, parental status, and age for secondary subgroup analyses. Residents will also report if they have personalized lead or other protective equipment, including lead glasses. Resident compliance with dosimeter use will be measured by self report of >80% use on operative days. Interim analysis will be performed at the 6-month time point and data collection will conclude at the 1 year time point. Data collection began in July 2018 and interim 6-month results will be available for presentation at the CORA annual meeting in June 2019. This is the first prospective study quantifying radiation exposure in Canadian orthopaedic residents and the results will provide valuable information for all Canadian orthopaedic training programs

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 residency, test safety of different implant doses, and assess efficacy over standard of care in a sheep model. The infraspinatus tendon (ISP) was detached and immediately repaired in 22 skeletally mature ewes. Repair was done with four suture anchors in a suture bridge configuration (n = 6 controls). Freeze-dried formulations containing 1% w/v chitosan (number average molar mass 35 kDa and degree of deacetylation 83%) with 1% w/v trehalose (as lyoprotectant) and 42.2 mM calcium chloride (as clot activator) were solubilized with autologous leukocyte-rich PRP and injected at the tendon-bone interface and on top of the repaired site (n = 6 with a 1 mL dose and n = 6 with a 2 mL dose). Acute implant residency was assessed histologically at 1 day (n = 2 with a 1 mL dose and n = 2 with a 2 mL dose). Outcome measures included MRI assessment at baseline, 6 weeks and 12 weeks, histopathology at 12 weeks and clinical pathology. MRI images and histological slides were scored by 2 blinded readers (veterinarian and human radiologist, and veterinarian pathologist) and averaged. The Generalized Linear Model task (SAS Enterprise Guide 7.1 and SAS 9.4) was used to compare the different groups with post-hoc analysis to test for pairwise differences. Ortho-R implants were detected near the enthesis, near the top of the anchors holes and at the surface of ISP tendon and muscle at 1 day. Numerous polymorphonuclear cells were recruited to the implant in the case of ISP tendon and muscle. On MRI, all repair sites were hyperintense compared to normal tendon at 6 weeks and only 1 out 18 repair sites was isointense at 12 weeks. The tendon repair site gap seen on MRI, which is the length of the hyperintense region between the greater tuberosity and tendon with normal signal intensity, was decreased by treatment with the 2 mL dose when compared to control at 12 weeks (p = 0.01). Histologically, none of the repair sites were structurally normal. A trend of improved structural organization of the tendon (p = 0.06) and improved structural appearance of the enthesis (p = 0.1) with 2 mL dose treatment compared to control was seen at 12 weeks. There was no treatment-specific effect on all standard safety outcome measures, which suggests high safety. Ortho-R implants (2 mL dose) modulated the rotator cuff healing processes in this large animal model. The promising MRI and histological findings may translate into improved mechanical performance, which will be assessed in a future study with a larger number of animals. This study provides preliminary evidence on the safety and efficacy of Ortho-R implants in a large animal model that could potentially be translated to a clinical setting

Purpose. Residency programs are continually attempting to predict the performance of both current and potential residents. Previous studies have supported the use of USMLE Step 1 and 2 as predictors of Orthopaedic In-Training Examination and eventual American Board of Orthopaedic Surgery board success, while others show no significant correlation. A strong performance on OITE exams does correlate with strong residency performance, and some believe OITE scores are good predictors of future written board success. The current study was designed to examine potential differences in resident assessment measures and their predictive value for written boards. Method. A retrospective review of resident performance data was performed for the past 10 years. Personalized information was removed by the residency coordinator. USMLE Step 1, USMLE Step 2, in-training exams (from first to fifth years of training), and written orthopaedic specialty board scores were collected. Subsequently, the residents were separated into two groups, those scoring above the 35th percentile on in-training examinations and those scoring below. Data were analyzed using correlation and regression analyses to compare and contrast the scores across all tests. Results. Significant difference was seen between the groups in regards to USMLE scores for both Step 1 and 2. Also, a significant difference was found between OITE scores for both the second and fifth years. Positive correlations were found for USMLE Step 1, Step 2, OITE 2 and OITE 5 when compared to performance on written boards. One resident initially failed written boards, but passed on the second attempt. This resident consistently scored in the 20th and 30th percentiles on the in-training exams. Conclusion. These results demonstrate that all the written tools of assessment are helpful in defining a residents ability to pass written boards, though they do not directly predict performance, though USMLE Step 1 and 2 scores along with OITE scores are helpful in gauging an orthopaedic residents performance on written boards. Lower USMLE score along with consistently low OITE scores likely define a resident at risk of failing their written boards. Close monitoring of the annual OITE scores is recommended and may be useful to identify struggling residents. Future work involving multiple institutions is warranted and would ensure applicability of our findings to other orthopedic residency programs

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 residency, 49.3% (35/71) had used the DAA in their clinical practice in the past or were using it at the present time. Unexpectedly, 42.9% (15/35) of respondents who had used the DAA in the past had abandoned it by the time of this survey. Only 22.5% (16/71) of all respondents believed that evidence-based medicine proves that the DAA has significant benefits compared to risks in contrast to other approaches. Conclusion. A comprehensive literature review found only three prospective randomized clinical trials (RCT) comparing the DAA with another approach with greater than one-year follow-up. Two showed minor benefits within the early postoperative period only, and one of those showed poorer mid-term results. Most of the published comparison studies with short follow-up show longer surgical times and greater blood loss for the DAA, and many three-month comparison studies show higher complication rates for the DAA using a proprietary traction table. The complications included problems with wound healing, lateral femoral cutaneous nerve injury, femoral component loosening, and femoral fractures. Because of the lack of evidence from RCTs showing superiority of the DAA over other approaches and reports of higher complications, the opinion of a large majority (77.5%; 55/71) of HS surgeons was that the DAA lacks sufficient evidence to warrant its use. Cite this article: Bone Joint J 2020;102-B(7 Supple B):57–61

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 residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures

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 residency rotation. Our question was „Can an Experienced Physiotherapist Become Proficient in Triaging for Surgically Appropriate Patients After a 2–3 month „Residency „. Method: Following a 3 month clinical residency an experienced physiotherapist and a spine surgeon independently interviewed, physically examined and reviewed diagnostic imaging of 31 patients. It was then independently concluded whether the patients were candidates for surgical treatment, required conservative management or whether further investigations were necessary to make the final determination. The level of agreement was calculated using Chance Corrected Agreement or Kappa values. Operational definitions were reviewed and a second group of 29 patients were assessed. Results: The initial Kappa score was .68 (considered good clinical agreement) and the final Kappa score was 0.84 (considered virtually interchangeable). Conclusion: A 3 month period can prepare an experienced orthopaedic physiotherapist to triage a waiting list for surgical candidates. The therapist can add value through being better prepared to direct conservative options. Expediting triage will facilitate the right person getting to the right intervention within a reasonable time frame. Addressing the backlog of referrals will also help identify the magnitude of surgical need

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 residency, but that half (35 respondents) had used this approach in practice at one time. Subsequently, 43% of those 35 DAA users had abandoned it. The DAA learning curve was estimated at over 50 cases by 47% of respondents. Only 23% of 71 respondents answered “yes” to the statement “Do you believe that evidence-based medicine proves significant benefits over risks of the DAA THA versus other approaches?” Financial factors were common reasons for beginning to use the technique including accommodating patient requests and preventing the loss of patients to other DAA surgeons. Conclusion. 15 years after the emergence of “minimally invasive” DAA THA, a literature review finds that only one small (44 patient) clinical trial with >1-year follow-up showed small early functional benefits but with longer average surgical times and higher blood loss. If the DAA procedure has minimal benefits, is more difficult to perform with a high complication rate (LFCN injury, femoral fracture and loosening) in the hands of non-specialists and has a long learning curve (that caused a significant percentage of HS DAA users to abandon it), then financial factors must be the main reasons for its popularity. For any tables or figures, please contact the authors directly

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 residency training. Qualitative focus groups and a literature review were used to develop a new instrument to assess Surgical TRainee Experiences of StresS in the Operating Room (STRESSOR). STRESSOR was used in a survey of Canadian surgical residents to assess trainee stress. Resiliency was measured using the 10-item Connor-Davidson Resiliency Scale (CD-RISC-10). The survey was distributed nationally and 171 responses were collected for a 36% response rate. The greatest sources of intraoperative stress were time pressure, attending temperament, and being interrupted by a pager. The STRESSOR instrument had strong reliability (Cronbach's α=0.92) and demonstrated good construct validity using confirmatory factor analysis. The mean CD-RISC-10 score was 28.8, which is similar to that of Canadian medical students. Resilience was protective against intraoperative stress (R2=0.16, p<0.001). Residents with higher stress or lower resilience were more likely to have seriously considered leaving their training program (Spearman's rho = 0.42, p<0.001). Screening for resilience may assist in selecting trainees who are better able to manage stress during surgery and reduce resident attrition. Resiliency training may help learners manage the high stress environment of the operating room, potentially improving surgical performance and learning in the next generation of surgeons

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 residency to decide which subspecialty to enter. They felt the ideal interview period should be held from January through March of the PGY-4 year. Over 50% of residents felt pressure to accept early offers, had to accept an offer before finishing interviewing or accepted their first offer. Sixty-eight percent (43/64) had to respond to an offer in less than one week. Seventy-six percent (31/47) felt they were given inadequate time to accept or reject offers. Thirty-six percent (17/47) asked for more time to think about an offer. Over 50% (33/65) accepted their first offer and 8% (5/47) had an offer withdrawn because they did not give a response within a designated time frame (exploded offer). Residents cancelled a mean of 2.7 interviews per resident (range 0–9). Eighty-percent (50/64) thought a match would be better than the current system, if most programs would adhere to it. Approximately 47% (41/88) of the residents favored a more centralized process involving all orthopedic surgery fellows, while 35% (31/88) favored a subspecialty based system. Conclusion: The RLF deliberations can be summarized as follows:. The current fellowship hiring process is decentralized, poorly functioning, unraveled and generally unfair. It creates anxiety for residents, residency directors, and fellowship directors alike. Residents are facing exploding offers, limited exposure to fellowship programs and, ultimately, an unraveling hiring market. Residents are in favor of changing the current decentralized process into either a more centralized clearing-house system or subspecialty-based match approach. In either system, accountability for both residents and fellowship directors is critical. Both the AOA and AAOS should devote resources to improve the fellowship hiring process

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 residency and fellowship, however, it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons armamentarium when treating patients undergoing primary and revision THA

Aims

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.

Aims

The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery.

Aims

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.

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 residency and fellowships in comparison to international respondents (48.0% vs. 44.5% vs. 25.6% respectively; p<0.001). Surgeons performing a higher volume of FAI surgery (over 100 cases per year) were significantly more likely to have practiced for more than 20 years (OR 1.91; 95% CI 1.01 to 3.63), be practicing at an academic hospital (OR 2.25; 95% CI 1.22 to 4.15), and have formal arthroscopy training (OR 46.17; 95% CI 20.28 to 105.15). High volume surgeons were over two-fold more likely to practice in North America and Europe (OR 2.26; 95% CI: 1.08 to 4.72). The exponential rise in the diagnosis and surgical management for FAI appears to be driven largely by experienced surgeons in developed nations. Our analysis suggests that although FAI management is early in the innovation cycle we are at a tipping point towards wider uptake and utilisation. The results of this survey will help guide further research and study

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, residency, fellowship, and in continuing education has been almost entirely non-economic in focus. Yet, we surgeons are now evolving from being primarily responsive for our patients' medical care to being also responsible for all expenditures associated with our patients' care. Similarly, while the cost of our patients' care was not even available to us, every dollar of expenditure for a patient's episode of care is now available to us in some circumstances. For example, a typical primary joint replacement episode may cost $30,000 for a patient insured by Medicare in the US. A surgeon performing 400 joint replacements per year is therefore authorizing upwards of $12M a year in health care spending by making the decisions to perform reconstructive procedures on those patients. The risk for value-based surgical episodes of care can be born by various entities including hospital systems or the surgeons themselves. Recent evidence demonstrates that quality improves and cost decreases more rapidly when surgeons take primary responsibility and risk for episodes of care as compared to when a hospital system or third party takes primary responsibility and risk. Yet, as surgeons, our education in the field of medical economics, value-based episodes of care, and payment reform is only just beginning. The more we understand about the cost and value of the services that we order for our patients, the more leadership can provide as healthcare evolves. The current presentation will describe the specific cost of care for the primary joint replacement patient preliminary experience with accepting risk and responsibility for these patients. It is likely that our patients will be best served if we surgeons provide as much leadership as possible in their care, both medically and economically

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 residency and fellowship, however it might find a resurgence as the limits of uncemented fixation in the elderly are encountered. National joint registers support the use of cemented femoral components, and actually demonstrate higher survivorship at short term when compared to all other uncemented femoral components. A cemented femoral component should be in the hip surgeons' armamentarium when treating patients undergoing primary and revision THA

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 residency training. There is a strong drive from patients, industry, surgeon marketing campaigns, and the media to perform THA through smaller incisions with quicker recoveries. The perceived advantage of the anterior approach is the lack of disturbance of the soft tissues surrounding the hip joint, less pain, faster recovery with the potential for earlier return to work, shorter hospital stay and improved cosmetic results. The potential disadvantages include less visibility, longer operation time, nerve injuries, femoral fractures, malposition and a long learning curve for the surgeon (and his / her patients). The anterior approach was first performed in Paris, by Robert Judet in 1947. The advantages of the anterior approach for THA are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to THA and his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation, while the posterior rotators and capsule provide active and passive stability and account for immediate stability of the hip and a low risk of dislocation. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intraoperative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally by lengthening the skin incision downward along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. The choice of approach used to perform a primary THA remains controversial. The primary goals are pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach as most of the positive data is based on comparisons with the anterolateral approach. The proposed benefits of the anterior approach are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the anterior approach in THA

Aims

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.

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 residency, 1 not willing to be seen) with no problems related to the replaced hip. Ninety-four hips in 85 patients were available for clinical and radiologic analysis. Clinical results of the 94 THAs with more than 15 years of follow-up were assessed preoperatively and postoperatively at 5, 10 and 15 years by means of standard evaluation tools: SF12, WOMAC and Harris Hip Score. Thigh pain frequency and intensity were also recorded. Radiographic analysis (Figure 2) was focused on stem alignment, bone ingrowth, radiolucent lines presence, width and progression, stress-shielding and heterotopic ossification (HTO). Student paired test and Kaplan-Meier survival analysis were used for statistical analysis. Results. All clinical evaluation tools showed at 5-year FU, 10-year FU and at latest FU (15–17 years) a statistically significant improvement compared to the preoperative scores. We observed a not constant thigh pain in 5 hips (4.75%). Nine stems were revised due to polyethylene wear (3 cases), late periprosthetic fracture (2 cases), infection (2 cases), subsidence (1 case) and instability (1 case). Stem related revision was a case of subsidence, related to occult intraoperative calcar crack and early revised (within 1 year); cumulative stem-related survival rate at 15 years was 99%. Alignment was varus in 5 cases and valgus in 1. Bone in-growth was observed in 93 hips (98%). Radiolucent lines were uncommon, non progressive, less than 2 mm, in Gruen zones 2 and 6. Stress-shielding was present as cortical reaction in 5 femurs in Gruen zones 3 and 5. Fifteen cases of HTO (grade I and II in 12 case and grade III in 3 cases) were observed. Conclusions. The Synergy stem demonstrated excellent clinical and radiographic results at 15–17 years FU in 85 patients. Survivorship (with stem revision as end point) was 99% at 15 years. Thigh pain was uncommon and the level of activity and autonomy is excellent. Radiographically bone ingrowth is evident in all stems and radiolucent lines are “benign” with no aseptic loosening

Aims

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.

Aims

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.

Aims

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?

Aims

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.

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 residency training program–we typically spend an average of 19 minutes of operating room time for the cementing of a total knee arthroplasty. Our average time expended for insertion of all three cementless implants is 47 seconds–representing a significant savings in the hospital operating room time charge. From the standpoint of the patient, the shorter operating time reduces the time under anesthesia, the blood loss, the risk of venous thromboembolism, as well as the infection risk–optimizing the conditions for a reduction in post-operative complications, directly impacting a potential reduction in morbidity and mortality. Overall, the performance of all cementless TKA at our facility is cost-saving, is easily performed and reproduced by orthopaedic residents, and brings potential advantages to the patient in the form of a reduction in complications and an improvement in outcomes. Cementless fixation is the wave of the future, and the future is now

Aims

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

Purpose. The ability to correctly interpret quantitative results is a crucial skill developed in medical school and surgical residency. It demands a basic understanding of epidemiological principles and modes of presenting data. Yet, there has been little investigation into the efficacy of current teaching methods and areas of difficulty among orthopaedic residents. Method. Forty orthopaedic residents attended a research course provided by the main author in preparation for this assessment. Immediately after formal teaching, these residents were administered a survey that assessed residents perceived and actual level of understanding of basic modes of presenting results including number needed to treat (NNT), relative risk (RR), odds ratio (OR), and absolute risk reduction (ARR). Residents were given a multiple choice clinical case scenario of fracture nonunion and asked to choose which result would be most efficacious at reducing nonunion. An All are equally efficacious option was given for each question. The multiple choice answers were purposefully identical with regard to effect size but answers differed in the way they were presented. Results. Over 81% of residents agreed or strongly agreed that they had a good understanding of the modes of presenting results. However, less than 20% of residents consistently identified that the choices to questions were identical with regard to effect on nonunion rate. When the effect sizes in the choices were coupled with significant p-values (p < 0.05) of variable sizes, significantly fewer residents identified the correct solution (p < 0.05). Confidence intervals were associated with a decrement in correct responses (p < 0.05). Conclusion. On average orthopaedic trainees have a poor understanding of presenting results and struggle to interpret them. Considerable confusion exists between measures of clinical significance and that of the effect size of treatment

We aimed to examine the influence of nursing home residency on mortality after sustaining an acute hip fracture in patients presenting to a metropolitan trauma centre. A prospective study of all adults aged 65 years and over who presented to a single tertiary referral hospital for management of a fracture of the proximal femur between July 2003 and September 2006. Residential status was obtained at admission. Patients were followed up to September 2007. Relative risk values for mortality were calculated comparing nursing home residents with non-nursing home residents. Survival analysis was performed. Relative risk of death was higher in nursing home patients compared to non-nursing home patients. This was particularly so in the first 30 days (RR 1.9). Survival analysis showed that 25% of patients in the nursing home group died by 96 days post-injury, compared with 435 days post-injury in the non-nursing home group. The age-adjusted hazard ratio for death in nursing home patients was 1.5 (95% CI: 1.1–2.1), however the effect of nursing home status decreased over the first 12–24 months. Nursing home residence confers an increased risk of death following hip fractures, especially in the immediate post-injury period. However, the relative risk of death decreased over time. This study provides some indication of the mortality risk in an easily definable population, without requiring an alternative assessment of comorbidities

Aims

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.

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 residency class in the average number of cases performed or OITE scores. We also found no statistical difference in the national OITE scores. Our data suggest that the impact of the 80 hour work has not had a detrimental effect in these two resident training measurements

Aims

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.

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 residency training (orthopaedic or neurosurgical). No such differences were found when comparing responses of the fellow trainees and their supervisors. Conclusion: This study demonstrates that fellowship trainees and supervisors have similar perceptions on the relative importance of specific core cognitive and procedural competencies required in achieving successful spine fellowship training. Furthermore, background specialty training (orthopaedic or neurosurgical) influences the perceptions of both fellow trainees and supervisors regarding the importance of specific cognitive and technical skills deemed necessary for successful training

Purpose: The RCPSC Orthopaedic Specialty Committee for Residency Training and the Examination Committee for Orthopaedic Surgery requested that work be completed to assist with identifying competencies that should be included in a core curriculum for graduating orthopaedic surgery residents in Canada. The purpose of this study was to determine competencies to be of greatest importance by orthopaedic surgeons whose primary affiliation was non-university, for the purpose of developing a core curriculum in orthopaedic surgery for graduating residents within Canada. Method: A 281-item list of competencies was developed consisting of three sections: a previously validated curriculum for musculoskeletal health, Orthopaedic Specialty objectives of the Royal College of Physicians and Surgeons of Canada, curricula representing orthopaedic programs from accredited academic orthopaedic programs within Canada and, a comprehensive procedure list. Competencies were compared to existing curricula within Canada. A content review was completed and a modified questionnaire was developed. A stratified, randomized selection of, non – university, orthopaedic surgeons rated each individual item on an integer scale 1 to 4 of increasing level of importance. Summary statistics across all respondents were given. Average mean scores and standard deviations were computed. Secondary analyses were computed in general, paediatrics, trauma and adult reconstruction. Results: 131/156 (84 %) of orthopaedic surgeons participated. 240/281 competencies (85.4%) were rated average scores of at least 3.0 suggesting probably important or important to demonstrate competency by completion of training. 41/281 items (15.6%) were given average scores between 2.0 and 2.93 thus suggesting not important. Conclusion: This study identified competencies necessary for a Core Curriculum for Orthopaedic Surgery. Complex procedures in various categories and content considered less essential for orthopaedic surgeons were rated to be less important. How curriculum is ultimately structured, delivered and implemented needs to be studied. We know that learning activities are “driven” by the evaluation of competencies. Is competency-based education on the horizon or should we be focused on assessing competencies within the current method of curriculum delivery?

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 residency candidates. Our purpose was to identify ways to enhance female interest in orthopaedic surgery as a career. Method: The effect of exposure on interest in orthopaedics was studied prospectively for two years. Enrollment data regarding student demographics, interest, and exposure to orthopaedic, general, or other surgical subspecialties was obtained from two medical schools. At 6 month intervals, students were offered electronically-based orthopaedic literature, elective lectures, and were resurveyed for exposure and interest level. Univariate analysis was performed between demographics, background, exposure variables and interest levels. Change in exposure was further analyzed against change in interest with a multivariate logistic regression model constructed using significant associations along with gender. Results: 274 females and 73 male controls enrolled. Baseline increased interest in orthopaedics was correlated in a multivariate model with personal experiences as musculoskeletal patient and/or researcher, among others (p< 0.05). Interim enhanced exposure to orthopaedic web materials was significantly associated with increased interest, intent to enroll in an elective, and intent to apply for orthopaedics or sports medicine. Interestingly, no associations with other surgical specialties were found, and gender was not a significant independent determinant of interest and intent in this model. Conclusion: This study demonstrates that interest among female medical students can be significantly increased by enhancing exposure to orthopaedic subject matter during medical school. Early exposure may prove a critical tool in recruiting more women into orthopaedic surgery, which will be necessary to meet the anticipated demands of the growing orthopaedic patient population

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 residency programs has clear strength in the traditional areas of microsurgical decompression for spinal stenosis and disc herniation. Deficits are revealed in the management of spinal trauma and spinal conditions requiring the use of implants, with the exception of anterior cervical stabilisation. In order to achieve a high level of competency, EANS trainees advocate the development of a post-residency spine sub-specialty training program

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: Bone Jt Open 2021;2-10:893–899.

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 residency programs in North America

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 residency training. Themes included: 1) what makes learning orthopaedic surgery unique? 2) creating the learning environment and; 3) preparation for specific milestones. Method. A prospective study involving 44/48 (92%) orthopaedic surgical residents from an accredited orthopaedic program attended a previously developed workshop on optimizing learning in orthopaedic surgery. The workshop was completed in June 2009. Residents completed an evaluation upon completion of the interventional workshop on desired behaviors to change by attending the workshop. These residents then progressed into their next level of training and were now in their PGY2 through PGY5 years. A second evaluation was completed by each resident 6 months later. The evaluation focused on behaviors that each resident perceived to have changed because of the workshop. These results were correlated with change in scores with the annual orthopaedic in training evaluation (OITE) written 5 months after the workshop by all participating residents. A retrospective review of the Orthopaedic in-Training Examination (OITE) results of PGY2s through PGY5s was completed. OITE mean change in scores and percentiles were computed on examinations written during the 2006 through 2009 academic years. Results. Forty-four residents initially attended the workshop. Thirty-nine attended a second session and 34/39 (87%) completed the second evaluation. Post-workshop evaluation forms were triangulated with change in scores from the OITEs recorded. A reverse relationship between the raw OITE scores and percentile scores as residents advanced through training. Paired samples t-tests were conducted to evaluate the possible impact of the intervention of residents OITE scores. There was a statistically significant increase in OITE raw scores between post-graduate residents who wrote the OITE in PGY2 academic year of training followed by participation in the workshop, and then wrote the OITE their PGY3 academic year (M = 141.77, SD = 15.98) to (M = 159.77, SD = 11.17), t (12) = −4.20, p < .0005 (two-tailed). Emerging themes from how residents changed behavior to optimize learning included: interactions with others during educational experiences, resources allocated for academic and clinical activitites and how residents managed their time