Background of study. Following the Montgomery ruling, consent is now a matter of law. The medical professionals have to show proof that risks and implications and material risks are explained to the patient and that they have accepted to go ahead with surgery. Materials and Methods. We devised a free web based programme (. www.consentplus.com. ) which introduces a documented checkpoint to the consent process in hip and knee replacement surgery. It enables reproducible high-quality bite-sized information delivery to patients and their families in an optimal environment. It utilises the flip classroom principle to facilitate dialogue between doctors and patients. It generates physical documentation to show patients’ knowledge and understanding of the risks; to produce a truly informed consent. Results. 1567 users completed the Consent PLUS process over 28 hospitals across the UK. 98.1% of users were satisfied with Consent PLUS in terms of quality of service and information delivered. Users’ self-rated knowledge increased by 29%, independent of age group, prior knowledge or check-point scores. Supportive documentation for 100% of the users, which facilitated the consent process but did not replace the consultation. 60% of users accessed the system via desktop computers, 23% via tablet and 17% via mobile phone. 55 consultant surgeons and 28 hospitals have been registered into the system by the users. 96.9% of users found Consent PLUS useful and 96.3% would recommend it to their friends. 92.6% would use it again. Conclusion. Consent PLUS can facilitate information delivery and improve patients’ understanding of the risks of surgery and its implications subjectively and objectively. Consent PLUS is a tool designed to enhance and facilitate the consent process, not to replace the current consent forms

BACKGROUNDS. Total knee arthroplasty (TKA) using an imageless navigation is widely used in these days. Despite the usefulness of navigation-assisted TKA, there are still limitations of accuracy. From previous studies, many factors have been suggested as causes of the discordance between pre-op planning and post-op results. In Addition, Registration of reliable landmark is very important factor in navigation-assisted TKA, fundamentally. Nevertheless, current method of registration process is substantially affected by subjective preference of operators. Until now, However, there is no consensus about the optimal range of reference point. Moreover, the tolerance of imageless navigation system is still questionable. We investigated the effect of variation during the manual registration in this study. We compared the measured alignment and calculated plan of navigation system which were collected from repeated independent registration processes. METHODS. From 7 March 2016 to 13 May 2016, 44 patients (49 knees) underwent navigation assisted TKA with Orthopilot® Aesculap system. The subject group were severe osteoarthritis patients, they have evaluated radiographically and clinically before the operation. we excluded candidates who have shown very severe mal-alignment (>20 °) and metaphyseal bowing in Pre-op radiographic evaluation. All patients were followed for postoperative long axis film that could measure the correction angle, and followed clinically for functional score. Authors executed multiple registration trials in a single case, each trial was implemented by different surgeons (Senior surgeon JHJ and trainee LJH1, LJH2). At first, Senior surgeon (JHJ) start the operation from initial approach. Standard sub-vastus approach was applied to all-patients. After the procedure of joint exposure, each participating surgeon did the examination of knee anatomy and registered optimal point of his own. It was repeated three times (J,L1,L2) via imageless navigation system. Then, we collected the information of measured limb alignments and calculated plans of tibia cutting from navigation system. RESULTS. 33 knees were evaluated as Gr. 4 in Kellgren-Lawrence classification. The other 16 knees were Gr. 3. In repeated registration processes, patients who were scored Gr. 3 have shown no significant differences in mechanical limb alignments, both coronal and sagittal. There were also no significant differences in Gr. 4 patients, too. Initial tibia planning has shown the largest variance between medial and lateral cutting level (0.4 ± 1.3 mm, in neutral alignment). But, no statistical significance was observed. There is a tendency that the deviation of tibia planning has diminished gradually with the progression of this study. In radiographic evaluation, all cases have satisfactory limb alignments postoperatively. CONCLUSION. Our experiment suggest that variation of landmark registration alone couldn't have a significant effect on the calculated alignment of navigation system. In this study, we concluded that tolerable range of registration process for alignment calculation is relatively wide. Additionally, we think that the cutting depth is more vulnerable than alignment calculation, and it may need further study with more cases. Measured limb alignment is almost reliable in imageless navigation. Even though operators were not so experienced for the registration process

Demographic changes will increase the number of surgical procedures in the next years. Therefore, quality assurance of clinical processes, such as the reprocessing of surgical instruments as well as intraoperative workflows will be of increasing importance to ensure patient safety. Surgical procedures are often complex and may involve risks for the patient. For fixation of screws, e.g. in case of pedicle screws, osteosynthesis plates or revision joint replacement surgery implants, the application of defined torques may be crucial in order to achieve optimal therapeutic results and minimal complication rates. In many cases a subjective rating of the surgeon is necessary as no adequate instrumentation is available. With the same subjective feeling, hammering or screwing in are performed to implant e.g. the acetabular component in THA. Our actual work is dedicated to the implementation of a functional prototypes of sensor- integrated instruments for specific types of intervention (especially in traumatology) and the evaluation of the sensor integrated surgical instruments in combination with RFID technology for smart process optimisation in the operating room as well as for reprocessing of surgical instruments and surgical management in combination with a knowledge-based planning, control and documentation system. Complementary (preferably wireless) sensors such for instrument identification, tracking or more complex measurements such as forces, torques, temperature or impacts during surgery as well as during reprocessing of reusable instruments could enable computer network based quality assurance in a much broader and comprehensive manner. Within the framework of the OR.NET initiative we follow the approach to integrate wireless sensors for measurement of temperature, force-torque as well as inertial sensors for orientation and impact control, depending on the specific type of application for monitoring of workflows during surgery as well as during reprocessing of reusable instruments and devices. The integration of smart surgical instruments into an open networked operating room based on the open communication standard IEEE 11073 knowledge-based workflow system, can help to improve the process and quality management

Aims. To compare the efficacy of decompression alone (DA) with i) decompression and fusion (DF) and ii) interspinous process device (IPD) in the treatment of lumbar stenosis with degenerative spondylolisthesis. Outcomes of interest were both patient-reported measures of postoperative pain and function, as well as the perioperative measures of blood loss, operation duration, hospital stay, and reoperation. Methods. Data were obtained from electronic searches of five online databases. Included studies were limited to randomised-controlled trials (RCTs) which compared DA with DF or IPD using patient-reported outcomes such as the Oswestry Disability Index (ODI) and Zurich Claudication Questionnaire (ZCQ), or perioperative data. Patient-reported data were reported as part of the systematic review, while meta-analyses were conducted for perioperative outcomes in MATLAB using the DerSimonian and Laird random-effects model. Forest plots were generated for visual interpretation, while heterogeneity was assessed using the I. 2. -statistic. Results. A total of 13 articles met the eligibility criteria. Of these, eight compared DA with DF and six studies compared DA with IPD. Patient-rated outcomes reported included the ODI and ZCQ, with mixed results for both types of comparisons. Overall, there were few statistically significant and no clinically significant differences in patient-rated outcomes. Study quality varied greatly across the included articles. Meta-analysis of perioperative outcomes revealed DF to result in greater blood loss than DA (MD = 406.74 ml); longer operation duration (MD = 108.91 min); and longer postoperative stay in hospital (MD = 2.84 days). Use of IPD in comparison to DA led to slightly reduced operation times (MD = –25.18 min), but a greater risk of reoperation compared to DA (RR = 2.70). Conclusion. Currently there is no evidence for the use of DF or IPD over DA in both patient-rated and perioperative outcomes. Indeed, both procedures can potentially lead to greater cost and risk of complications, and therefore, a stronger evidence base for their use should be established before they are promoted as routine options in patients with degenerative spondylolisthesis

Introduction. The accumulation of proteins and bacteria on implant surfaces is a critical concern in the biomedical field, especially with respect to the potential of biofilm formation on implant surfaces. Material surface wettability is often used as a predictor of potential colonization of specific bacterial strains. Surface roughness has also been shown to have a strong relationship with biofilm formation, as rougher surfaces tend to have a stronger affinity to harbor bacterial colonies. The modification of implant surfaces to impart a biofilm resistant layer can come at the expense of increasing surface roughness however, and it is therefore important to determine how the variables of wettability and roughness are affected by any new surface coating technologies. In the current work, a novel CoBlast (C) process that impregnates alumina (A) at 50 μm grit (5) or 90 μm grit (9) sizes, with the possible addition of polytetrafluoroethylene (P) onto titanium surfaces, combined with a plasma coating process called BioDep, that coats the surface with chitosan (X) with the possible addition of vancomycin (V), were evaluated for wettability and surface roughness to determine their potential as biofilm resistant treatments on implants. Materials and Methods. N=65 titanium alloy samples (n=5 for 13 sample modification types as described above and in the figure legends below) were analyzed for surface roughness and wettability. Following cleaning in ethanol, roughness testing (Ra, Rq, Rt and Rz, Wyko NT-2000 optical profilometer @ 28.7× magnification, FOV of 164×215 μm) at 5 different surface locations per specimen, and contact angle analysis was performed (2 μL water drops, KRUSS EasyDrop). Statistical differences between groups was determined using ANOVA. Results and Discussion. Figure 1a summarizes the roughness results, with significant roughening being observed with between surface blanks and all surface modification techniques, especially the CoBlasted 90 μm grit treatments. As expected, wettability (shown in Figure 1b) was significantly affected by PTFE modifications and also by the introduction chitosan and vancomycin. Conclusions. As can be seen from these results, changing the coating of a material can change the surface topography and the wettability of the surface, which can be beneficial for different applications. The results from this work show that the CoBlast and BioDep processes significantly affect both wettability and roughness, and that the benefits and potential drawbacks of each must be considered when assessing their potential for biofilm resistance. PTFE-coated samples would be best used when wanting to prevent a hydrophobic substance from binding to the material, while the alumina-coated or blank samples would be best used to prevent a hydrophilic substance from binding. In the future, nonpolar liquid wettability will be assessed to better mimic in-vivo conditions and to determine surface energy to be able to make better conclusions about the relationship between surface roughness and wettability. For any figures or tables, please contact the authors directly

Purpose of study:. The presence of an L5 transverse process fracture is reported in many texts to be a marker of pelvis fracture instability. There is paucity of literature to support this view. Available studies have been performed on patients who were already known to have a pelvis fracture. No study has attempted to document the presence of this lesion in the absence of a pelvis fracture. Primary aim: To identify the correlation between the presence of a L5 transverse process fracture and an unstable pelvic ring injury. Secondary aim: To establish whether a L5 transverse process fracture can occur in the absence of a pelvis fracture. Methods:. We conducted a retrospective review of all CT scans performed in patients who presented to a Level 1 Trauma Unit for blunt abdomino-pelvic trauma between January 1, 2012 and August 28, 2013. A total of 203 patients met our inclusion criteria. Results:. Fifty four of these 203 patients (26%) sustained a pelvis fracture. Of these 54 patients 26 (48%) had an unstable fracture pattern according to the AO classification. Five of these 26 patients (19%) had an associated L5 transverse process fracture. Seven (12%) had an L5 transverse process fracture associated with a stable fracture pattern. Three patients (1.4%) had an isolated L5 transverse process fracture in the absence of a pelvis fracture. Conclusion:. This study confirms the association between the presence of a L5 transverse process fracture and an unstable pelvis fracture pattern. This injury is rarely seen in the absence of a pelvis fracture so its presence should alert the treating clinicians to the existence of a pelvis fracture

INTRODUCTION. The elimination of motion and disc stress produced by spinal fusion may have potential consequences beyond the index level overloading the spinal motion segments and leading to the appearance of degenerative changes. So the “topping-off” technique is a new concept instructing dynamic fixation such as interspinous process device (IPD) for the purpose of avoiding adjacent segment disease (ASD) proximal to the fusion construct. MATERIALS AND METHODS. The study simulated spinal fusion in L4-L5, fusion combined DIAM in L3-L4. The ROM and maximum von Miss stresses were analyzed in flexion, extension, lateral bending, and torsion in response to hybrid method, compared to intact modeland fusion model. RESULTS. The investigation revealed that decreased ROM, intradiscal stress in implanted level but a considerable increase in stresses at more upper level (L2-L3) during flexion and extension in hybrid model, comparing with the fusion model. CONCLUSIONS. The raise of intradiscal pressure at the adjacent segment to a rigid fusion segment can be reduced when the rigid construct is augmented with an interspinous process device. However, the burden of stress over total spinal segments was still the same, the stress and ROM were just shift to supraadjacent levels

A cleaning process reduces the contamination risk in bone impaction grafting but also modifies the grain size distribution. The cleaned allograft shows a higher mechanical stability than the untreated group. In revision total hip replacement, bone loss can be managed by impacting porous bone chips. The bone chips have to be compacted to guarantee sufficient mechanical strength. To improve the safety of bone grafts and to reduce the risk of bacterial and viral contamination, cleaning processes are used to remove the organic portion of the tissue while maintaining its mechanical characteristics. A cleaning procedure described by Coraca-Huber et al. was compared to untreated allografts by performing a sieve analysis, followed by an uniaxial compression test. Differences in grain size distribution and weight loss during the cleaning procedure were compared to data from literature. Yield stress limits, flowability coefficients as well as initial density and density at the yield limit of the two groups were determined for each group over 30 measurements. The measurements were taken before and after compression with an impaction apparatus (dropped weight). The cleaning process reduced the initial weight by 56%, which is comparable to the results of McKenna et. al. Cleaned allograft showed a 25% lower weight of bone chips sized > 4 mm compared to data from a previous study. The cleaned bone chips showed a statistically significant (p > 0.01) higher yield limit to a compression force (0.165 ± 0.069 MPa) compared to untreated allograft after compaction (0.117 ± 0.062 MPa). The flowability coefficient was 0.024 for the cleaned allograft and 0.034 for the untreated allograft. Initial density as well as the density at the yield limit was higher for the untreated allografts, as the sample weight was twice as high as in the cleaned group, to compensate for the washout of the organic portion. The cleaned bone grafts showed a higher compaction rate, which was 31%, compared the the untreated group with a compaction rate of 22%. The cleaned allograft showed a higher compaction rate, which means that the gaps between the single grains are filled out with smaller particles, resulting in better interlocking. In the untreated allograft the interlocking mechanism is hindered by the organic elements. This observation is confirmed by a reduced flowabillity and a higher yield stress limit. The loss of weight as well as a higher compaction rate implies that more cleaned graft material is needed to fill bone defects in hip surgery. Sonication may damage the bone structure of the allograft and reduce the size of the particles

The study aim was to simulate oblique spinous process abutment (SPA) in cadaveric spines and determine how this affects coupled motion in the coronal plane. L4-S1 spinal segments from thirteen cadavers were loaded on a materials testing machine in pure compression at 1kN for 10 minutes. Reflective markers on the vertebral bodies were used to assess coronal motion using a motion analysis system. Oblique SPA was simulated by attaching moulded oblique aluminium strips to the L4 and L5 spinous processes. In each specimen, both a right- and left-sided SPA was simulated, in random order, and compression at 1kN was again applied. All tests were then repeated after endplate fracture. Coronal plane motion at baseline was compared with values following simulated SPA using Mann Whitney U-tests. Pre-fracture, SPA increased coronal motion by 0.28° and 0.34° on right and left sides respectively, compared to baseline, only the former was significant (P=0.03). Post-fracture, SPA decreased coronal motion by 0.36° and 0.46° on right and left sides respectively, only the latter was significant (P=0.03). Simulated oblique SPA in the intact spine initiated an increase in coronal motion during pure axial loading. These findings provide limited evidence that oblique SPA may be causative in DLS

Implant alignment in knee arthroplasty has been identified as critical factor for a successful outcome. Human error during the registration process for imageless computer navigation knee arthroplasty directly affects component alignment. This cadaveric study aims to define the error in the registration of the landmarks and the resulting error in component alignment. Five fresh frozen cadaveric limbs including the hemipelvis were used for the study. Five surgeons performed the registration process via a medial parapatellar approach five times. In order to identify the gold standard point, the soft tissues were stripped and the registration was repeated by the senior author. Errors are presented as mm or degrees from the gold standard registration. The error range in the registration of the femoral centre in the coronal plane was 6.5mm laterally to 5.0mm medially (mean: −0.1, SD: 2.7). This resulted in a mechanical axis error of 5.2 degrees valgus to 2.9 degrees varus (mean: 0.1, SD: 1.1). In the sagittal plane this error was between −1.8 degrees (extension) and 2.7 degrees (flexion). The error in the calculation of the tibial mechanical axis ranged from −1.0 (valgus) to 2.3 (varus) degrees in the coronal plane and −3.2 degrees of extension to 1.3 degrees of flexion. Finally the error in calculating the transepicondylar axis was −11.2 to 6.3 degrees of internal rotation (mean: −3.2, SD: 3.9). The error in the registration process of the anatomical landmarks can result in significant malalignment of the components. The error range for the mechanical axis of the femur alone can exceed the 3 degree margin that has been previously been associated with implant longevity. The technique during the registration process is of paramount importance for image free computer navigation. Future research should be directed towards simplifying this process and minimizing the effect of human error

Quality assurance for training in trauma and orthopaedics was provided by the JCHST through the SAC for Trauma and Orthopaedics. To date there have been written SAC standards; some are compulsory and others advisory and will generate requirements or recommendations to change if unmet on inspection. There has been a major change in the way postgraduate training is monitored and quality assured, with the formation of the PMETB, which now has the combined responsibility for all postgraduate training. The aims and objectives of our study were to measure the effectiveness of the current quality assurance system for training in Trauma and Orthopaedics, and to determine the reduction in the number of unmet compulsory standards at the end of the visits process and how effectively these requirements were implemented. We also identified the deficiencies in each component of training and determined the current general profile of the quality of training in Trauma and Orthopaedics. The inspection visits, progress and revisit reports were collected from training regions that were visited after the standards were implemented. In 109 units, in the 3 years studied, the inspection process reduced the overall unmet standards from a mean of 14.8% (10.3-19.2%) to 8.9% (6.5%-12.7%). The number of unmet requirement per unit fell from 4.6 to 2.8 (p<0.05). 27% of units did not improve. Overall 15% of standards were deficient, least in Scottish units and most in Irish units. Currently registrars do 1.4 trauma lists, 2.8 elective lists, 1.3 fracture clinics and 2.1 elective clinics per week. This is the first multi-regional study of a national accreditation process. Quality assurance requires standards setting and rectification. These findings are important for the imminent restructuring by the Postgraduate Medical Education Board

In professional football a key factor regarding injury is the time to return to play. Accurate prediction of this would aid planning by the club in the event of injury. It would also aid the club medical staff. Gaussian processes may be used for machine learning tasks such as regression and classification. This study determines whether machine-learning methods may be used for predicting how many days a player is unavailable to play. A database of injuries at one English Premier League Professional Football Club was reviewed for a number of factors for each injury. Twenty-five variables were recorded for each injury, including time to return to play. This was determined to be the response variable. We used a Gaussian process model with a Laplacian kernel to determine whether the return to play could be predicted from the other variables. The root mean square error was 13.186 days (S.D.: 8.073), the mean absolute error was 8.192 days (S.D.:13.106) and the mean relative error 171.97% (S.D.:75.56%). A linear trend was observed and the model demonstrated high accuracy with greater errors being observed for cases where the value of the response variable was higher, i.e. in those cases where the time to return to play was lengthy. This is the first step in attempting to design a computer-based model that will accurately predict the time for a professional footballer to return to play. The model is extremely accurate for most cases, with errors increasing as the severity of the case increases too

Introduction. Total knee arthroplasty (TKA) has traditionally been performed as an effective treatment for patients with end-stage knee OA, by relieving pain, restoring function, and correcting deformity. One-leg standing (OLS) test is a widely used clinical tool to evaluate postural steadiness in a standing position for elderly people. According to previous reports, one-leg standing time was associated with subjects' age, self-assessment of their health status, body mass index, mortality, and the risk of falls. Therefore, it is important to know knee condition including OLS in older patients with knee OA. However, it is unknown whether TKA will be really beneficial for OLS in the elderly people. It was hypothesized that postoperative recovery would be more slowly in older patients than in younger patients. Our purpose was to investigate factors affecting the OLS time in patients with end-stage knee OA and to clarify an age-related recovery process following TKA in the early postoperative period. Methods. A total of 80 knees in 40 patients (35 females and 5 males) were enrolled in the current investigation. Mean age was 75 (60–82) years old. All the patients had bilateral varus deformities with radiographic OA of grade 4 severities, according to Kellgren-Lawrence grade. All the patients were divided into 2 Groups; patients older than 76 years (Group O) and younger than 75 years (Group Y). After unilateral TKA using Balanced Knee System®, posterior stabilized design (Ortho Development, Draper, UT), postoperative evaluations including OLS time, knee flexion angle during standing (KFA), and Visual Analogue Scale (VAS), were done preoperatively and daily from postoperative day 3 to 20 in each group, because epidural catheter was removed on postoperative day 2. As a statistical analysis, values of preoperative measurements were used as controls in each group. Statistical difference between the data was evaluated using two-tailed repeated-measures of analysis of variance (ANOVA). After a significant P value (< 0.05) was determined, a post hoc Dunnett test was performed to compare selected mean values, and P-values of < 0.05 was considered as significant. Results. 20 patients (mean 78 years old) were allocated to Group O and 20 patients (mean 69 years old) were allocated to Group Y. In terms of preoperative demographic data, no significant differences were detected between the two groups. Evaluation of change in VAS, KFA, and OLS were presented in Figure 1, 2, and 3, respectively. Similar pain reduction and similar improvement of KFA were observed in both Groups. On the other hand, significant differences were detected between both groups in OLS time. Discussion. In terms of OLS, according to previous reports, OLS balance in patients with knee OA improved significantly 11 days after TKA in younger patients (mean 61 years). However, unfortunately, OLS time in older patients did not improve for 20 days after TKA. Specifically, longer rehabilitative period was required in older patients than in younger patients for significant recovery of OLS time. Therefore, risk of falling still exists especially for older patients in the early postoperative period after TKA

Patients offered fluid two-hours preoperatively have improved satisfaction, fewer complications and no increased intra-operative risk. Our hospital has prolonged pre-operative starvation times for trauma patients. Failure-Modes-and-Effects-Analysis (FMEA) was used to identify points of inefficiency in the preoperative starvation system. Data was collected from patients, ward-staff and computer-systems, on pre-operative starvation times and food provision following cancellation. A process map of the system was created. Failure-modes-and-effects were identified at interview and stakeholders were asked to risk-evaluate each failure-mode by providing consequence scores, probability of failure and of detection. Over 7-days, 27 patients were reviewed. Average fasting times were 6.84 (2–22.25) hours for fluid, and 12.03 (3–28.75) hours for food. Five patients were cancelled with a mean NMB time of 17.25 (3–28.75) hours. The highest risk scores identified were regarding the decision to place a patient on the list (10), keeping patients NBM (10.16) and being cancelled and fed (10.11). Process-mapping and FMEA can be applied to the pre-operative starvation of trauma patients to identify parts of the system that will have the biggest impact if improved. Engaging the multidisciplinary-team allowed all members to feel involved in risk assessment and quality improvement. Using FMEA should facilitate change and improve the system of pre-operative starvation

This text has been removed at the authors' request.

Purpose

Coracoid transfer is an effective reconstructive procedure for complex glenohumeral joint instability. Recently, the congruent-arc Latarjet procedure has been described which orients the coracoid graft undersurface flush to the glenoid articular margin. The purported advantage of this modification is that the radii of curvature of the coracoid undersurface and the anterior glenoid rim are believed to be similar, and therefore, congruent. The purpose of this study was to determine the dimensions of the coracoid and to compare the radius of curvature (ROC) of the coracoid undersurface to the ROC of the intact glenoid and various glenoid bone-loss scenarios.

This study aimed to describe the morphology of the coracoid process and determine the frequency of commonly observed patterns. The second purpose was to determine the location of inferior tunnel exit with superior based tunnel drilling and the superior tunnel exit with inferior based tunnel drilling. A sample of 100 dry scapulae for the morphology aspect and 52 cadaveric embalmed shoulders for tunnel drilling were used. The coracoid process was described qualitatively and categorized into 6 different shapes. A transcoracoid tunnel was drilled at the centre of the base. Twenty-six shoulders were used for the superior-inferior tunnel drilling approach and 26 for the inferior-superior tunnel drilling approach. The distances to the margins of the coracoid process, from both the entry and exit points of the tunnel, were measured. Eight coracoid processes were of convex shape, 31 of hooked shape, 18 of irregular shape, 18 of narrow shape, 25 of straight shape, and 13 of wide shape. The mean difference for the distances between superior entry and inferior exit from the apex was Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation 3.65+3.51mm (p=0.002); 1.57+2.27mm for the lateral border (p=0.40) and 5.53+3.45mm for the medial border (p=0.001). The mean difference for the distances between inferior entry and superior exit from the apex was 16.95+3.11mm (p=0.0001); 6.51+3.2mm for the lateral border (p=0.40) and 1.03+2.32 mm for the medial border (p=0.045). The most common coracoid process shape observed was a hooked pattern. Both superior to inferior and inferior to superior tunnel drilling directed the tunnel from a more anterior and medial entry to a posterior-lateral exit. Superior to inferior drilling resulted in a more posteriorly angled tunnel. With inferior to superior tunnel drilling cortical breaks were observed at the inferior and medial margin of the tunnel

In the current healthcare environment, cost containment has become more important than ever. Perioperative services are often scrutinized as they consume more than 30% of North American hospitals’ budgets. The procurement, processing, and use of sterile surgical inventory is a major component of the perioperative care budget and has been recognized as an area of operational inefficiency. Although a recent systematic review supported the optimization of surgical inventory reprocessing as a means to increase efficiency and eliminate waste, there is a paucity of data on how to actually implement this change. A well-studied and established approach to implementing organizational change is Kotter's Change Model (KCM). The KCM process posits that organizational change can be facilitated by a dynamic 8-step approach and has been increasingly applied to the healthcare setting to facilitate the implementation of quality improvement (QI) interventions. We performed an inventory optimization (IO) to improve inventory and instrument reprocessing efficiency for the purpose of cost containment using the KCM framework. The purpose of this quality improvement (QI) project was to implement the IO using KCM, overcome organizational barriers to change, and measure key outcome metrics related to surgical inventory and corresponding clinician satisfaction. We hypothesized that the KCM would be an effective method of implementing the IO. This study was conducted at a tertiary academic hospital across the four highest-volume surgical services - Orthopedics, Otolaryngology, General Surgery, and Gynecology. The IO was implemented using the steps outlined by KCM (Figure 1): 1) create coalition, 2) create vision for change, 3) establish urgency, 4) communicate the vision, 5) empower broad based action, 6) generate general short term wins, 7) consolidate gains, and 8) anchor change. This process was evaluated using inventory metrics - total inventory reduction and depreciation cost savings; operational efficiency metrics - reprocessing labor efficiency and case cancellation rate; and clinician satisfaction. The implementation of KCM is described in Table 1. Total inventory was reduced by 37.7% with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1333 hours per annum and labour cost savings of $39 995 per annum. Depreciation cost savings was $64 320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80% post-IO. This was the first study to show the success of applying KCM to facilitate change in the perioperative setting with respect to surgical inventory. We have outlined the important organizational obstacles faced when making changes to surgical inventory. The same KCM protocol can be followed for optimization processes for disposable versus reusable surgical device purchasing or perioperative scheduling. Although increasing efforts are being dedicated to quality improvement and efficiency, institutions will need an organized and systematic approach such as the KCM to successfully enact changes. For any figures or tables, please contact the authors directly

Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget. In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears. In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model. Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits. The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects

The 2020-2021 Canadian Residency Matching Service (CaRMS) match year was altered on an unprecedented scale. Visiting electives were cancelled at a national level, and the CaRMS interview tour was moved to a virtual model. These changes posed a significant challenge to both prospective students and program directors (PDs), requiring each party to employ alternative strategies to distinguish themselves throughout the match process. For a variety of reasons, including a decline in applicant interest secondary to reduced job prospects, the field of orthopaedic surgery was identified as vulnerable to many of these changes, creating a window of opportunity to evaluate their impacts on students and recruiting residency programs. This longitudinal survey study was disseminated to match-year medical students (3rd and 4th year) with an interest in orthopaedic surgery, as well as orthopaedic surgery program directors. Responses to the survey were collected using an electronic form designed in Qualtrics (Qualtrics, 2021, Provo, Utah, USA). Students were contacted through social media posts, as well as by snowball sampling methods through appropriate medical student leadership intermediates. The survey was disseminated to all 17 orthopedic surgery program directors in Canada. A pre-match and post-match iteration of this survey were designed to identify whether expectations differed from reality regarding the effect of the COVID-19 pandemic on the CaRMS match 2020-2021 process. A similar package was disseminated to Canadian orthopaedic surgery program directors pre-match, with an option to opt-in for a post-match survey follow-up. This survey had a focus on program directors’ opinions of various novel communication, recruitment, and assessment strategies, in the wake of the COVID-19 pandemic. Students’ responses to the loss of visiting electives were negative. Despite a reduction in financial stress associated with reduced need to travel (p=0.001), this was identified as a core component of the clerkship experience. In the case of virtual interviews, students’ initial trepidation pre-CaRMS turned into a positive outlook post-CaRMS (significant improvement, p=0.009) indicating an overall satisfaction with the virtual interview format, despite some concerns about a reduction in their capacity to network. Program directors and selection committee faculty also felt positively about the virtual interview format. Both students and program directors were overwhelmingly positive about virtual events put on by both school programs and student-led initiatives to complement the CaRMS tour. CaRMS was initially developed to facilitate the matching process for both students and programs alike. We hope to continue this tradition of student-led and student-informed change by providing three evidence-based recommendations. First, visiting electives should not be discontinued in future iterations of CaRMS if at all possible. Second, virtual interviews should be considered as an alternative approach to the CaRMS interview tour moving forward. And third, ongoing virtual events should be associated with a centralized platform from which programs can easily communicate virtual sessions to their target audience