In recent literature, the fragility index (FI) has been used to evaluate the robustness of statistically significant findings of dichotomous outcomes. This metric is defined as the minimum number of outcome events to flip study conclusions from significant to nonsignificant. Orthopaedics literature is frequently found to be fragile with a median FI of 2 in 150 RCTs across spine, hand, sports medicine, trauma and orthopaedic oncology studies. While many papers discuss limitations of FI, we aimed to further characterize it by introducing the Fragility Likelihood (FL), a new metric that allows us to consider the probability of the event to occur and to calculate the likelihood of this fragility to be reached. We systematically reviewed all randomized controlled trials in the Journal of Bone and Joint Surgery (Am) over 10 years. The FL was calculated with the following formula: A x B x C x 100% (A= FI; B = probability of the event in the group with the smallest number of events; C= probability of the non-event in the group with the highest number of events). A smaller FL demonstrates more robust results and conversely, a larger FL illustrates a higher likelihood of fragility being reached and more fragile the findings. The median FI for the statistically significant outcomes was 2 (Mean: 3.8; Range 0-23). The median FL for the statistically significant outcomes was 11% (Mean: 22%, Range: 2%-73%). This means that the probability of reaching non-significance is only 11% when considering the probability of the event to occur. When comparing studies with the same FI we found the FL to range from 3% to 43%. This illustrates the large differences in robustness between trials with equal FI when the likelihood of the event was taken into consideration. As orthopaedic studies are frequently reported as fragile, we found that by calculating the FL, studies may be more robust than previously assumed based off FI alone. By using the FL in conjunction with FI and p-values will provide additional insight into the robustness of the reported outcomes. Our results indicate that by calculating the FL, study conclusions are stronger than what the FI alone predicts. Although conducting RCTs in surgery can be challenging, we must endeavor to critically evaluate our results so we can answer important orthopaedic questions with certainty

Introduction. Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) helps restore range of motion. This study identifies MUA risk factors to support early interventions to improve functionality. Methods. Data was retrospectively reviewed in 2,925 primary TKAs from October 2013 through December 2015 from 13 orthopedic surgeons using hospital and private practice electronic medical records (EMR). Statistical analysis evaluated MUA and non-MUA groups, comparing demographic, operative, hospital-visit, and clinical factors. T-test, chi-square test, ANOVA and regression analysis were performed. Significance was set at p<0.05. Results. Of 2,925 TKAs, 208 MUAs were performed (7.1%) with no significant differences between groups in sex, BMI, or diabetes status. Mean age of the MUA group was 61.98 years old, and 66.89 years old in the non-MUA group (p<0.005). The ratio of MUA patients with high cholesterol was 3.37% (7/208), and 1.10% (30/2717) in the non-MUA group (p=0.014). The ratio of African-American patients in the MUA group was 6.73% (14/208), and 2.94% (80/2717) in the non- MUA group (p=0.003). Of cases with device data recorded in the EMR (n=1890), MUA incidence in patients receiving a cruciate-retaining (CR) device was 14.58% (50/343), and 9.57% (148/1547) in patients receiving a posterior-stabilized (PS) device (p=0.006). A CR-device patient was 52.35% more likely to undergo MUA than a PS-device patient (95% CI, 1.13–2.05). MUA rate by surgeon training was 6.7% for joint fellowship, 6.8% for general fellowship, and 12.0% for sports medicine fellowship (p=0.015). Further analysis showed that rate of CR-device use was 13.3% for joint-fellowship trained surgeons, 10.2% for general fellowship, and 74.7% for sports medicine fellowship (p<0.001). With the numbers available for this investigation, there were no significant differences found between groups in relation to surgeon, high-volume (>150 TKAs annually) or low-volume surgeons, length of stay, discharge disposition, or smoking status. Conclusion. MUA risk factors include a lower mean age, high cholesterol, African-American, surgeon fellowship training, and receiving a cruciate-retaining device

Musculoskeletal (MSK) disorders continue to be a major cause of pain and disability worldwide. The mission statement of the Canadian Orthopaedic Association (COA) is to “promote excellence in orthopaedic and musculoskeletal health for Canadians,” and orthopaedic surgeons serve as leaders in addressing and improving musculoskeletal health. However, patients with MSK complaints most commonly present first to a primary care physician. According to a survey of family physicians in British Columbia, 13.7-27.8% of patients present with a chief complaint that is MSK-related (Pinney et Regan, 2001). Therefore, providing excellent MSK care to Canadians requires that all physicians, especially those involved in primary care, be adequately trained to diagnose and treat common MSK conditions. To date, there has been no assessment of the total mandatory MSK training Canadian family medicine residents receive. It is also unclear, despite the prevalence of MSK complaints among Canadian patients, if current family physicians are competent or confident in their ability to provide fundamental MSK care. The purpose of this study is to determine the amount of mandatory MSK training Canadian family medicine residents are currently receiving. Web-based research was used to determine how many weeks of mandatory MSK training was incorporated into current Canadian family medicine residency training programs. This information was gathered from either the Canadian Resident Matching Service website (carms.ca) or the residency program's individual website. If this information was not available on a program's website, a program administrator was contacted via email in order to ascertain this information directly. MSK training was considered to be any rotation in orthopaedic surgery, spine surgery, sports medicine, or physiatry. 156 Canadian family medicine residency training sites were identified. Information pertaining to mandatory MSK education was collected for 150 sites (95.5%). Of the 150 training sites, 102(68 %) did not incorporate any mandatory MSK training into their curriculum. Of the 48 programs that did, the average number of weeks of MSK training was 3.37 weeks. 32/48 programs (66.7%) included 4 weeks of MSK training, which represents 3.8% of a 2-year training program. Current Canadian family medicine residents are not receiving sufficient musculoskeletal training when compared to the overall frequency of musculoskeletal presentations in the primary care setting. Understanding current family medicine physicians’ surveyed confidence and measured competence with respect to diagnosing and treating common musculoskeletal disorders could also prove helpful in demonstrating the need for increased musculoskeletal education. Future orthopaedic initiatives could help enhance family medicine MSK training

Australia is a foundation member of the Asia Pacific Orthopaedic Association—thus, recognising our geographical position in the most rapidly advancing region in the world. It is a serious mistake to think of Asia as ‘third world’. Research, education and surgical techniques are at the forefront of modern technology. Australia has to be a part of this ‘learn and teach’ movement. We have much to gain through exchange and travelling fellowships; paediatric, spinal, trauma and arthroplasty fellowships are available. The Orthopaedic Sports Medicine Travelling Fellowship is co-ordinated with corresponding organisations in Europe, North America and South America and previous travelling fellows become part of the influential Magellan Society. APOA has many sections (knee, hip, hand, spine, trauma, infection, sports medicine and paediatrics), with each having regular Congresses. Join APOA and attend the Triennial Congress in Taipei November 2010 and be impressed at the level of research

Introduction. Meniscal injuries are very common cause of knee pain and resultant attendance to the orthopaedics or sports medicine clinics. The current protocol stands at clinical examination at first contact and establishing a diagnosis with clinical indicators like joint line tenderness, McMurray's, Apley's and weight-bearing test for meniscal pathology followed by MRI scan to confirm the diagnosis. Either surgical or conservative management follows this. We aim to assess clinical examination alone provide sufficient evidence for further management of meniscal injury and does a role of MRI scan exist to corroborate the findings. Methodology. We retrospectively studied 88 patients attending the sports medicine clinic for the duration 2004–2007 examined by senior clinical assessor. We investigated the co-relation of the clinical and MRI findings to validate if there exists an actual clinical justification to use MRI scan in every patient. We divided the data in further subsets of 57 patients in whom both clinical examination and MRI scan were performed and were validated by arthroscopy. The data obtained was analysed for parameters of accuracy, sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV]. Results. The comparison of clinical examination against MRI scans alone in 88 patients provided a accuracy of 81.81%, sensitivity of 95.77% and specificity of 23.52%. The assessment revealed that clinical examination yielded accuracy of 89.47%, sensitivity of 96%, specificity of 42 %, PPV of 92%, NPV of 60% while MRI scan was 87.70% accurate, 86% sensitive, with specificity of 100%, PPV of 100%, NPV of 57.14%. Conclusion. From the results yielded by the study we can conclude that in experienced hands the clinical examination is as robust as MRI scan for meniscal injury of knee and can negate the need for MRI scan to be performed in every painful knee with suspicious meniscal injury

The purpose of this study was to validate a dry model for the assessment of performance of arthroscopic rotator cuff repair (RCR) and labral repair (LR). We hypothesised that the combination of a checklist and a previously validated global rating scale (GRS) would be a valid and reliable means of assessing RCR and LR when performed by residents in a dry model. An arthroscopic RCR and LR was performed on a dry model by residents, fellows, and sports medicine staff. Any prior RCR and LR exposure was noted. Participants were given a detailed surgical manuscript and technique video before the study began. Evaluation of residents was performed by staff surgeons with task-specific checklists created using a modified Delphi procedure, and the Arthroscopic Surgical Skill Evaluation Tool (ASSET). The hand movements and arthroscopic view of the procedures were recorded. Both videos were scored by a fellow blinded to the year of training of each participant. A total of 35 residents, six fellows and five staff surgeons performed both arthroscopic RCR and LR on a dry model model (48 total). The internal reliability (Cronbach's Alpha) of the test using the total ASSET score was high (>0.8)). One-way analysis of variance for the total ASSET score and the total checklist score demonstrated a difference between participants based upon year of training (p<0.05). Post hoc analysis also demonstrated a significant difference in global ratings and checklist scores between junior residents (PGY1–3) and senior residents (PGY4&5), senior residents and fellows, and fellows and staff. A good correlation was seen between the total ASSET score and prior exposure to RCR and LR. The inter-rater reliability (ICC) between the examiner ratings and the blinded assessor ratings for the total ASSET score was good (0.8). The results of this study provide evidence that the performance of a RCR and LR in a dry model is a valid and reliable method of assessing a resident's ability to perform these procedures, prior to performance in the operating room

Femoroacetabular impingement (FAI) is a common cause of hip pain in the young adult. Uncertainty regarding surgical indications, outcome assessment, management preferences and perceptions of the literature exist. We conducted a large international survey assessing the perceptions and demographics of orthopaedic surgeons regarding FAI. A survey was developed using previous literature, focus groups and a sample-to-redundancy strategy. The survey contained forty-six questions and was emailed to national orthopaedic associations and orthopaedic sports medicine societies for member responses. Members were contacted on multiple occasions to increase response rates. Nine hundred orthopaedic surgeons from twenty national and international organisations completed the survey. Surgeons responded across 6 continents, 58.2 % from developed nations with 35.4 % having sports fellowship training. North American and European surgeons reported significantly greater exposure to hip arthroscopy during residency and fellowships in comparison to international respondents (48.0% vs. 44.5% vs. 25.6% respectively; p<0.001). Surgeons performing a higher volume of FAI surgery (over 100 cases per year) were significantly more likely to have practiced for more than 20 years (OR 1.91; 95% CI 1.01 to 3.63), be practicing at an academic hospital (OR 2.25; 95% CI 1.22 to 4.15), and have formal arthroscopy training (OR 46.17; 95% CI 20.28 to 105.15). High volume surgeons were over two-fold more likely to practice in North America and Europe (OR 2.26; 95% CI: 1.08 to 4.72). The exponential rise in the diagnosis and surgical management for FAI appears to be driven largely by experienced surgeons in developed nations. Our analysis suggests that although FAI management is early in the innovation cycle we are at a tipping point towards wider uptake and utilisation. The results of this survey will help guide further research and study

INTRODUCTION. Understanding the biomechanics of the anatomical knee is vital to innovations in implant design and surgical procedures. The anterior – posterior (AP) laxity is of particular importance in terms of functional outcomes. Most of the data on stability has been obtained on the unloaded knee, which does not relate to functional knee behavior. However, some studies have shown that AP laxity decreases under compression (1) (2). This implies that while the ligaments are the primary stabilizers under low loads, other mechanisms come into play in the loaded knee. It is hypothesized this decreased laxity with compressive loads is due to the following: the meniscus, which will restrain the femur in all directions; the cartilage, which will require energy as the femur displaces across the tibial surface in a plowing fashion; and the upwards slope of the anterior medial tibial plateau, which stabilizes the knee by a gravity mechanism. It is also hypothesized that the ACL will be the primary restraint for anterior tibial translation. METHODS. A test rig was designed where shear and compressive forces could be applied and the AP and vertical displacements measured (Figure 1). The AP motion was controlled by the air bearings and motor, allowing for the accurate application of the shear force. Position and force data were measured using load cells, potentiometers, and a linear variable differential transducer. Five knee specimens less than 60 years old and without osteoarthritis (OA), were evaluated at compressive loads of 0, 250, 500, 750 N, with the knee at 15° flexion. Three cycles of shear force at ±100 N constituted a test. The intact knee was tested, followed by testing after each of the following resections: LCL, MCL, PCL, ACL, medial meniscus, and lateral meniscus. RESULTS. The average displacement of the tibia without load was 6.17 mm anterior and −4.92 mm posterior. Under load the posterior translation of the tibia was reduced essentially to zero. After ACL resection, the anterior tibial displacement increased substantially, with a further increase after medial meniscus resection. Cartilage deformation had a minimal effect. DISCUSSION. The hypotheses that the ACL and the upwards tibial slope would provide stability under load were validated. The ACL was essential under all load conditions because the posterior tibial surface was flat (figure 2). The medial meniscus provided vertical stability, as a space buffer (figure 3), and in two specimens under load it provided the same restraint as the ACL (figure 2). The experiment was limited by lack of muscle action, the number of specimens, and a single flexion angle. SIGNIFICANCE. The test rig and methodology had capabilities exceeding those of previous work in determining the mechanisms of AP knee stability under load due to its frictionless air bearings. The results have application ranging from sports medicine to total knee design. The stabilizing effect of the tibial slope seen here validates tibial osteotomies for improved stability. The importance of reproducing ACL function in total knee design is emphasized. For figures/tables, please contact authors directly.

Aims

The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery.

Anterior Cruciate Ligament (ACL) rupture is one of the commonest injuries in sports medicine. However, the rates of the reported graft re-rupture range from 2–10%, leading to around 3000 to 10000 revision ACL reconstructions in United States per annum. Inaccurate tunnel positions are considered to be one of the commonest reasons leading to failure and subsequent revision surgery. Additionally, there remains no consensus of the optimal position for ACL reconstructions. The positions of the bone tunnels in patients receiving ACL reconstruction are traditionally assessed using X-rays. It is well known that conventional X-ray is not a precise tool in assessing tunnel positions. Thus, there is a recent trend in using three-dimensional (3D) CT. However, routine CT carries a major disadvantage in terms of significant radiation hazard. In addition, it is both inconvenient and expensive to use CT as a regular assessment tools during the follow-up. The goal of the present work is to develop a novel 2D-3D registration method using single X-ray image and a surface model. By performing such registration for two post-operative X-rays, we can further calculate the 3D tunnel positions after ACL reconstructions. Our framework consists of five parts: (1) a surface model of the knee, (2) a 2D-3D registration algorithm, (3) a 3D tunnel position calculation, (4) a graphic user interface (GUI), and (5) a semi-transparency rendering. Among them, the crucial part is our 2D-3D registration method that estimates the relative position of the knee model in the imaging coordinate system. Once registered, the 3D position of an ACL tunnel in the knee model is calculated from the imaging geometry. The only interaction required is to mark the ACL tunnels on the X-rays through the GUI. We propose two 2D-3D registration methods. One is a contour-based method that uses pure geometric information. Most methods in this category accomplish the registration by extracting contours in X-rays, establishing their correspondences on the 3D model, and calculating the registration parameters. Unlike these methods, which need point-to-point correspondences, our method optimises the registration parameters in a statistical inference framework without giving or establishing point-to-point correspondences. Due to the use of the statistical inference, our method is robust to the spurs and broken contours that automatically extracted by the contour detector. The second method takes into account both the geometric shape of the object and the intensity property (intensity changes) of the image, where the intensity changes can be detected via image gradients. The use of gradient is based on the interpretation that two images are considered similar, if intensity changes occur at the same locations. The angles between the image gradients and the projected surface normals were used as a distance measure. The summation of the measures for all projected model points gives us the gradient term, which we multiply the contour-based measurement. Multiplication is preferred over addition because addition of the terms would require both terms to be normalised. To evaluate the feasibility of our methods, a simulation study was conducted using Digitally Reconstructed Radiographs (DRR) of a sawbone underwent a single-bundle ACL reconstruction performed by an experienced orthopedic surgeon. The real position of the bone tunnel entry point was obtained using the CT images, which were acquired using a custom-made well-calibrated cone-beam CT. The knee model was built by downsampling and smoothing the high-resolution CT reconstructions. It is important in our experiments to make the model different from the original reconstruction since this simulates the condition in which patient's CT is unavailable. Two DRRs generated from approximately anteroposterior and lateral viewpoints were used. For each DRR, 50 trials of 2D-3D registration were carried out for the femoral part using 50 different initialisations, which were randomly selected from the values independently and uniformly distributed within ±10 degrees and ±10 mm of the ground-truth. Compared with the ground-truth established using the CT images, our single image contour-based method achieved accurate estimations in rotations and in-plane translations, which were (−0.67±1.38, −0.98±0.84, −0.42±0.71) degrees and (0.11±0.26, −0.06±1.20) mm for the anteroposterior image, and (−0.78±0.76, −0.37±0.87, 0.70±0.88) degrees and (−0.14±0.22, 0.31±0.71) mm for the lateral one, respectively. The same experiments were also performed using the second method. However, it did not produce desirable results in our experiments. The tunnel entry point was then calculated using the averaged registration result of our contour-based method. The entry point of the tunnel was obtained with high accuracy of 1.25 mm distance error from the real position of the entry point. For the 2D-3D registration, the estimated off-plane translations showed relatively low accuracy. It is well known that the depth can be difficult to be accurately estimated using one single image. As the result showed, the accuracy in rotations and in-plane translations is more important for ACL tunnel position estimation in our framework. As for the image gradient, it is too sensitive to the small perturbation caused by image noises. A more robust way of integrating the gradient information into our contour-based method is required. We propose a novel approach for estimating the 3D position of bone tunnels in ACL reconstruction using two post-operative X-rays. It was tested in a sawbone study using DRRs. The most significant advantage of our approach is to potentially eliminate the necessity of acquiring a patient's CT. The success in developing and validating the proposed workflow will allow convenient and precise assessment of tunnel positions in ACL reconstruction with minimal risk of radiation hazard

Aims

COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic.

Aims

The purpose of our study was to determine which groups of orthopaedic providers favour virtual care, and analyze overall orthopaedic provider perceptions of virtual care. We hypothesize that providers with less clinical experience will favour virtual care, and that orthopaedic providers overall will show increased preference for virtual care during the COVID-19 pandemic and decreased preference during non-pandemic circumstances.

Aims

Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care.

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

The aim of this study is to report the 30 day COVID-19 related morbidity and mortality of patients assessed as SARS-CoV-2 negative who underwent emergency or urgent orthopaedic surgery in the NHS during the peak of the COVID-19 pandemic.

We evaluated the top 13 journals in trauma and orthopaedics by impact factor and looked at the longer-term effect regarding citations of their papers.

All 4951 papers published in these journals during 2007 and 2008 were reviewed and categorised by their type, subspecialty and super-specialty. All citations indexed through Google Scholar were reviewed to establish the rate of citation per paper at two, four and five years post-publication. The top five journals published a total of 1986 papers. Only three (0.15%) were on operative orthopaedic surgery and none were on trauma. Most (n = 1084, 54.5%) were about experimental basic science. Surgical papers had a lower rate of citation (2.18) at two years than basic science or clinical medical papers (4.68). However, by four years the rates were similar (26.57 for surgery, 30.35 for basic science/medical), which suggests that there is a considerable time lag before clinical surgical research has an impact.

We conclude that high impact journals do not address clinical research in surgery and when they do, there is a delay before such papers are cited. We suggest that a rate of citation at five years post-publication might be a more appropriate indicator of importance for papers in our specialty.

Cite this article: Bone Joint J 2014;96-B:414–19.

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and sds were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training.

Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are ‘driven’ by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes.