Introduction. We present the first 12 consecutive patients, undergoing elective paediatric limb reconstruction with an external fixator, for the 12-month period October 2020-October 2021. This is a single surgeon series for a newly appointed Consultant with limited previous experience. Arrangements were made for mentoring by a senior surgeon recently retired from the NHS but still active in private practice. Materials and Methods. The average age of patients was 10.5years at the time of frame application (5—15 years). Four frames in three patients were for Blount's; two for sequelae of NF1; two for posteromedial tibial bow with shortening, two for fibula hemimelia; one congenital short femur, one for sequelae of neonatal sepsis and one for bone loss following tumour resection. Results. We present early outcomes and complications for this challenging cohort. Two frames were revision frames, and a further two had had previous frame treatment. Where shortening was a primary component of the deformity (six cases) the mean lengthening required was 5cm (4–6cm). Conclusions. The benefits of this arrangement include enabling newly appointed Consultants to take on complex cases from the start of appointment, dealing with enormous waiting pressures and minimising complications. The BOA reported this year that 25% of the over 45 consultant workforce intend to retire within three years. In this context, a renewed focus is needed on succession planning, proleptic appointments, and novel schemes to retain experienced surgeons within complex NHS practice: we present a successful example of this strategy

Introduction. Surgical experience has been shown to improve the clinical outcomes in Total hip arthroplasty. The objective of this study was to compare clinical and radiological outcomes between Consultants and NCHDs grade surgeons for the Exeter total hip replacement taken from the Cappagh National Orthopaedic Hospital Joint Register. Methods & Materials. Between 2005 and 2008, 2749 primary total hip replacements were done, 433(15.78%) were Exeter total hip system. 380(86%) out of 433 were included in the study, 227(59%) were females and 154(41%) were males. A consultant was the primary surgeon for 193(51%) patients and an NCHD was the primary surgeon for 187(49%) patients. Mean age, at time of operation was 68 years. Clinical outcome was assessed with WOMAC and SF36 scoring system. Patients were invited to fill in the WOMAC and SF36 questionnaire, pre-operatively, at 6 months and at 2 years after the operation. Radiographs were evaluated for radiolucency with a standardized technique. Results. Mean WOMAC scores for consultant grade surgeons were: 61(pre op), 23.34(6 months post op) and 22.96(at 2 years post op) with standard deviations of 15.61(pre-op), 17.9(at 6 months) and 17.19(at 2 years). Average SF36 scores were 42.40(pre-op), 70.15(at 6 months) and 71.30(at 2 years) with standard deviations of 17.94(pre op), 18.02(6 months) and 22.59(2 years). NCHD grade surgeons had average WOMAC scores: 62.55(pre op), 22.36(6 months) and 25.35(2 years). Average SF36 scores were: 41.1(pre-op), 67.47(6 months) and 66.63(2 years). The difference in the mean WOMAC scores between consultants grade and NCHD grade surgeons were 1.55(pre-op), 0.98(6months) and 2.39(2 years), while the difference between the mean SF36 were 1.3(pre-op), 2.68(6 months) and 4.67(2 years). Student T Test was used to correlate differences between the 2 groups. The difference in outcomes between the 2 groups was not significant (P<0.05). Conclusion. We found out that both groups had similar outcome and survival, with no significant difference when using an Exeter Total Hip Arthroplasty

Introduction and aims. Low back pain is a common complaint, affecting up to one third of the adult population costing over £1 billion to the NHS each year and £3.5 billion to the UK economy in lost production. The demand for spinal injections is increasing allowing for advanced spinal physiotherapists to perform the procedure. The objective of this study was to investigate outcome following spinal injections performed by consultant spinal surgeon (n=40) and advanced spinal physiotherapists (ASP) (n=40) at our centre. Method and Materials. Data on 80 patients who had received caudal epidural (n=36), nerve root block (n=28) and facet joint injections (n=16) form August 2010 to October 2011 consented to be in the study. 40 patients in each group completed Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) before and 6 weeks after the procedure and patient satisfaction questionnaire investigating their experience and any complications related to the spinal injection retrospectively. The study included 32 males and 48 females. Mean age 57 years, range 21–88. [Consultant group M:17, F:23 mean age: 55, range 21–81. ASP group M:15, F:25 mean age 59, range 22–88]. Measures of patient satisfaction and outcome were obtained; using 2 tailed independent samples t-test with 95% confidence interval, statistical significance was investigated. Results. Data analysis shows that there are no significant differences (p>0.05) in either overall patient satisfaction or outcomes between patients of the surgeon vs physiotherapists. Patients of the surgeon were found to be more satisfied with the procedure itself (p< 0.05). Conclusion. Physiotherapists are able to provide spinal injections with equal efficacy to spinal surgeons, with no reduction in overall patient outcome. Benefits of this scheme include greater number of spinal injections performed. Therefore, reducing the overall waiting times. Further, multi-centre studies on larger populations are required to investigate injection treatment by physiotherapists

The role of dual consultant operating (DCO) in general orthopaedics has not been researched; where it has shown benefit in other specialties, there is a lack of information on how DCO affects the surgeons themselves. We wanted to explore the potential effects of DCO on stress, as a foundation for further research to guide support for our surgeons. We conducted a survey among orthopaedic consultants around New Zealand, containing questions pertaining to the demographics of respondents, their experience with DCO, what the expected risks and benefits of DCO would be, and provided two high-stress exemplar clinical scenarios where respondents were asked to rate their expected stress level at baseline, with a more junior consultant present, and with a more senior consultant present. We found 99% of respondents had been involved in DCO at some point in their careers, yet only 38% were involved in DCO on at least a monthly basis. Perceived benefits greatly outweighed potential risks: 95% felt DCO would decrease their stress, 91% felt it improved intraoperative decision making, and 89% felt it provided more enjoyment at work and enhanced collegiality. A decrease in perceived stress was seen from baseline with a more junior consultant available and a greater decrease in stress seen with a more senior consultant, particularly in a complex elective setting. All respondents felt there is benefit in DCO and the vast majority feel it has positive effects on stress levels. In a time where burnout is more prevalent, using tools such as DCO could be an effective way to decrease stress, enhance enjoyment and collegiality — challenging some key contributors to burnout — and support mentorship with further skill acquisition. This research provides a good base to pursue further qualitative and quantitative research into the area, with a view to addressing barriers to provision of regular DCO

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

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

Abstract. Hospitals during Covid 19 were faced with extreme pressures notably on Emergency Departments. This led to delays in treatment for patients in Trauma and Orthopeadics. In order to support Emergency Departments and improve the service provided, this District General Hospital introduced a Specialty Doctor and Consultant led walk in trauma clinic running on weekdays from 9am-5pm. This abstract focusses on three factors. Firstly the time spent in A&E, secondly the time taken for patients to receive basic radiographic imaging and finally availability of the next fracture clinic appointment. A random sample of 100 patients were selected over a 4 week period prior to introduction of this service and compared with 100 patients since this service began. The average time spent in A&E before this service was 197 minutes which was reduced by 86% by to 27 minutes. The average time taken to receive basic imaging reduced by 18.5% from 81 minutes to 66 minutes. Finally prior to the introduction of these clinics the waiting time of the next fracture clinic varied from 3 to 17 days where as now the patient can be seen by a Consultant in a fracture clinic the next working day. Our findings show the walk in Trauma clinic service has proven to be an invaluable service to this DGH and the NHS. As a result of this service patients are receiving a higher quality of care sooner and a case can be made for the introduction of these clinics throughout the country

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

Aims. The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement. Methods. This is a cross-sectional study using an anonymous 13-section web-based survey distributed to female-identifying T&O trainees, speciality and associate specialist surgeons (SASs) and locally employed doctors (LEDs), fellows, and consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out. Results. A total of 226 UK female T&O surgeons completed the survey. All regions of the UK were represented. Overall, 99/226 (44%) of respondents had at least one child, while 21/226 (9.3%) did not want children. Median age at first child was 33 years (interquartile range 32 to 36). Two-thirds (149/226; 66%) of respondents delayed childbearing due to a career in T&O and 140/226 (69%) of respondents had experienced bias from colleagues directed at female T&O surgeons having children during training. Nearly 24/121 (20%) of respondents required fertility assistance, 35/121 (28.9%) had experienced a miscarriage, and 53/121 (43.8%) had experienced obstetric complications. Conclusion. A large proportion of female T&O surgeons have and want children. T&O surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female T&O surgeons with decision making and assist employers with workforce planning. Further steps are necessary in order to support female T&O surgeons having families. Cite this article: Bone Jt Open 2023;4(12):970–979

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. Methods. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration. Results. Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001). Conclusion. Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons. Cite this article: Bone Jt Open 2024;5(8):637–643

Anatomically specific fixation devices have become mainstream, yet there are anatomical regions and clinical conditions where no pre-contoured plates are available, such as for glenohumeral arthrodesis. In a case series of 4 glenohumeral arthrodesis patients, a consultant orthopaedic surgeon at GCUH implemented 3D printing technology to create reconstructions of each patient's shoulder girdle to pre-contour arthrodesis plates. Our aim was to quantify the cost-benefit & intra-operative time savings of this technique in glenohumeral arthrodesis. We hypothesized that the use of 3D printing for creating patient specific implants through pre-operative contouring of plates will lead to intra-operative time and cost savings by minimising time spent bending plates during surgery. This study analysed 4 patients who underwent shoulder arthrodesis by a single consultant orthopaedic surgeon at GCUH between 2017-2021. A CT-based life-size model of each patient's shoulder girdle was 3D printed using freely available computer software programs: 3D Slicer, Blender, Mesh Mixer & Cura. Once the patient's 3D model was created, plate benders were used to contour the plate pre-op, which was then sterilised prior to surgery. Arthrodesis was performed according to AO principles of fixation. The time spent pre-bending the plate using the 3D model was calculated to analyse the intra-op time and cost-saving benefits. For the 4 cases, the plate pre-bending times were 45, 40, 45 & 20 minutes (average 38.8 mins). The intra-op correction time to make small adjustments to the plate was 2 min/ case. 3 plates needed minor (3 degree) adjustment to fine-tune scapula spine contouring. 1 plate needed a 5 degree correction to fine-tune hand position. On average, the pre-bending of the plate saved approximately 38.8 mins intra-op/ case. These shorter anaesthetic and operating times equate to approximately $2586 saving/ case, given an estimate of $4000/hour of theatre costs. We conclude that pre-bending plates around 3D-printed life-size models of an individual's shoulder girdle prior to surgery results in approximately 38.8 mins time saving intra-op when used in shoulder arthrodesis. This is a viable and effective technique that will ultimately result in significant operative time and financial savings

Introduction. Osteomyelitis is a challenge in diagnosis and treatment. 18F-FDG PET-CT provides a non-invasive tool for diagnosing and localizing osteomyelitis with a sensitivity reaching 94% and specificity reaching 100%. We aimed to assess the agreement in identifying the geographic area of infected bone and planned resection on plain X-ray versus 18F-FDG PET-CT. Materials & Methods. Clinical photos and X-rays of ten osteomyelitis patients were shown to ten consultant surgeons; they were asked to draw the area of infection and extent of planned surgical debridement; data will be compared to 18F-FDG PET-CT results. Results. We tested the agreement between the surgeons in every parameter. Regarding height, there was poor agreement between surgeons. Regarding perimeter, the ten surgeons showed low-moderate agreement. The ten surgeons showed a low-moderate agreement for circularity. Results document the variability of assessment and judgement based on plain X-rays. In comparison to PET-CT, All parameters were significantly different in favour of 18F-FDG PET-CT over X-ray (P < 0.001). Conclusions. 18F FDG PET-CT provides a three-dimensional tool for localizing the exact location of the infected bone and differentiating it from the normal bone. Thus, it could be beneficial in precise pre-operative planning and surgical debridement of chronic osteomyelitis

The attitudes of orthopaedic surgeons regarding radiology reporting is not well-described in the literature. We surveyed Orthopaedic Surgeons in Australia and New Zealand to assess if they routinely review formal radiology reports. An anonymized, 14 question online survey was distributed to consultant surgeons of the Australian and New Zealand Orthopaedic Associations (AOA, NZOA). Two hundred respondents completed the survey (Total number of Fellows: 283 NZOA, 1185 AOA). 18.5% of respondents always reviewed the formal Radiology report, 44.5% most of the time, 35% sometimes and 2% never. By imaging modality, MRI reports were the most frequently reviewed (92%), followed by ultrasound (74%) and nuclear medicine (63%). Only 10% of surgeons consulted formal reports for plain radiography. 55% of surgeons were still likely to disagree with the MRI report, followed by 46% for plain radiography. In cases of disagreement, only 21% of surgeons would always contact the reporting radiologist. The majority of Surgeons (85.5%) think there should be more collaboration between the disciplines, although only 50.5% had regular attendance of a Radiologist at their departmental audit. This survey reveals that the majority of orthopaedic surgeons are not routinely reading radiology reports. This points towards a need for further interdisciplinary collaboration. To our knowledge, this is the first survey directly assessing attitudes of orthopaedic surgeons towards radiology reports

Abstract. Background. Different surgical sub specialities rely on fixed number of porters each morning to bring patients to operating theatre. In daily morning trauma meetings usual practice is to present the whole list of one theatre and then move on to next theatre list. Once all the theatres trauma list are presented, porters are sent to get patients to theatre. With different sub-specialities starting simultaneously and competing for fixed numbers of porters, this can cause significant delay in getting the patients to anaesthetic room. Methods. Retrospective pilot project in level 1 major trauma centre were more that two trauma list a day is a common norm. Pilot project:. First (Golden) patient for every trauma list would be presented at the start of the trauma meeting. Meeting would pause and consultant chairing the meeting would request the trauma theatre representative to send for these patients. Once this is done the meeting would recommence as usual. Results. (a). The porters were sent on an average more than 30 minutes earlier in the pilot week. (b). This was further reflected in the patients being brought into holding bay. (c). The patients were in the anaesthetic room on an average 40 minutes before in pilot group compared to usual practice. Conclusion/Findings. Presenting first patient of each trauma list and then asking theatre to send porter to get the patient to theatre can save appreciable time. Implications. To run an hour of theatre costs £1200. This initiative can save lot of money for NHS

Introduction. Despite the established guidelines on lower extremity free flap reconstruction by the British Orthopaedic Association Standard for Trauma (BOAST-4) the post-operative care has yet to be standardised. There is currently no coherent evidence in the literature regarding clinical monitoring, warming, dangling and compression; the optimal regimes and their respective physiological benefits. The aim of this study is to survey all UK Major Trauma Centres (MTCs) with regards to the post-operative care of lower extremity free flaps and elucidate the current protocols for clinical monitoring, warming, dangling and compression. Materials & Methods. All UK-based adult MTCs were surveyed. We formulated a detailed questionnaire to enquire about the post-operative care of lower extremity free flap reconstructions; the number of free flap reconstructions per month and take backs per month and for which post-operative methods a protocol is used in each MTC. We asked specific questions concerning: clinical monitoring, warming, dangling and compression. This questionnaire was distributed to consultant leads in the form of multiple choice questions, with an option of free-text box for further comments, using JISC online surveys. Results were analysed in Excel and presented in percentages. Results. The 28 adult MTCs were contacted. The results showed a lack of formal regional protocols with great variability, suggesting there is no general consensus on post-operative care of lower extremity free flap reconstructions with regards to clinical monitoring, warming, dangling and compression. Conclusions. This survey of UK MTCs on the post-operative protocols for lower extremity free flap reconstruction demonstrated lack of evidence, consensus and large variability in common practice which requires standardisation

BACKGROUND. Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00. AIM. To investigate whether routine pretransfusion blood sampling for trauma admissions exceeds requirements. METHODS. Electronic records were used to collect pretransfusion sampling data for all adult non-elective trauma patients listed for theatre under a trauma and orthopaedics consultant between 1/1/2023-31/1/2023. Data were collected on unnecessary samples, rejected samples and total excess samples. RESULTS. 113 patients (mean age[±SD] 64.09[±19.96]) underwent 132 procedures. On average, unnecessary sampling occurred at a rate of 0.48 samples per operation, equating to a cost of £945.00/month. Samples were rejected by the laboratory at a rate of 0.25 samples per operation. Common reasons for rejection were ‘patient date of birth discrepancy’ (between sample and request form), ‘patient address discrepancy’ and ‘signature discrepancy’. Overall, total excessive sampling occurred at a rate of 0.60 samples per operation. CONCLUSION. Nearly half of trauma patients undergo unnecessary blood testing in anticipation of potential perioperative transfusion. This has implications for sustainability, financial cost and patient welfare. This signals poor understanding of WBS requirements and is an area that requires improvement

Physician health is a global concern, with increasing research efforts directed towards the challenge. Australia has limited published specialty-specific well-being data for trainees and consultants in medicine and surgery. We measured distress in Australian Orthopaedic trainees using the Physician Well-Being Index (PWBI, MedEd Web Solutions) using an online anonymous survey sent by the Australian Orthopaedic Association. The survey response rate was 38% (88/230). Forty-four percent of survey respondents met criteria for distress. Self-reported burnout in the 30 days prior was reported by 63% of respondents. Fifty-eight percent of females and 41% of males met criteria for distress. Of the 19% or respondents identifying as an ethnic minority, 53% were distressed compared to 42% of those identifying as non-ethnic minority. Trainees without a mentor had a 50% distress rate compared to those with a mentor (37% distress rate). Twenty-five percent of all trainees wished they had picked a career outside of medicine and 16% wished they had pursued a medical career other than Orthopaedic Surgery. Of those trainees who had already passed the fellowship exam, 17% wished they had pursued a career outside of medicine and 21% wished they had pursued a medical career in an area other than Orthopaedic Surgery. These findings suggest concerning rates of career regret and gender-related trends in distress in Australian Orthopaedic trainees. Females may be over-represented in our results as 17% of the source population was female compared to 22% of respondents. Further research is required across all Australian specialties to gain further understanding of factors contributing to distress and to assist in the development of strategy to protect against physician burnout

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

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

Aim. To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics. Methods. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressure. Plantar flexed metatarsal heads secondary to progressive claw toe deformity and hindfoot equinus from changes within the gastrocnemius-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus, secondary to motor neuropathy results in progressive increase in forefoot plantar pressures. Consecutive patients, who presented to our Diabetic Foot clinic since February 2019 with forefoot ulcers or recurrent forefoot callosity were treated with TAL in the first instance, and in patients with recurrent or non-healing ulcers, by proximal dorsal closing wedge osteotomy; a 2-stage treatment pathway. Patients were followed up at 3, 6, and 12 months to assess ulcer healing and recurrence. Results. One hundred and twelve patients (146 feet) underwent TAL by 3 consultants in the out-patient clinics. Of these, 96 feet were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 feet (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. In 12 feet (10%), the ulcer failed to heal or recurred, the MRI scan in these patients showed plantar flexed metatarsals secondary to progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy. In patients with osteomyelitis, the intramedullary canal was curetted and filled with local antibiotic eluting agents such as Cerament G. ®. The osteotomy site was stabilised with a percutaneous 1.6mm k-wire. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after out-patient percutaneous TAL alone. TAL is a safe and effective initial out-patient procedure with improved patient outcomes