Background. The internet has revolutionized the way we live our lives. Over 60% of people nationally now have access to the internet. Healthcare is not immune to this phenomenon. We aimed to assess level of access to the internet within our practice population and gauge the level of internet use by these patients and ascertain what characteristics define these individuals. Method. A questionnaire based study. Patients attending a mixture of trauma and elective outpatient clinics in the public and private setting were invited to complete a self-designed questionnaire. Details collected included basic demographics, education level, number of clinic visits, history of surgery, previous clinic satisfaction, body area affected, whether or not they had internet access, health insurance and by what means had they researched their orthopedic complaint. Results. 292 completed the questionnaire (146 M, 146 F). 17 were incomplete and excluded from final analysis. Multiple logistic regression found younger age (O.R. 2.22 in 20–35 age group), possession of health insurance (O.R. 2.65) and higher levels of education (O.R. 8.22 for tertiary education) were all significantly associated with a higher level of access to the internet. Among those with internet access, a second regression analysis showed that a positive history of surgery (O.R. 2.82) and possession of a trade qualification (O.R. 5.15) were the best predictors of internet use to research one's orthopedic condition. Conclusion. Our study showed a level of access comparable with national statistics. It was consistent with previous studies showing younger and better educated had greater access. We believe that this shows there is a niche for increased information provision for those patients who require surgery, but we must be aware access is not available to everyone in the community

Introduction

The use of osseointegrated limb replacement prostheses for amputees are rapidly growing in popularity due to the many benefits over conventional sockets. Many institutions worldwide are beginning to provide this surgical option to their patients and are advertising the service online. The aim of this study was to assess the quality and reading level of related information available online.

Aims. This study assesses patient barriers to successful telemedicine care in orthopaedic practices in a large academic practice in the COVID-19 era. Methods. In all, 381 patients scheduled for telemedicine visits with three orthopaedic surgeons in a large academic practice from 1 April 2020 to 12 June 2020 were asked to participate in a telephone survey using a standardized Institutional Review Board-approved script. An unsuccessful telemedicine visit was defined as patient-reported difficulty of use or reported dissatisfaction with teleconferencing. Patient barriers were defined as explicitly reported barriers of unsatisfactory visit using a process-based satisfaction metric. Statistical analyses were conducted using analysis of variances (ANOVAs), ranked ANOVAs, post-hoc pairwise testing, and chi-squared independent analysis with 95% confidence interval. Results. The survey response rate was 39.9% (n = 152). The mean age of patients was 51.1 years (17 to 85), and 55 patients (38%) were male. Of 146 respondents with completion of survey, 27 (18.5%) reported a barrier to completing their telemedicine visit. The majority of patients were satisfied with using telemedicine for their orthopaedic appointment (88.8%), and found the experience to be easy (86.6%). Patient-reported barriers included lack of proper equipment/internet connection (n = 13; 8.6%), scheduling difficulty (n = 2; 1.3%), difficulty following directions (n = 10; 6.6%), and patient-reported discomfort (n = 2; 1.3%). Barriers based on patient characteristics were age > 61 years, non-English primary language, inexperience with video conferencing, and unwillingness to try telemedicine prior to COVID-19. Conclusion. The barriers identified in this study could be used to screen patients who would potentially have an unsuccessful telemedicine visit, allowing practices to provide assistance to patients to reduce the risk of an unsuccessful visit. Cite this article: Bone Jt Open 2021;2(9):745–751

Reverse shoulder arthroplasty (RSA) is increasingly performed recently. The patients seeking internet as a source of information may get misleading and a false sense of expectation. This study aimed at analysing patient information on internet and establish list of available quality websites to safely recommend to the patients. The study analysed 310 websites from 10 top search engines exploring the quality of patient information using an assessment tool. Search engines used were metasearch (Metacrawlers and Mamma), general search (Google, Altavista, Yahoo, MSN, AOL, Lycos) and health search engines (Medhunt and Excite Health). The study was undertaken by two independent researcher over a four-week period in November 2011. Each Website was evaluated according to RSA-specific content using a point value system with shoulder disease and surgery specific key words on an ordinal scale. Adequacy of the content was analysed in regard with description of diagnosis, procedure, alternate options, postoperative protocol, complications and prognosis. Excluding the repetitions 104 websites were analysed for accessibility, relevance, authenticity, adequacy of patient information and accountability. The median time since update was 12 months. More than 90% of the websites were found to be of poor quality. Only 25% sites targeted mainly people with shoulder problems. 8% of websites were from non profit organisations. Most of these websites were promoting either their service 80 (76%) or some product 12 (11%). The strength of association between two reviewers was very high (r = 0.899). Intra-rater reliability was significant (r = 0.955) with p level < 0.01. The reading level of most of websites were too high for average consumers. There is need for government organizations and professional societies to regulate the information provided by Internet. Until long-term data are available, patients should be warned when using the Internet as a source for health care information

Aim. In our Bone Infection Unit, epidural anaesthesia and sedation (EA+Sed) is the technique of choice for complex orthoplastic surgery involving lower limb free tissue transfer (LLFTT) (1) as it avoids complications of prolonged general anaesthesia (GA). Following our initial reports of successful use of audio-visual distraction (AVD) as an adjunct to regional anaesthesia we wished to evaluate the AVD effect on the patients’ experience during long duration, complex orthoplastic surgery for chronic osteomyelitis under EA+Sed. Method. Our AVD equipment consists of a WiFi connected tablet and noise reducing head phones, providing access to downloaded music, films and the internet. Patients are also allowed to use their own equipment. All patients were fully informed about AVD and EA+Sed as a choice of anaesthesia. EA was established in the anaesthetic room and continued perioperatively. Sedation with propofol was titrated to the patients’ requirements to ensure comfort during surgery. All patients were followed up postoperatively with a structured questionnaire. Results. Ten patients underwent LLFTT surgery for chronic bone infection under EA+Sed+AVD (picture). Mean duration of surgery was 550 min (480 −600 min). Patients used the AVD to listen to music, watch movies, play internet games and use e-mail and social media. All 10 patients were very satisfied, and 9 reported feeling comfortable or very comfortable intraoperatively. All rated their experience better than previous GAs, with quicker general recovery. All patients would recommend this technique to others. Conclusions. Our case series of patients undergoing prolonged surgery for osteomyelitis under EA+Sed has shown very positive impact of AVD on patients’ experience and confirmed our earlier encouraging observations. This clinical service improvement deserves further evaluation and funding

The use of patient reported outcome measures (PROMs) of function is increasing in popularity. Self reported outcome instruments are used to measure change in health status over time allowing for the collection of accurate and relevant data on the quality of healthcare services. With recent changes outlined by the government, it will become increasingly important for surgeons to be able to demonstrate, with quantitative data, positive benefit of the surgery they perform. This study demonstrates the effectiveness of, and issues involved with setting up a PROMs database in a busy orthopaedic unit. We have previously shown that a high proportion of our orthopaedic patients have access to the Internet. Suitable patients were identified at foot and ankle clinics or from surgical lists, and the well validated Foot and Ankle Ability Measure (FAAM) regional scoring system was used. The FAAM is a self-reported, region specific, instrument consisting of 21-item activities of daily living (ADL) subscale and an eight-item sports subscale. This was completed pre-operatively and also online at six-months post operatively, using limesurvey, a free online survey with internet/email based responses. The software was simple to use and took about 4 hours to develop. 77% of the patient cohort for the period of study had email access and the majority of patients without email were happy to have the questionnaire completed over the phone. This took approximately ten minutes per survey. Patients who did not conduct the study prior to their admission were able to fill it in on the ward using a laptop. This project has demonstrated that the initiation and continuation of a PROMs data collection system is feasible in a busy orthopaedic unit, producing reliable data which will enable us to monitor and improve standards of clinical practice. We discuss the issues involved with its introduction and usage

Increasing demand for total hip and total knee arthroplasty in an era of economic uncertainty and shrinking budgets has put pressure on surgeons to deliver excellent results and early functional recovery with shorter hospital stays. Patients receiving these operative interventions tend to be younger and more active. Their ultimate source of information is the Internet, which may be compromised by low quality, non-peer reviewed information, or information not at an appropriate reading level for comprehension by lower literacy individuals. Unfortunately, not all patients undergoing total hip and total knee arthroplasty are satisfied with their operative intervention. The most significant etiology of this dissatisfaction is reported to be lack of clarification and alignment of expectations between the surgeon and the patient, which may result from misinformation or lack of understanding by the patient. Furthermore, in the era of rapid recovery, length of stay has significantly decreased from 3–5 days a decade ago, now down to 1–2 days, and in some cases same day surgery. In an effort to mitigate this compromise in communication, we have developed a set of frequently asked questions and responses. These are divided into preoperative questions, perioperative questions, and postoperative questions. These are part of our patient educational materials and provide both office and hospital staff with structured responses to avoid miscommunication and misinformation. We have found it to be imperative that all information provided by the office and hospital have a consistent message

Background:. With the increase in the average age of the population, the incidence of symptomatic rotator cuff tears will also increase. Combined with more access to information via the internet etc., the patient population is more informed of the treatment modalities available and is expecting good reproducible results of their surgeries. Study:. 288 of 426 consecutive open rotator cuff repairs (2010–2012) were examined at 6 month follow up and evaluated for ranges of motion, the integrity of the deltoid and specifically the sonographic integrity of the cuff. All procedures were done in the same manner by the same surgeon (TdB). At the 6 months follow-up all had a sonar of the repaired cuff. As a second part of the study 319 of 462 consecutive cuff repair patients were phoned and evaluated by means of the ASES score insofar satisfaction with their shoulder as well as functional outcome are concerned. Results:. Pain. None – 53%. Little – 24%. Occasional – 21%. Often – 2%. Cuff integrity – perfect 72%. –. small effusion/thin but healed – 23%. –. defective – 5%. ASES score -Average 93 at average follow up 40.43 months. Conclusion:. The results show a high patient satisfaction rate, good functional outcome and especially good cuff integrity following this manner of cuff repair

Aims

The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales.

Aims

Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Electronic PROMs have many potential uses in orthopaedic practice. The primary objective of this three-phase pilot study was to measure uptake using a web-based ePROM system following the introduction of two separate process improvements. 80 consecutive new elective orthopaedic patients in a single surgeon's practice were recruited. Group 1 (n=26) received a reminder letter, Group 2 (n=31) also received a SMS message via mobile or home telephone and Group 3 (n=23) also had access to Tablet Computer in clinic. Overall 79% of patients had Internet access. 35% of Group 1, 55% of Group 2 and 74% of Group 3 recorded an ePROM score (p=0.02). There was no significant age difference between groups. In Group 3, 94% of patients listed for an operation completed an ePROM score (p=0.006). Collecting PROM data effectively in everyday clinical practice is challenging. Electronic collection should improve healthcare delivery, but is in its infancy. This pilot study shows that the combination of SMS reminder and access to Tablet Computer within clinic setting enabled 94% of patients listed for an operation to complete a score on a clinical outcomes web-based system. Further process improvements, such as additional staff training and telephone call reminders, may further improve uptake

We evaluated the quality of guidelines on thromboprophylaxis in orthopaedic surgery by examining how they adhere to validated methodological standards in their development. A structured review was performed for guidelines that were published between January 2005 and April 2013 in medical journals or on the Internet. A pre-defined computerised search was used in MEDLINE, Scopus and Google to identify the guidelines. The AGREE II assessment tool was used to evaluate the quality of the guidelines in the study. . Seven international and national guidelines were identified. The overall methodological quality of the individual guidelines was good. ‘Scope and Purpose’ (median score 98% interquartile range (IQR)) 86% to 98%) and ‘Clarity of Presentation’ (median score 90%, IQR 90% to 95%) were the two domains that received the highest scores. ‘Applicability’ (median score 68%, IQR 45% to 75%) and ‘Editorial Independence’ (median score 71%, IQR 68% to 75%) had the lowest scores. . These findings reveal that although the overall methodological quality of guidelines on thromboprophylaxis in orthopaedic surgery is good, domains within their development, such as ‘Applicability’ and ‘Editorial Independence’, need to be improved. Application of the AGREE II instrument by the authors of guidelines may improve the quality of future guidelines and provide increased focus on aspects of methodology used in their development that are not robust. Cite this article: Bone Joint J 2014;96-B:19–23

Introduction. Fifth metatarsal fractures are a common injury suffered by professional footballers. It is frequently reported in the media that such an injury will result in a 6-week absence from play. The purpose of this study was to assess frequency of media reporting of fifth metatarsal fractures, the time that is predicted by the media before the player will return to soccer and the actual time taken for the player to return to play. Methods. Internet search engines identified 40 professional footballers that suffered 49 fifth metatarsal fractures between 2001 and 2011. Information was collected from various media and team websites, match reports, photography and video evidence to provide data regarding the mechanism of injury, playing surface conditions, frequency of fractures per season, fracture treatment, estimated amount of time to be missed due to the injury and time taken to return to play. Results. 49 fractures were identified in the 40 players. 6 players suffered a recurrence of a previous fifth metatarsal fracture. 3 players sustained 5. th. metatarsal fractures in their contralateral foot. There was a trend of increased reporting of fifth metatarsal fractures over the course of the decade. 43% of fractures were sustained without contact with another player, 24% were suffered in a tackle. 77% of fractures were sustained in dry conditions. 90% of fractures were treated surgically. Mean return to play time was 14.6 weeks (range 5 to 34 weeks). The mean estimated absence in the media was 7.8 weeks (range 2 to 16 weeks), median 6 weeks. Conclusions. Fifth metatarsal fractures are being commonly reported in professional footballers with an increasing trend. Most are treated surgically. It appears that the commonly quoted period of 6 weeks before return to play is unrealistic. It should be expected that a player would be unavailable for 3 months

In acute orthopedic trauma care rapid communication between the resident and consultant surgeon is important. Teleradiology and internet facilities have been explained for transferring the x-ray images. Advanced technology found to be impractical for many countries like Sri Lanka. Objective. To determine the applicability of mobile phone multimedia message system (MMS) in acute trauma care to transfer the X-ray images and identify the practical issues related to it. Methodology. A cross sectional survey was done for a period of 01 yr. Digital photos of X-ray images were taken by using a phone camera and communicated between the senior resident and the consultant. MMS images were analyzed in relevant to the, adequacy of MMS images, quality of the MMS image and relevant area of visualization to reach a radiological diagnosis to decide the acute management plan of the patient. Analyzed the issues related to the processing and transmission of MMS Images. Results. 220 X-rays were evaluated. In 93.4 percent times was able to achieve a radiological diagnosis and decide an acute management plan. In 95% of images area of visualization is adequate. Reasons for poor quality images were analyzed. The external factors that determine the quality of the MMS images were identified. The poor quality of MMS images due to illuminator, blurring and cross bars in the MMS image increases the relative risk of achieving radiological diagnosis by factor 1.09, 3.07 and 1.32 respectively. Conclusion. The results suggest that MMS images are useful tool to communicate between consultant and the resident to decide the management plan for the patient in acute trauma care. But still the clinical assessment and on site assessment is the gold standard. Multimedia messages can be used to speed up the management process and helpful when there is time distance between the consultant and the resident

Background. Smartphones are now a ubiquitous presence within the modern healthcare setting. Uses such as internet, database software and storage of medical textbooks, all contribute to the clinical value of the devices. Within orthopaedics, transmission of digital images via smartphones is now routinely used to obtain instant second opinions of trauma radiographs. However questions remain as to whether smartphone image quality is sufficient for primary diagnosis and secondary consultation. Aim. To assess the accuracy of diagnosis made when radiographs are viewed on a smartphone screen in comparison with a standard digital monitor. Also to assess the diagnostic confidence, diagnostic difficulty, subjective image quality and formulation of management plan. Method. 30 orthopaedic registrars viewed a total of 900 radiographs–450 radiographs were viewed on a 3.5inch, 640×960 PPI smartphone screen and 450 on a standard digital monitor. Likert scales were used to assess the diagnostic accuracy, confidence and difficulty along with image quality and management plan. Initially images were viewed on the smartphone screen and after one week the same images were viewed on the digital monitor. Results were then compared. Results. There was no difference in diagnostic accuracy between smartphone and digital monitors although participants tended to be more confident in their diagnosis when made on the larger screen of the digital monitor. Diagnostic difficulty was higher in the smartphone group and image quality was lower. However there was a high correlation between management plans made after viewing images in both modalities. Discussion. This study demonstrates that although participants found the image quality poorer and found it marginally more difficult to make a diagnosis the same diagnosis was arrived at and the same management plan formulated using a smartphone compared to a standard digital monitor. Therefore smartphone based teleradiology appears to have a valid use in orthopaedic trauma

Aims

The ongoing COVID-19 pandemic has disrupted and delayed medical and surgical examinations where attendance is required in person. Our article aims to outline the validity of online assessment, the range of benefits to both candidate and assessor, and the challenges to its implementation. In addition, we propose pragmatic suggestions for its introduction into medical assessment.

Purpose. Current practice requires all post-operative hip and knee arthroplasty patients complete a series of clinical questionnaires at each visit. The patients responses to these questionnaires are used as a clinical evaluation tool for the surgeons to assess functionality, satisfaction and pain at routine pre and post-operative visits. The recent installation of 4 touch screen computer terminals, located in the patient waiting area, has created the opportunity to have the patients complete these questionnaires by using only the touch screen entry system. This eliminates the need for clinic staff to manually enter the patients responses into the clinics database, eliminate potential data entry errors, and will significantly reduce the amount of time and paper required to prepare questionnaires for each patient. In addition to possibly increasing the volume of data we can collect in our clinic, this also allows the surgeon to have immediate access to the patients responses which can be reviewed prior to seeing the patient in the office. Our goal was to determine the overall level of patient satisfaction with using the new touch screen direct entry system, the efficiency of completion and the quality of data entry occurring from the direct entry system. Method. During the month of April, 2010, a consecutive series of 100 patients entering the orthopaedic clinic, were directed to the touch screen kiosks to complete the required questionnaires (SF-12, Oxford Knee/Hip, Harris Hip/Knee Society Score, and the Patient Satisfaction Survey). Once the patients completed the touch screen questionnaires they were asked to complete a paper copy of the Touch Screen Satisfaction Questionnaire. This questionnaire asked 6 questions regarding their satisfaction with the touch-screen system, the ease/difficulty of use, and which method they would prefer to complete such questionnaires if given a choice. Results. Our sample resulted in a mean age of 68.5 years (range 41.7 to 93.8 years), with 53 females and 47 males. Ninety-six percent of patients who used this system reported they had never used a touch-screen for health purposes, 71% found it very easy to use, and 49% reported that it was very quick to use. When polled about their preferences regarding questionnaires, 82% of patients preferred to use the touch-screen system, over filling out paper copies (2%), using an external internet site from home (1%) and 15% reported having no real preference for any of these methods. Patients were unable to continue without answering all questions, therefore this method of data collection prevents the occurrence of missing values and incomplete records. Conclusion. Our results support our initial hypothesis that the new touch-screen system is a superior tool for obtaining clinically relevant patient information regarding function, pain and satisfaction in an effective and timely manner. These findings support our decision to integrate touch-screen systems into the information flow in an orthopaedic clinic

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve.

Cite this article: Bone Joint Open 2020;1-6:272–280.

The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club.

The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions.

It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development.

A recent Supreme Court ruling in the United Kingdom has significantly altered the emphasis of informed consent, moving from a historically ‘doctor-focused’ to a more ‘patient-focused’ approach, in line with the situation in other international jurisdictions.

The reasons for the change are discussed with some recommendations about how our attitudes need to change in the future.

Cite this article: Bone Joint J 2015;97-B:1159–61.