The purpose of this study was to assess the knowledge acquired from completing online case-based e-learning modules. A secondary objective was to identify how students use these independent resources and gauge their level of support for this novel instructional strategy. Fourth year medical students were randomized to either a module or control group. Both groups received the standard musculoskeletal medical school curriculum, while the students in the module group were also given access to case-based online modules created to illustrate and teach important orthopaedic concepts related to unique clinical presentations. The first module depicted an athlete with an acute knee dislocation while the second module portrayed a patient with hip pain secondary to femoral acetabular impingement (FAI). All participating students completed a knowledge quiz designed to evaluate the material presented in the module topics, as well as general musculoskeletal concepts taught in the standard curriculum. Following the quiz, the students were invited to share their thoughts on the learning process in a focus- group setting, as well as an individual survey. Demographic data was also collected to gauge student's exposure to and interest in orthopaedics, emergency medicine, anatomy and any prior relevant experience outside of medicine. Twenty-five fourth year medical students participated in the study with 12 randomized to the module group and 13 to the control group. The regression revealed students in the module group did on average 18.5 and 31.4 percentage points better on the knee and hip quizzes respectively, compared to the control group, which were both significant with a p-value < 0.01. Additionally, students who had completed an orthopaedics elective did 20 percentage points better than those who had not, while there was no significant improvement in students who had just completed their core orthopaedics rotation. The feedback collected from the survey and small group discussion was positive with students wishing more modules were available prior to musculoskeletal clinical skills sessions and their orthopaedics rotations. Medical students given access to online case-based e-learning modules enjoyed the innovative teaching strategy and performed significantly better on knowledge quizzes than their classmates who only received the standard musculoskeletal curriculum

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

Introduction. Although multiple studies have consistently demonstrated that orthopaedic surgeons receive greater transfers of value than other specialties, the industry payments of providers involved in practice guideline formation have not been explored. Therefore, the purpose of our analysis was to evaluate the industry payments among authors of the Appropriate Use Criteria (AUC) from the American Academy of Orthopaedic Surgeons (AAOS). Methods. The publicly available web portal (. OrthoGuidelines.org. ) from the AAOS was queried for all AUCs released over the past decade for the management of musculoskeletal pathologies. For each AUC available through this portal, information related to the AUC and its respective voting members were recorded. We used this information to conduct a retrospective cross-sectional analysis of the CMS Open Payments Database. This information was utilized to determine the number of total value of industry payments to AUC voting committee members during the year of voting for AUC criteria. The total amount of industry payment to AUC voting members was calculated, per each AUC, annually, as well as per orthopaedic subspecialty. The average total industry payment per voting member was calculated for each AUC and compared with the average total industry payment per orthopaedic surgeon nationally, in the same year. All descriptive data analyses were performed in Microsoft Excel 2016 (MicrosoftCorp). Results. A total of 18 different AUCs were included in our analysis. Among the 214 voting members of these AUCs, there was a mean (± standard deviation) of 16.23 (± 39.80) payments totaling USD$20,886.30 (± $123,268.95). Combined industry payments for the voting authors of each guideline ranged from $1,432.53 (Carpal Tunnel Syndrome guideline) to $2,757,444.88 (Surgery for Degenerative Lumbar Scoliosis guideline) (Table 1). Notably, the average payment per voting member was less than the average for all orthopaedic providers in the respective year for a majority (16/18) of AUCs (Table 1). Only average payments of voting members for the Non-Surgical Management Knee Osteoarthritis guideline (13,089.38 vs. $8,183.93) and Surgery for Degenerative Lumbar Scoliosis ($250,676.81 vs. $16,477.55) exceeded yearly averages among all orthopaedic surgeons with payment disclosures. Although authors for AUCs related to osteoarthritis management received the largest quantity of payments (n=491; Figure 1), the AUCs for spine related pathologies received the largest amount of industry payments ($2,757,444.88; Figure 2). Discussion and Conclusion. Our analysis demonstrated that authors on current AAOS appropriate use criteria voting panels collectively received low amounts of industry payments. Specifically, a majority of authors declared industry payments lower than the average value reported among all orthopadic providers per respective year. Therefore, our analysis suggests that there has been limited industry influence in the formation of these practice guidelines. This information should provide peace of mind for invested parties and encourage providers engaged in the formation of future guidelines to limit and fully disclose relationships with industry. Future analyses are needed to evaluate if and how industry relationships among individual providers and the boards of orthopaedic societies shape practice decisions. For any figures or tables, please contact the authors directly

A good understanding of musculoskeletal pathologies not only requires a good knowledge of normal human anatomy but also an insight in human evolution and development. Biomechanical studies of the musculoskeletal system have greatly improved our understanding of the human musculoskeletal system via medical imaging, modeling and simulation techniques. The same techniques are, however, also used in the study of nonhuman species and a comparison of human and nonhuman data can yield interesting insight in form-function relationships and mechanical constraints on motion. Anatomical and biomechanical studies on dogs and rabbits have already yielded valuable insight in disease mechanisms and development of musculoskeletal pathologies such as osteoarthritis (OA). Nonhuman primates have, however, rarely been studied in this context, though they may prove particularly valuable as they can provide us with an evolutionary context of modern human anatomy and pathology. The high prevalence of osteoarthritis in modern humans and its rare occurrence in wild primates has previously been explained as due to human joints being ‘underutilized’ or ‘underdesigned’. Modern humans are highly specialized for bipedalism, while nonhuman primates typically use a wide range of locomotor modes and joint postures to travel through the three-dimensionally complex forest canopy. These hypotheses can, however, be challenged, as it seems more likely that the low occurrence of OA in wild primates is due to a combination of underreporting of the disease and absence of the ageing effect in these species. Our understanding of musculoskeletal function and disease in modern humans would clearly benefit from more studies investigating the occurrence and characteristics of OA in nonhuman primates

Diagnosing musculoskeletal pathology from radiographs is an important skill in orthopaedics and emergency medicine. Knowing which fractures are more likely to be missed allows a high index of suspicion when looking at certain radiographs. Likewise, knowing which fractures will be rigorously followed up if they are missed helps to increase index of suspicion for those fractures. Therefore we used a prospectively gathered database of missed radiographic diagnoses to determine which injuries are missed most commonly and how these injuries are followed up. Four hundred and thirty two missed radiographic diagnoses were recorded from a total of thirty seven thousand, two hundred and seventy nine radiographs (37,279) in an emergency medicine department over three years. The most common area in which fractures were missed was the foot (22%), followed by hand (19%) and wrist (15%). The most common diagnosis to be missed was fracture of a proximal phalanx, followed by fracture of a distal radius and fracture of a metatarsal. The hip, knee, cervical spine and wrist were the areas most likely to be followed up, each with 32–35% of missed diagnoses being followed up in this way. The areas most likely to be further imaged with CT or MRI were the knee and hip. Two of the missed fractured femurs were managed operatively. Our results show that missed radiographic diagnosis are most commonly of the foot and hand, and that missed diagnosis of knee and femur fractures are followed up most rigorously. By showing which radiographs are most likely to contain missed fractures, and what these fractures are, we allow orthopaedic trainees to increase their level of diagnostic suspicion when reviewing these radiographs

Aims

To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS).

Identifying the core competencies of musculoskeletal medicine has been the basis for the development of the Australian Musculoskeletal Education Competencies (AMSEC) project. AMSEC aims to ensure Australian health professionals are suitably equipped through improved and appropriate education to address the increasing burden of both acute and chronic musculoskeletal disease. The AMSEC project has consisted of four distinct phases. The first two phases were consultative and highlighted concerns from medical educators, specialists and students that current curricula inadequately address the increasing scientific information base in MSK medicine and management. In phase three, Multidisciplinary Working Groups were established to detail competencies in MSK areas such as physical examination, red flag emergencies, basic and clinical science, patient education and self-management, procedural skills and rehabilitation and a web portal was developed. Phase four will see the core competencies completed, endorsed by the relevant professional colleges and integrated into Australian Medical School curricula. By bringing together experts from different groups involved in musculoskeletal education, it has been possible to agree on the core competencies required of a graduating medical student and from these determine the required underlying basic knowledge, skills and attitudes. These competencies are based on actual needs determined from current disease impact studies and the experience of professionals working in the various areas of musculoskeletal related clinical practice. This multidisciplinary and multi-professional approach, which includes consumer groups, has allowed a broader and more complete perspective of requirements. Both improved horizontal and vertical integration are facilitated and more efficient implementation is possible. By linking these core competencies to specific anatomy and basic science knowledge requirements, justification of the need to address current deficits in these areas was achieved. A standardised evidenced based approach to physical examination was developed allowing a unified approach to the resourcing and teaching of this skill by orthopaedic surgeons, rheumatologists and others. The ability to outline competency requirements vertically from medical student to resident, general practitioner and specialist is greatly facilitated by combining specialist educators with those of the universities and general practitioners. For the specialists, this approach yields excellent education leverage for very little additional effort. AMSEC has undertaken significant inter and intra disciplinary consultations to identify and classify core MSK competencies at a basic, median and advanced level of specialisation across professions. This novel national integrated model to address education needs offers many benefits and could be translated into other areas of medicine

Tendinopathy is a debilitating musculoskeletal condition which can cause significant pain and lead to complete rupture of the tendon, which often requires surgical repair. Due in part to the large spectrum of tendon pathologies, these disorders continue to be a clinical challenge. Animal models are often used in this field of research as they offer an attractive framework to examine the cascade of processes that occur throughout both tendon pathology and repair. This review discusses the structural, mechanical, and biological changes that occur throughout tendon pathology in animal models, as well as strategies for the improvement of tendon healing.

Cite this article: Bone Joint Res 2014;3:193–202.