Mortality following hip arthroplasty is affected by a large number of confounding variables each of which must be considered to enable valid interpretation. The aim of this study was to establish whether it is possible to determine a true cause-and-effect relationship between the risk of mortality and data that are routinely collected by the NJR and to establish the degree to which variation in the mortality rate could be explained by each variable. Relevant variables available from the 2011 NJR data setwere included in a Cox model. We carried out two analyses:. Firstly, we conducted an analysis of data collected from the NJR data set used in preparation of the NJR's 8th Annual Report (2011) looking for an association between the variables collected and the risk of mortality. Secondly, as social deprivation is also known to influence mortalityrates but is not routinely collected as part of the NJR data set, a further analysis was performed which included social deprivation data derived from partial postcodes. Mortality rates in hip arthroplasty patients were lower than in the age matched population across all hip types. Age at surgery, ASA grade, diagnosis, gender, provider type, hip type and lead surgeon grade all had a significant effect on mortality. Schemper's statistic showed that only 18.98% of the variation in mortality was explained by the variables available in the NJR data set. It is inappropriate to use Registry data to study an outcome affected by a multitude of confounding variables when these cannot be adequately accounted for in the available data set

The NZ Standards of Service Provision for Sarcoma patients were developed by the NZ Sarcoma working group and published by the Ministry of Health (MOH) in 2013. Although not formally enacted by the MOH we aimed to determine the impact of these published standards and referral pathways on disease-specific survival of patients with soft-tissue sarcoma in NZ. The Middlemore Musculoskeletal Tumour Unit database was searched. Patients referred for treatment in our centre with a diagnosis of soft tissue sarcoma in the five-year period before (n=115) and after (n=155) were included. We excluded patients with bone sarcomas and retroperitoneal soft tissue sarcomas. The rate of referral after inappropriate treatment reduced after implementation of the Standards (24% vs 12%, p=0.010). The number of patients referred with tumours larger than 50mm decreased (74.8% vs 72.3%, p=0.021) and fewer had metastases at diagnosis (11.3% vs 3.2%, p=0.017). Mortality was lower in the group after introduction of the Standards (45% vs 30%, p=0.017). The estimated disease-specific survival curve between the two groups shows a trend towards increased survival in the post-standards group, although not reaching statistical significance. Local recurrence rate and metastasis rate after definitive treatment were similar between the two groups. Patients had a shorter duration of symptoms before referral in the post-Standards group although this was not statistically significant. Since implementation of the Standards, patients have been referred more promptly, with fewer inappropriate treatments. The time to mortality curve indicates a trend towards improved disease-specific survival. We conclude that the pathway for investigation and referral for this condition has become clearer, supporting the ongoing use of the Sarcoma Standards, and that these should be formally implemented by the MOH

Introduction. Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS. Methods. This project demonstrates the importance of efficient VFC process in reducing the burden on the fracture clinics. We completed preformed a retrospective cross-sectional study, analysing two cycles in May (n=305) and September (n=332) 2021. We reviewed all VFC referrals during this time assessing the quality of the referral, if they went on to require a face to face follow up and who the referring health care professional was. Following the cycle in May we provided ongoing education to A&E staff before re-auditing in September. Results. Between the two cycles there was an average 19% improvement in quality of the referrals, significant reduction in number of inappropriate referrals for soft tissue knee and shoulder injuries from 15.1% (n=50) to 4.5% (n=15) following our intervention. There was an 8% increase in number of fracture clinic appointments to 74.4% (n=247), primarily due to an increase number of referrals from nurse practitioners. Radial head fractures were targeted as one group that were able to be successfully managed in VFC, despite this 64% (n=27) of patients were still seen in the outpatient department following VFC referral. Conclusion. Despite the decrease in the number of inappropriate referrals, and the increase in quality of referrals following our intervention. The percentage of VFC referrals in CAVUHB is still higher than other centres in with established VFCs in England. This possibly highlights the need for further education to emergency staff around describing what injuries are appropriate for referral, specifically soft tissue injuries and radial head fractures. In order to optimise the VFC process and provide further cost savings benefits while reducing the strain on fracture clinics

Knee arthroscopy with debridement is commonly performed to treat osteoarthritis and degenerative meniscal tears in older adults; however robust evidence does not support sustained benefit from this procedure. Current Canadian guidelines advise against its use as first line treatment. Characterizing the use of this low value procedure will facilitate efforts to maximize quality of care, minimize harm and decrease healthcare costs. We sought to understand:. 1). the volume and variations of arthroscopic knee debridement across Canada. 2). The costs associated with potentially unnecessary arthroscopy. 3). The characteristics of surgeons performing knee arthroscopy in older adults. Data were derived from National Ambulatory Care Reporting System (NACRS), the Discharge Abstract Database (DAD) and the National Physician Database for years 2011-12 to 2019-20. The study included all elective knee arthroscopies (CCI codes 1.VG.80.DA,1.VG.80.FY and 1.VG.87.DA) performed in day surgery and acute care settings in 9 provinces and 3 territories of Canada. Quebec was not included in the analysis due to different reporting methods. We set a threshold of 60 years of age at which it would be highly unlikely that a patient would undergo arthroscopy to treat anything other than osteoarthritis or degenerative meniscal tear. Trends at national and provincial levels were analyzed using regression. Costs were estimated separately using the 2020 case mix groups (CMG) and comprehensive ambulatory care classification system (CACS) methodologies. Surgeons were classified by decade of graduation from medical school (1989 and prior, 1990-99, 2000-09 and 2010+) and categorized based on the proportion of their patient population who were above (“high proportion inappropriate”) or below (“low proportion inappropriate”) the overall national proportion of ≥ 60 years of age. The number of knee arthroscopies decreased by 37% (42,785 in 2011-12 to 27,034 in 2019-20) overall and 39% (11,103 in 2011-12 to 6,772 in 2019-20) in those 60 years and older (p 25% of patients 60 years and older. Fifty four percent of surgeons who graduated prior to 1989 were considered high proportion inappropriate, whereas only 30.1% of surgeons who graduated in 2010 or later were considered high proportion inappropriate (p < 0 .0001). Knee arthroscopy continues to be a common procedure in patients over 60 despite strong evidence for lack of benefit. Lower rates in this population in some provinces are encouraging for potential opportunity for improvement. Efforts at practice change should be targeted at surgeons in practice the longest. Canada spends over $12,000,000 per year on this procedure, decreasing its use could allow these resources to be directed to other areas of orthopaedics that provide higher value care

We test the clinical validity and financial implications of the proposed Choosing Wisely statement: “Using ultrasound as a screening test for shoulder instability is inappropriate in people under 30 years of age, unless there is clinical suspicion of a rotator cuff tear.”. A retrospective chart review from a specialist shoulder surgeon's practice over a two-year period recorded 124 patients under the age of 30 referred with shoulder instability. Of these, forty-one had already had ultrasound scans performed prior to specialist review. The scan results and patient files were reviewed to determine the reported findings on the scans and whether these findings were clinically relevant to diagnosis and decision-making. Comparison was made with subsequent MRI scan results. The data, obtained from the Accident Compensation Corporation (ACC), recorded the number of cases and costs incurred for ultrasound scans of the shoulder in patients under 30 years old over a 10-year period. There were no cases where the ultrasound scan was considered useful in decision-making. No patient had a full thickness rotator cuff tear. Thirty-nine of the 41 patients subsequently had MRI scans. The cost to the ACC for funding ultrasound scans in patients under 30 has increased over the last decade and exceeded one million dollars in the 2020/2021 financial year. In addition, patients pay a surcharge for this test. The proposed Choosing Wisely statement is valid. This evidence supports that ultrasound is an unnecessary investigation for patients with shoulder instability unless there is clinical suspicion of a rotator cuff tear. Ultrasound also incurs costs to the insurer (ACC) and the patient. We recommend x-rays and, if further imaging is indicated, High Tech Imaging with MRI and sometimes CT scans in these patients

Same day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients. A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between April 1, 2019 to March 31, 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge. The cohort consisted of 527 consecutive patients. One hundred and one (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). Two individual surgeons, later operative start time (OR 1.3, 95% CI, 1.15-1.55, p=0.001), ASA class IV (OR 3.4, 95% CI, 1.4-8.2; p=0.006) and undergoing a THA (OR 2.0, 95% CI, 1.2-3.1, p=0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anesthetic were found (p>0.05). The 30-day readmission or 6-month reoperation were similar between groups (p>0.05). Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge

Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. To be a valid predictor of disease and management, radiographic evaluation should include frontal and lateral views of the spine and a complete view of the pelvis, leading to accurate Cobb angle measurements and Risser staging. The study objectives were to determine 1) the adequacy of index images to inform treatment decisions at initial consultation by generating a score and 2) the utility of index radiology reports for appropriate triage decisions, by comparing reports to corresponding images. We conducted a retrospective chart and radiographic review including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1-April 30, 2021. A score was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity (view of full spine, coronal=two, lateral=one, pelvis=one, ribcage=one). Index images were considered inadequate if repeat imaging was necessary. Comparisons were made between index radiology report, associated imaging, and new imaging if obtained at initial consultation. Major discrepancies were defined by inter-reader difference >15°, discordant Risser staging, or inaccuracies that led to inappropriate triage decisions. Location of index imaging, hospital versus community-based private clinic, was evaluated as a risk factor for inadequate or discrepant imaging. There were 94 patients reviewed with 79% (n=74) requiring repeat imaging at initial consultation, of which 74% (n=55) were due to insufficient quality and/or visualization of the sagittal profile, pelvis or ribcage. Of index images available for review at initial consult (n=80), 41.2% scored five out of five and 32.5% scored two or below. New imaging showed that 50.0% of those patients had not been triaged appropriately, compared to 18.2% of patients with a full score. Comparing index radiology reports to initial visit evaluation with <60 days between imaging (n=49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients, with 18.4% (95% CI 10.0, 31.4) categorized as major discrepancies. Risser stage was reported in only 14% of index radiology reports. In 13.8% (n=13) of the total cohort, surgical or brace treatment was recommended when not predicted based on index radiology report. Repeat radiograph (p=0.001, OR=8.38) and discrepancies (p=0.02, OR=7.96) were increased when index imaging was obtained at community-based private clinic compared to at a hospital. Re-evaluation of available index imaging demonstrated that 24.6% (95% CI 15.2, 37.1) of Cobb angles were mis-reported by six to 21 degrees. Most pre-referral paediatric spine radiographs are inadequate for idiopathic scoliosis evaluation. Standardization of spine imaging and reporting should improve measurement accuracy, facilitate triage and decrease unnecessary radiation exposure

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Aim. Corynebacterium is a rare etiologic agent of BJI. We aimed to describe this rare clinical condition and to assess treatment failure determinants. Method. All adult patients with proven Corynebacterium BJI (i.e. consistent clinical/radiological signs, AND ≥2 reliable positive bacteriological samples, AND treated as such) were included in a retrospective cohort study. After cohort description, determinants of treatment failure (i.e, infection persistence, relapse, requirement of additional surgical procedure, and BJI-related death) were determined using stepwise logistic regression and Kaplan Meier curve analysis. Results. The 51 included BJI were more frequently chronic (88.2%), orthopaedic device-related (ODI, 74.5%) and polymicrobial (78.4%). Surgery was performed in 92.2% of cases, and considered as appropriate in 76.5% of them. The main first-line antimicrobials were glycopeptides (68.6%), betalactams (50%) and/or clindamycin (10.0%). Three (5.9%) patients received daptomycin as part of first-line regimen, and 8 (15.7%) at any point of treatment. After a follow-up of 60.7 (IQR, 30.1–115.1) weeks, 20 (39.2%) treatment failures were observed, including 4 (20%) Corynebacterium-documented relapse. Independent risk factors were initial biological inflammatory syndrome (OR 16.1; p=0,030) and inappropriate surgical management (OR 7.481; p=0.036). Interestingly, all patients receiving daptomycin as part of first-line regimen failed (p<0.001), including one patient with a Corynebacterium-documented relapse with a daptomycin increased MIC. Among patients with ODI, survival curve analysis disclosed a worst prognosis in case of prosthetic joint infection (p=0.030), unappropriate surgical management (p=0.029) and daptomycin use as first-line regimen (p<0.001). Conclusions. Corynebacterium BJI is a poorly known condition, frequently chronic and polymicrobial. An important rate of failure was observed, associated with inappropriate surgical management and daptomycin use as part of first-line regimen. As described for other clinical conditions such as infective endocarditis, daptomycin should be avoid or used in combination therapy to prevent resistance selection and treatment failure

Aim. Our hospital is a referral center for Bone and Joint Infection (BJI) with a 15-bed orthopedic unit. Patients benefit from a multidisciplinary team management (surgeons, anesthetists, infectious disease physicians, microbiologists, dietician etc.). Computerized drug prescriptions are performed by anesthetists, surgical residents, surgeons and infectious disease physicians. Since 2015, a pharmacist has been included in ward rounds and in weekly multidisciplinary consultative meetings, where antibiotic treatment strategies are decided for hospitalized patients. This work aimed to assess the impact of a pharmacist in this unit to limit prescription errors. Method. Prospective monocentric study of all pharmacist's advice or interventions during 15 weeks in 2016 and 2017. A complete pharmaceutical analysis of prescriptions is performed twice a week at least. This analysis is based on doses control and drug interactions, but also takes into account biological and clinical data of patients (patient history, renal function, symptoms, adverse effects…). In case of a prescription error, a computerized message and/or a phone call is sent to the prescriber. Each pharmacist's intervention is recorded and classified according to the French Society of Clinical Pharmacy. The pharmacist collected the number of pharmaceutical advice (when spontaneously solicited by any member of the multidisciplinary team), the different types of prescription errors, the pharmacological class associated to these errors, the types of pharmacist's interventions and their impact on prescriptions. Results. During ward rounds, 24 pharmaceutical advices were asked spontaneously by physicians about drug treatment optimization, predominantly about preparation and administration of injectable antibiotics or about doses adaptation. Regarding medication problems detected by the pharmacist, there were 145 prescription errors: inappropriate dose (38/145), too long-duration treatment (24/145), drug omission (18/145), drug overlap (13/145), inappropriate route (13/145), drug interaction (10/145), non-adherence to guidelines (15/145), omission of specific monitoring (4/145), other (10/145). The main pharmacist's interventions were drug discontinuations (53/145, 37%) and dose adjustments (37/145, 26%). In this specific BJI unit, 67/145 (46%) pharmacist's interventions were related to antibiotic drugs, 29/145 (20%) to drugs for digestive disorders and 16/145 (11%) to cardiovascular drugs. Most of pharmacist's interventions were accepted by prescribers (123/145, 85%), with immediate correction of prescriptions. Conclusions. Most prescription errors concerned doses and durations of treatments. Antibiotic prescriptions were often susceptible to errors. The involvement of a pharmacist in this bone and joint infection unit allows a better medication safety

Background. Many Accident and Emergency units employ a “one size fits all” policy with regard to referring patients with musculoskeletal injury for further review in fracture clinic. This may result in inappropriate timings of review in the clinic wasting patient time, clinic time and hospital resources. Aim. Our firm employs a rapid review of all radiographs and A&E notes of all musculoskeletal injury patients referred to our fracture clinic on a weekly basis. We aimed to investigate the impact this review has on the running of our clinic and what benefits were gained. Patients and Methods. Over a three month period all the rapid trauma review meetings were audited with respect to time taken; number of referrals; outcome of referral and staff members present. During this time an audit of the number of patients reviewed in fracture clinic by the Consultant orthopaedic surgeon was also undertaken to allow the average time taken for review of a patient in the clinic to be established. Results and Discussion. Over the three month period 117 patients were reviewed with 44(38%) being given a later appointment; 6(5%) being given an earlier appointment; 8(7%) being discharged to general practice or physiotherapy and 4(3%) being referred to a different clinic. Man time taken to review was 2.4minutes per patient. Mean time for review in fracture clinic was 12.6minutes. Taking the changes to later appointment, discharges and changes to different clinic to be inappropriate referrals, 4.7 occurred per review meeting. This equated to a mean time saved per fracture clinic of 60.6 minutes. Conclusion. This data supports the use of a rapid trauma review meeting to ensure appropriate timing of review of musculoskeletal injury patients. It saves time wasted on inappropriate reviews, saves patient dissatisfaction with being seen unnecessarily and allows patients who should be reviewed more promptly to be identified and reviewed appropriately

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication. . In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians. Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care. Cite this article: Bone Joint J 2015;97-B:434–41

Background. Established hip and knee arthroplasty registers exist in many countries but this is not the case with spinal implants. Moreover, in the case of a rod intended to guide spinal growth in a child and then be removed, the definition of ‘failure’ (revision) used for hip or knee arthroplasty is inappropriate. How can the performance of such spinal implants be judged?. Methods. Ninety-six MAGnetic Expansion Control (MAGEC) spinal rods were obtained from multiple centres after removal from the spines of 52 children with scoliosis. Clinical details were assessed and divided between unplanned revision operations (‘failures’) and those which were planned. Of the explanted rods, 49 were tested for the amount of force they could output, using the manufacturer's supplied test jig. Sixty-five rods were cut apart so that the internal components (bearings, O-ring seals, drive pins) could be assessed, alongside if there was evidence of internal wear. Results. Seventy-four per cent of revision operations were unplanned. Eighty per cent of explanted rods were unable to produce the force expected from a new rod. All rods (100%) that were successfully cut open showed signs of internal wear. Non- functional bearings were seen in 74% of cases, obvious seal damage in 57% of cases and broken drive pins in 47% of cases. Conclusion. Despite potential clinical benefits, explanted MAGEC rods showed consistent and substantial damage. The majority of rods showed zero force output and most revision operations were unplanned. Independent explant analysis allows appraisal of new technology in arthroplasty for patient benefit

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.

Introduction. Up to 60% of total hip arthroplasties (THA) in Asian populations arise from avascular necrosis (AVN), a bone disease that can lead to femoral head collapse. Current diagnostic methods to classify AVN have poor reproducibility and are not reliable in assessing the fracture risk. Femoral heads with an immediate fracture risk should be treated with a THA, conservative treatments are only successful in some cases and cause unnecessary patient suffering if used inappropriately. There is potential to improve the assessment of the fracture risk by using a combination of density-calibrated computed tomographic (QCT) imaging and engineering beam theory. The aim of this study was to validate the novel fracture prediction method against in-vitro compression tests on a series of six human femur specimens. Methods. Six femoral heads from six subjects were tested, a subset (n=3) included a hole drilled into the subchondral area of the femoral head via the femoral neck (University of Leeds, ethical approval MEEC13-002). The simulated lesions provided a method to validate the fracture prediction model with respect of AVN. The femoral heads were then modelled by a beam loaded with a single joint contact load. Material properties were assigned to the beam model from QCT-scans by using a density-modulus relationship. The maximum joint loading at which each bone cross-section was likely to fracture was calculated using a strain based failure criterion. Based on the predicted fracture loads, all six femoral heads (validation set) were classified into two groups, high fracture risk and low fracture risk (Figure 1). Beam theory did not allow for an accurate fracture load to be found because of the geometry of the femoral head. Therefore the predicted fracture loads of each of the six femoral heads was compared to the mean fracture load from twelve previously analysed human femoral heads (reference set) without lesions. The six cemented femurs were compression tested until failure. The subjects with a higher fracture risk were identified using both the experimental and beam tool outputs. Results. The computational tool correctly identified all femoral head samples which fractured at a significantly low load in-vitro (Figure 2). Both samples with a low experimental fracture load had an induced lesion in the subchondral area (Figure 3). Discussion. This study confirmed findings of a previous verification study on a disease models made from porcine femoral heads (Preutenborbeck et al. I-CORS2016). It demonstrated that fracture prediction based on beam theory is a viable tool to predict fracture. The tests confirmed that samples with a lesion in the weight bearing area were more likely to fracture at a low load however not all samples with a lesion fractured with a low load experimentally, indicating that a lesion alone is not a sufficient factor to predict fracture. The developed tool takes both structural and material properties into account when predicting the fracture risk. Therefore it might be superior to current diagnostic methods in this respect and it has the added advantage of being largely automated and therefore removing the majority of user bias. For any figures or tables, please contact the authors directly

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

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

The United States is in the midst of an opioid epidemic, with the World Health Organization reporting that American's consume 99% of the world's supply of hydrocodone and 83% of the world's oxycodone. Additionally, pre-operative opioid use has been associated with worse clinical outcomes and higher rates of complications following TKA. This is especially important in the TKA population given that approximately 15% of patients are either dissatisfied or very dissatisfied at least one year after their TKA procedure. Given the concerning rise is opioid use the American Academy of Orthopaedic Surgeons (AAOS) has recently released an information statement with practice recommendations for combating this excessive and inappropriate opiate use. However, little is known regarding peri-operative opioid use for TKA patients. Therefore, the purpose of this study was to: 1) identify rates of opioid use prior to primary TKA, 2) evaluate post-operative trends in opioid use throughout the year following TKA and 3) identify risk factors for prolonged opioid use following TKA. Overall, 31% of TKA patients are prescribed opioids within 3-months prior to TKA; this percentage has increased over 9% during the years included in this study. Pre-operative opioid use was most predictive of increased refills of opioids following TKA, however, other intrinsic patient characteristics were also predictive of prolonged opioid use. These characteristics remained predictive after controlling for opioid user status. The increasing rates of opioid prescribing prior to TKA are concerning, especially given literature concluding opioids have minimal effect on pain or function in patients with osteoarthritis and pre-operative opioid use is associated with poor outcomes and more complications following TKA. This data provides an important baseline for opioid use trends following TKA that can be used for future comparison and identifies risk factors for prolonged use that will be helpful to prescribers as the AAOS works to decreased opioid use, misuse and abuse within the United States. Our data on THA and unicompartmental arthroplasty is similar with an increase in pre-THA use of 9% with 38% receiving narcotics within 3 months of surgery and continued use in opioid users (9 times non-opioid users at 12 months)

Cervical total disc replacement has been in practice for years now as a viable alternative to cervical fusion in suitable cases, aspiring to preserve spinal motion and prevent adjacent segment disease. Reports are rife that neck pain emerges as an annoying feature in the early postoperative period. The facet joint appears to be the most likely source of pain. 50 patients were prospectively followed up through 5 years after having received disc replacement surgery, indicated for symptomatic soft disc herniation of the cervical spine presenting with radiculopathy. • All were skeletally mature and aged between 22 to 50. • All had failed a minimum of 6 months conservative therapy. • Up to 2 disc levels were addressed. C3 till C7 levels. • Single surgeon (first author). • NDI > 30% (15/50). • Deteriorating radicular neurology. We excluded those with degenerative trophic changes of the cervical spine, focal instability, trauma, osteoporosis, previous cervical spine surgery, previous infection, ossifying axial skeletal disease and inflammatory spondyloarthritides. The device used was an unconstrained implant with stabilizing teeth. Over the 5 years, we studied their postoperative comfort level via the Neck Disability Index (NDI) and Visual Analogue Score (VAS). Pre-operative and post-operative analysis of the sagittal axis and of involved facet joints were done. 22 patients suffered postoperative neck pain as reflected by the NDI and VAS scores. Of these, 10 reported of neck pain even 24 months after surgery. However, none were neurologically worse and all patients returned to their pre-morbid functions and were relieved of pain by 28 months. All 22 patients reported of rapid dissolution of neckache after peri-facetal injections of steroids were done under image guidance. We draw attention to the facet joint as the pain generator, triggered by inappropriate implant height, eccentric stresses via hybrid constructs, eccentric loading due to unconstrained devices and unaddressed Luschka joint degeneration. Such factors require careful selection of patients for surgery, necessitate proper pre-operative templating and call for appropriate technical solutions during surgery

Simulated learning is increasingly prevalent in many surgical training programs as medical education moves towards competency based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated diagnosis where the standard of care in patients less than six months of age is an orthotic device such as the Pavlik Harness. However, despite widespread use of the Pavlik Harness and the potential complications that may arise from inappropriate application, no formal educational methods exist. A video and model based simulated learning module for Pavlik Harness application was developed. Two novice groups (residents and allied health professionals) were exposed to the module and at pre-intervention, post-intervention and retention testing were evaluated on their ability to apply a Pavlik Harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skill (OSATS) and a Global Rating Scale (GRS) specific to Pavlik Harness application. A control group who did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik Harness alone would affect ability. All groups were compared to a group of clinical experts who were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t-tests and ANOVA. Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik Harness (p<0.05) to the level of expert clinicians and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve nor did they achieve competency. The simulated learning module has been shown to be an effective tool for teaching the application of a Pavlik Harness and learners demonstrated retainable skills post intervention. This learning module will form the cornerstone of formal teaching for Pavlik Harness application in developmental dysplasia of the hip