In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimise exposure on the wards. In order to maintain throughput of elective cases, our hospital was forced to convert as many cases as possible to same day procedures rather than overnight admission. In this retrospective analysis we review the cases performed as same day arthroplasty surgeries compared to the same period 12 months previous.

We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties in a three month period between October and December in 2019 and again in 2020, in the middle of the SARS-CoV-2 pandemic. Patient demographics, number of out-patient primary arthroplasty cases, length of stay for admissions, 30-day readmission and complications were collated.

In total, 428 patient charts were reviewed for the months of October-December of 2019 (n=195) and 2020 (n=233). Of those, total hip arthroplasties comprised 60% and 58.8% for 2019 and 2020, respectively. Demographic data was comparable with no statistical difference for age, gender contralateral joint replacement or BMI. ASA grade I was more highly prevalent in the 2020 cohort (5.1x increase, n=13 vs n=1). Degenerative disc disease and fibromyalgia were less significantly prevalent in the 2020 cohort. There was a significant increase in same day discharges for non-DAA THAs (2x increase) and TKA (10x increase), with a reciprocal decrease in next day discharges. There were significantly fewer reported superficial wound infections in 2020 (5.6% vs 1.7%) and no significant differences in readmissions or emergency department visits (3.1% vs 3.0%).

The SARS-CoV-2 pandemic meant that hospitals and patients were hopeful to minimise the exposure to the wards and to not put strain on the already taxed in-patient beds. With few positives during the Coronavirus crisis, the pandemic was the catalyst to speed up the outpatient arthroplasty program that has resulted in our institution being more efficient and with no increase in readmissions or early complications.

Aims

Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA.

Aims

In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimize exposure on wards. In order to maintain throughput of elective cases, our hospital (St Michaels Hospital, Toronto, Canada) was forced to convert as many cases as possible to same-day procedures rather than overnight admission. In this retrospective analysis, we review the cases performed as same-day arthroplasty surgeries compared to the same period in the previous 12 months.

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.

Background and Aims

Daily senior review is of paramount importance to provide optimal clinical care and facilitate timely discharge. Also, the General Medical Council state in Good Medical Practice 2013 that “work should be recorded clearly, accurately and legibly…containing relevant clinical findings, decisions made and actions agreed”. This audit aims to evaluate whether all trauma and elective Orthopaedic patients at one unit receive a daily senior review, which is fully documented in the case-notes, and whether a Comprehensive Unit-based Safety Programme (CUSP) toolkit can better facilitate this?

Objectives

Numerous complications following total knee replacement (TKR) relate to the patellofemoral (PF) joint, including pain and patellar maltracking, yet the options for in vivo imaging of the PF joint are limited, especially after TKR. We propose a novel sequential biplane radiological method that permits accurate tracking of the PF and tibiofemoral (TF) joints throughout the range of movement under weightbearing, and test it in knees pre- and post-arthroplasty.

Backround: The etiology of Legg-Calvé-Perthes disease (LCPD) is incompletely understood. Previous studies suggest associations with coagulation problems, anatomical abnormalities in the femoral head blood supply and risks for cardiovascular disease. Therefore, we hypothesized that patients with LCPD might have a higher risk of cardiovascular diseases and diseases of blood and blood-forming organs.

Methods: 3,141 patients with LCPD aged 2–15 years, diagnosed between 1965 and 2005 were identified using the Swedish inpatient register. 15,595 individuals without LCPD were randomly selected from among the Swedish general population, matched by year of birth, age, sex, and region of residence. Cox proportional hazard regression, adjusted for socioeconomic index, was used to estimate the relative risks. The patients were also compared with their same-sex siblings.

Results: Patients with LCPD had a hazard ratio (HR) of 1.70 (95% CI 1.39–2.09) for cardiovascular disease compared with individuals without LCPD. The point estimate was slightly higher among those older than 30 at follow-up (HR=2.10, 95% CI: 1.52–2.91). There were statistically significant higher risks for diseases of blood and blood-forming organs (1.41, 1.07–1.86), which were more pronounced among those older than 30 years at follow-up (2.70. 1.50–4.84). Patients had also statistically significant higher risks for hypertensive disease (2.97, 1.87–4.72), and nutritional anemia (2.92, 1.58–5.40). When siblings were used as the comparison group, the results were consistent for cardiovascular disease.

Conclusion: The results are consistent with the hypothesis that an insufficient blood supply to the femoral head due to vascular pathology and other causes are involved in the etiology of LCPD.

Introduction: The Lachman test for anterior cruciate ligament (ACL) deficiency, requires a subjective assessment of joint movement, as the tibia is pulled anteriorly. This study has objectively quantified this movement using a magnetic tracking device.

Materials and Methods: Ten patients aged 21 to 51 years were assessed as having unilateral ACL deficiency with conventional clinical tests. These patients were then reassessed using a magnetic tracking device (Polhemus Fastrak). Patients had magnetic sensors attached around the femoral and tibial mid-shafts using elasticated Velcro straps. The Lachman test was then performed with the patient lying within range of the system’s magnetic source. The test was performed three times on the normal and injured knees of each patient. During the tests, sensor position and orientation data was collected with an accuracy better than 1 mm and 1 degree, respectively. The data was sampled at 10Hz and stored on a computer for post-test analysis. This analysis deduced the tibial displacement resulting from each Lachman pull.

Results: The main Lachman movement is an anterior displacement of the tibia with respect to the femur. The mean anterior movement for the normal knees was 5.6 mm (SD=2.5). By comparison the ACL deficient knees had a mean anterior movement of 10.2 mm (SD=4.2). This is 82 % more. A paired t test of this data showed it to be highly significant with P = 0.005. In addition to the anterior movement, there was also a small proximal tibial movement. In the normal knees the mean movement was 0.7 mm (SD=1.9). In the injured knees the mean movement was 2.1 mm (SD=3.4). However, this difference was not significant (P = 0.12).

Conclusion: This study has quantified the movement produced during the Lachman test for ACL deficiency. The results compare well with reported results from similar arthrometer tests[1]. The main advantage of the magnetic tracker is that its lightweight sensors cause minimal disturbance to the established clinical test. It therefore offers a convenient and non-invasive method of investigation.

The inhibition of neural input by infiltration of local anaesthetic around the operation site prior to the trauma of an operation may reduce subsequent pain post-operatively. Prevention of the normal phenomenon of central and peripheral sensitisation in the nervous system stops the post operative hypersensitivity state that manifests as a decrease in the pain threshold at the site of injury. The underlying clinical principle is for therapeutic intervention to be made in advance of the pain rather than as a reaction to it ¹. We performed a prospective double blind randomised clinical trial to measure the effect of pre operative infiltration of local anaesthetic around arthroscopy wounds compared to post-operative infiltration on post operative pain relief.

Thirty six patients undergoing day case unilateral knee arthroscopy between October 2000 and March 2001 were studied. All patients gave written informed consent. They were randomised into 2 groups using block randomisation to ensure equal group sizes. The sealed envelope technique was used. The pre-operative group had 10ml 0.25% bupivicaine infiltrated around the arthroscopy portal site following induction of general anaesthesia (G.A.), the post-operative group received 10ml 0.25% bupivicaine after the procedure but before reversal of the G.A. The injection technique and G.A. used were standardised. Pain was assessed using a 10cm Visual Analogue Score (VAS) at pre-operative, 1, 2 and 24h post-operative. At each assessment the patients were blinded to the previous scores that they had submitted. Oral analgesic use in the post-operative 24 hours was also recorded.

There were 18 patients in each group. Demographic details did not differ between the 2 groups. One patient in the post-operative group was excluded, as intravenous sedation was required in recovery due to an extreme anxiety state. The mean Visual Acuity Pain Scores (VAS) were lower in the post-operative group (1.3) compared to the pre-operative group (1.58) at pre-operative assessment. However this difference was not statistically significant (p =0.5607). At 1h post op the mean VAS in the post op group was 1.58 and in the pre op group 2.59 (p =0.18). The mean VAS at 2h post op in the pre op group was 1.76 compared to 1.82 in the post op group (p =0.9932).

At 24h the pre op group had a lower mean VAS (2.25) than the post op group (2.4). This difference was however not statistically significant (p =0.7418).

Analysis of the postoperative analgesia requirement in both groups failed to reveal a statistically significant difference (p =0.3965). In day case knee arthroscopy under general anaesthesia there is no beneficial role in the use of pre-emptive local anaesthetic infiltration around the arthroscopy portal sites as compared to post-operative infiltration.

The aim of this study was to investigate if the rotational axis of normal human shoulders moves during flexion in the sagittal plane.

Twenty four shoulders were measured in twelve normal volunteers, aged 25-42, height range 1.65-1.88 m and weight range 63–120 Kg. Each subject had surface markers placed on their iliac crests, mastoid processes and upper arms. Joint movement was video recorded as shoulders were actively flexed and extended in the sagittal plane. For each joint, a typical flexion sweep was selected and replayed into a computerised imaging system, where still frames were captured at 20 degree intervals from 20 to 120 degrees. These images were analysed to extract the co-ordinates of each marker. The coordinates were then processed to determine the Instant Centres of Rotation (ICR) for each angle of flexion. These ICR’s were then plotted to derive the Rotational Axis Pathway (RAP) for each shoulder joint.

The results indicate that throughout the flexion arc, the rotational axis is located in the region of the humeral head. At the start of the arc the rotational axis is in the anterio-superior part of the shoulder joint. As the shoulder flexes forward the rotational axis moves posteriorly following a curved pathway. In 18 cases the RAPs moved posterio-inferiorly and in six cases the RAPs moved posterio-superiorly. The pathways can be quantified in terms of their curved pathway lengths and the displacements of their end points from their start points. In the case of the 18 posterio-inferior pathways, the mean pathway length was 98.3 mm (SD=31.5) and the mean posterior/inferior displacements were 59.6 mm (SD=34.7) and 43.2 mm (SD=24.6) respectively. In the case of the 6 posterior-superior pathways, the mean pathway length was 109.4 mm (SD=40.2) and the mean posterior/ superior displacements were 94.7 mm (SD=43.9) & 20.9 mm (SD=11.1) respectively. The variation in inferior-superior displacement of the axis may be due to normal variations in scapula movement during forward flexion.

This investigation indicates that in normal subjects, the rotational axis moves posteriorly during flexion.