Abstract. Background. Recruitment of patients to participate in Randomised control trials (RCTs) is a challenging task, especially for trauma trials in which the identification and recruitment are time-limited. Multiple strategies have been tried to improve the participation of doctors and recruitment of patients. Aim. To study the effect of a trainee advocate (trainee Principal investigator-tPI) on influencing junior doctors to take part in trials and its effect on recruitment for a multicenter prospective hip fracture RCT. Methods. A retrospective study comparing the number of junior doctors participating in trials and patients recruited before and after the introduction of informal tPI role at UHW Cardiff. Results. The target recruitment set by the central trial unit was 9/month. Excluding the research team, there were 6 trainees actively recruiting in the before period (Feb’19-July’19) in comparison with 12 in the after period (Sept’19-Feb’20). TPI had a direct influence on 9 of the 11 trainees to get involved in the trials by guidance and nudging. There were 105 eligible patients of which 62 were recruited (59% of eligible pts, 115% of target) in the before period in comparison with 102 recruited (76% of eligible pts, 189% of target) out of the 135 eligible patients in the after period. The proportion of recruitment done by the research team to that of trainees was 79%:21% in the before period in comparison with 30%:70% in the after period further improving to 15%:85% in the last 3 months. Conclusion. TPI can work alongside the PI and research team to be a valuable link person coordinating and engaging local trainees to take part in trials. This may be particularly beneficial in hospitals where there is no dedicated research team. TPI role could be formalized for many trials and can be used as a leadership & management potential building experience for trainees. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Since the emergence of the COVID-19 pandemic, the NHS has been under unprecedentedpressure. Elective surgery had ceased, and trauma surgery has decreased dramatically. Surgical training is multi-faceted and requires a specialist trainee to have a timetable which includes regular elective non-emergency operating, trauma operating and training in outpatient clinics. Consequently, training in theatre and the achievement of operative numbers and index procedures had not been possible for Trauma and Orthopaedic (T&O) specialist trainees. The Joint Committee on Surgical Training (JCST) has clear training index requirements for all T&O specialist trainees. In this study, we surveyed specialist trainees in the North West London deanery against the annual requirements set by the JCST guidelines. In addition, we retrospectively assessed the total number of trauma referrals and operations scheduled in our unit during the COVID-19 outbreak compared to that one year previously. The aim of this study is to objectively assess the effect the pandemic has on T&O specialist training. A total of 24 responses were collected from specialist trainees. The results of the survey showed 87% of trainees believed that their training had been affected. 75% of trainees felt they were not on track to meet operative numbers for the year, and 71% felt index number achievement had been affected. Trauma case numbers dropped by 20% compared to that one year previously. We recommend timely, planned and conscientious remediation for specialist trainees’ educational requirements. Specialist trainees must take responsibility for their training and use of additional educational opportunities. Clinical supervisors and training programme directors must provide additional support and guidance to achieve ARCP outcomes however in some scenarios extension of training may be necessary

Radioprotective gowns are an essential part of operating in orthopaedicse. As we are aware from the evidence, surgeons, and in particular orthopaedic surgeons, are at risk of developing chronic neck and back pain. This is likely a result of the combination of of long operations, heavy equipment, radioprotective gowns and poor ergonomic set up. Women are a minority in orthopaedics. Amongst trainees there has been an improvement with 20–25% of current trainees are women, however at consultant level this percentage is a lot lower at 5–7%. Radioprotective gowns worn by trainees are frequently not well fitted and few surgeons have access to bespoke fitted gowns. A questionnaire given to 32 trainees in the region found a significant burden of back pain in trainees and 57% of surgeons felt their gowns were not appropriately fitted. In this study every woman questioned reported back pain as a result of operating and 87% felt the gowns used exacerbated back pain, this figure was 56% in men. 80% of surgeons felt that surgeons would benefit from bespoke fitted gowns, even those that did not themselves have severe back pain. 45% of trainees felt their pain was moderate to severe. In surgery we have the responsibility to protect ourselves and our colleagues from work based injury and illness. Back pain should not be ignored as a symptom and radioprotective gowns is a good place to start. Overall the majority the gowns exacerbated their back pain during or after procedures, worse in women as described above. We can use this data and do what we can to provide trainees with a range of sizes whilst working in hospitals during their training. Anectodally women sizes were less available in the departments and we can work to improve this and reduce the burden of pain amongst surgeons

To investigate the utility of virtual reality (VR) simulators in improving surgical proficiency in Orthopaedic trainees for complex procedures and techniques. Fifteen specialty surgeons attending a London Orthopaedic training course were randomised to either the VR (n = 7) or control group (n = 8). All participants were provided a study pack comprising an application manual and instructional video for the Trochanteric Femoral Nail Advanced (TFNA) procedure. The VR group underwent additional training for TFNA using the DePuy Synthes (Johnson and Johnson) VR simulator. All surgeons were then observed applying the TFNA in a Sawbones model and assessed by a blinded senior consultant using three metrics: time to completion, 22-item procedure checklist and 5-point global assessment scale. Participant demographics for the VR and control groups were similar in context of age (mean [SD]: VR group, 31.0 [2.38] years; control group, 30.6 [2.39] years), gender (VR group, 5 [71%] men; control group, 8 [100%] men) and prior experience with TFNA (had applied TFNA as primary surgeon: VR group, 6 [86%]; control group, 7 [88%]). Although statistical significance was not reached, the VR group, on average, outperformed the control group on all three metrics. They completed the TFNA procedure faster (mean [SD]: 18.2 [2.16] minutes versus 19.78 [1.32] minutes; p<0.189), performed a greater percentage of steps correctly (79% versus 66%; p<0.189) and scored a higher percentage on the global assessment scale (75% versus 65%; p<0.232). VR simulators offer a safe and accessible means for Orthopaedic trainees to prepare for and supplement their theatre-based experience. It is vital, therefore, to review and validate novel simulation-based systems and in turn facilitate their improvement. We intend to increase our sample size and expand this preliminary study through a second upcoming surgical course for Orthopaedic trainees in London

The aim is to investigate if there is a relation between patellar height and knee flexion angle. For this purpose we retrospectively evaluated the radiographs of 500 knees presented for a variety of reasons. We measure knee flexion angle using a computer-generated goniometer. Patellar height was determined using computer generated measurement for the selected ratios, namely, the Insall–Salvati (I/S), Caton–Deschamps (C/D) and Blackburne–Peel (B/P) indices and Modified I/S Ratio. A search of an NHS hospital database was made to identify the knee x rays for patients who were below the age of forty. A senior knee surgeon (DC) supervised three trainee trauma and orthopaedics doctors (HA, JM, ES) working on this research. Measurements were made on the Insall–Salvati (I/S), Caton–Deschamps (C/D) and Blackburne–Peel (B/P) indices and Modified I/S Ratio. The team leader then categorised the experimental measurement of patients’ knee flexion angle into three groups. This categorisation was according to the extent of knee flexion. The angles were specifically, 10.1 to 20, 20.1 to 30, and 30.1 to 40 degrees of knee flexion. Out of the five-hundred at the start of the investigation, four hundred and eighteen patients were excluded because they had had either an operation on the knee or traumatic fracture that was treated conservatively

In the last years, 3d printing has progressively grown and it has reached a solid role in clinical practice. The main applications brought by 3d printing in orthopedic surgery are: preoperative planning, custom-made surgical guides, custom-made im- plants, surgical simulation, and bioprinting. The replica of the patient's anatomy, starting from the elaboration of medical volumetric images (CT, MRI, etc.), allows a progressive extremization of treatment personalization that could be tailored for every single patient. In complex cases, the generation of a 3d model of the patient's anatomy allows the surgeons to better understand the case — they can almost “touch the anatomy” —, to perform a more ac- curate preoperative planning and, in some cases, to perform device positioning before going to the surgical room (i.e. joint arthroplasty). 3d printing is also commonly used to produce surgical cutting guides, these guides are positioned intraoperatively on given landmarks to guide the surgeon to perform a specific surgical act (bone osteotomy, bone resection, implant position, etc.). In total knee arthroplasty, custom-made cutting guides have been developed to help the surgeon align the femoral and tibial components to the pre-arthritic condition with- out the use of the intramedullary femoral guide. 3d printed custom-made implants represent an emerging alternative to biological reconstructions especially after oncologic resection surgery or in case of complex arthroplasty revision surgery. Custom-made implants are designed to re- place the original shape and size of the patient's bone and they allow an extreme personalization of the treatment for every single patient. Patient-specific surgical simulation is a new frontier that promises great benefits for surgical training. a solid 3d model of the patient's anatomy can faithfully reproduce the surgical complexity of the patient and it allows to generate surgical simulators with increasing difficulty to adapt the difficulties of the course with the level of the trainees performing structured training paths: from the “simple” case to the “complex” case

Surgical training in the UK is under increasing pressure with a high demand for service provision. This raises concerns about the resultant negative impact this is having on training opportunities for surgical trainees in theatre due to a high demand for surgical procedures to be performed expediently by consultants. This is due to the assumption that trainee take significantly longer time to operate in theatre and thus result in a slow progress of theatre lists. Our study evaluated the differences in operative time between orthopaedic trainees and orthopaedic consultants, as well as provide realistic timings for each stage encompassed within the entire duration a patient is in theatre. From our trauma unit electronic theatre database, we retrospectively collected data for six Joint Committee of Surgical Training (JCST) mandatory procedures. Information collected included patients' ASA grading, total surgical time and grade of surgeons. A total of 956 procedures were reviewed: 71.8% hip procedures, 14.2% intramedullary nail fixations and 14.2% ankle fixations. 46.2% and 53.8% of the procedures were performed by consultants and trainees as first surgeon, respectively. On average, consultants were found to be 13 minutes quicker in performing the hip procedures and this difference was found to be statically significant (p < 0.05). However, trainees were found to be quicker in performing intramedullary femoral nailings and simple ankle fixations, but consultant were faster at performing intramedullary tibial nailings and complex ankle fixations. However, the differences were not found to be statistically significant (p > 0.05)

The process of gaining informed consent can be a complex and much debated pursuit, especially within a paediatric setting. The role of the trainee surgeon and its explanation to children and their families prior to an operation has not been explored from the resident surgeons' point of view. Ten face-to-face interviews were conducted with orthopaedic surgery trainees at a tertiary level paediatric hospital in Toronto, Canada. These were transcribed and subsequently thematically coded by 3 reviewers. Three main themes were identified from the interviews. 1) Surgical trainees feel their level of participation and autonomy gradually increases dependent on their observed skills and level of training. 2) Trainees feel the consent process is adequate but acknowledge it is often purposely vague with regards to their intra-operative involvement as this is often unpredictable and it avoids patient/family anxiety. 3) Trainees believe families are aware of their participation however most likely underestimate their role during operations. Trainees in surgical specialties believe their level of autonomy is variable dependent on a number of factors and that this impacts on the ability to be more specific when gaining informed consent. This must be balanced with a family's right to an appropriate understanding of their child's operation and who is performing it. It may be that further patient education regarding trainees and their role in operations would help develop a more thorough and patient centred informed consent process

Background. Visual representation help make the ever-increasing data more attractive, thought provoking and informative. In the field of surgical training, Procedure Based Assessment is a structured method of assessing surgical performance and skills of trainees in the UK and is a valuable tool for trainers in the Annual Review of Competence Progression. Trainers can view PBA's on the online-based Intercollegiate Surgical Curriculum Programme individually in a long-form format with no visual representation. Aim. To assess the effect of an originally devised EVR tool of PBA's in the context of ARCP on 10 aspects including speed of assessment, assimilation of data, ease of interpretation and identification of trainees’ weaknesses and strengths. Methodology. 1) ISCP PBA data collected for three volunteered specialty trainees (ST4, ST5 & ST6) enrolled in Warwick Trauma and Orthopaedic training programme, for a six-month period from 1st July 2013 till 31st December 2013. 2) An EVR was generated using Tableau Desktop software, and two other EVR's originally devised to visually represent the trainees’ PBA's and integrated into three interactive PDF files. 3) Twelve trainer consultants participated in a mock ARCP and rated their experience in assessing the trainee's using the new EVR method compared to the ISCP website on three surveys. 4) A mock ARCP was set up for 12 consultants. To minimise bias, six assessors were randomised into two equal groups. Groups A were asked to use the ISCP website to formulate an ARCP decision and then use the EVR interactive tool. Group B used the EVR tool followed by browsing the ISCP website. 5) Assessors rated their experience after using each method and also at the end of the mock ARCP on three surveys. Responses recorded on a Visual Analogue Scale and statistically analysed using non-parametric a two-tailed Mann Whitney U test. Results. Comparing responses to the EVR and ISCP surveys shows that users thought that using the EVR tool is more useful, accessible, easy to learn and use, time efficient and appealing. It also allowed them to better identify trainees’ areas of strengths and weaknesses and formulate a final ARCP outcome decision in relation to PBA's (p < 0.001). Strong agreement to develop the EVR tool and have incorporated into the current ISCP website have been demonstrated (p < 0.001). Comparison of total responses to the EVR and ISCP surveys between group A and group B showed no significant statistical difference. Conclusion. The project shows that Enhanced Visual Representation tool has the potential to be a positive addition to the ISCP website to improve the process of surgical training and feedback

Background. Training within surgery is changing from the traditional Halstedian apprenticeship model. There is need for objective assessment of trainees, especially their technical skills, to ensure they are safe to practice and to highlight areas for development. In addition, due to working time restrictions in both the UK and the US, theatre time is being limited for trainees, reducing their opportunities to learn such technical skills. Simulation is one adjunct to training that can be utilised to both assess trainees objectively, and provide a platform for trainees to develop their skills in a safe and controlled environment. The insertion of a dynamic hip screw (DHS) relies on complex psychomotor skills to obtain an optimal implant position. The tip-apex distance (TAD) is a measurement of this positioning, used to predict failure of the implant. These skills can be obtained away from theatre using workshop bone simulation, however this method does not utilise fluoroscopy due to the associated radiation risks. FluoroSim is a novel digital fluoroscopy simulator that can recreate digital radiographs with workshop bone simulation for the insertion of a DHS guide-wire. In this study, we present the training effect demonstrated on FluoroSim. The null hypothesis states that no difference will be present between users with different amounts of exposure to FluoroSim. Methods. Medical students were recruited from three London universities and randomised into a training (n=23) and a control (n=22) cohort. All participants watched a video explanation of the simulator and task and were blinded to their allocation. Training participants completed 10 attempts in total, 5 attempts in week one, followed by a one week wash out period, followed by 5 attempts in week 2. The control group completed a single attempt each week. For each attempt, 5 metrics were recorded; TAD, procedural time, number of radiographs, number of guide-wire retires and cut-out rate (COR). Results. No significant difference was present for any metric between the groups at baseline; randomisation had produced heterogeneous groups minimising selection bias. Intragroup training effect (comparison of initial and last attempt) was significant for all metrics in the training group (p < 0.05) but for no metrics in the control group. The intergroup training effect (comparison of training group attempt ten to control group attempt ten) was present for procedural time, number of radiographs and number of guide-wire retries (p < 0.05). Significance was not reached for TAD and COR. Conclusion. FluoroSim shows skill acquisition with repeat exposure, so the null hypothesis can be rejected. This study has demonstrated the merits of FluoroSim as a training adjunct for psychomotor skill development in a DHS setting

The Exeter Trauma Stem (ETS) is a monoblock unipolar prosthesis currently in use throughout various orthopaedic departments. It can be a useful procedure for specialty trainees in developing modern cementation techniques in hip arthroplasty. We propose that in order for this procedure to be a valid training tool that, as well as having a standardized surgical approach and operative technique, outcomes should be easily assessed and should be similar if performed by either a trainee or consultant. All ETS procedures carried out at our institution from January 2009 until September 2011 were reviewed retrospectively. Patient demographics and operative details were recorded from patient notes. Radiographic evaluation involved the Barrack cementation grading system, Dorr's criteria, stem alignment and leg length measurement. There was no significant difference in operative time between ETS performed by consultant or by specialty trainee. On postoperative x-ray, cement mantles were Barrack grade A or B in 55.6% (trainees) versus 61.9% (consultants). Stem alignment was neutral in 50% and varus in 50% of cases for trainees, versus 28.6% and 71.4% of cases for consultants. In total, 69.2 % of patients had lengthening of the operated limb with a mean increase of 10.4mm (2–25) for trainees and 9.3mm (2–18) for consultants. Both trainees and consultants can attain a good cement mantle. However, from our results stem alignment is less accurate by trainees with half being placed in varus. Our results highlight the difficulty of obtaining correct leg length positioning with the ETS with trainees and consultants having similar discrepancies. The ETS is a useful procedure for orthopaedic trainees to attain adequate skills in modern cementation techniques with similar post-operative radiographic outcomes to consultants. The tendency for trainees to be less accurate with stem positioning could be improved with supervision or careful pre-operative templating

Postgraduate training in orthopaedics has traditionally been delivered through an apprenticeship model. However, junior doctor working patterns have more recently moved away from a team based structure, potentially affecting training experience. We aimed to compare the perceived quality of training between medical students, junior non-orthopaedic trainees and orthopaedic specialty trainees. We conducted an anonymous questionnaire of all medical students and trainees rotating through our unit over 24 months. The questionnaire contained 6, 10-point Likert rating scale questions and free text responses. Results were collated and analysed according to training stage. Of 82 questionnaires distributed, 60 (73%) were completed (18 specialty registrars, 22 junior trainees and 20 medical students). Junior trainees consisted of 8 GPSTs and 14 Foundation Year (FY2) doctors, only one of whom had specifically chosen an orthopaedic placement. Median Likert rating of training experience was (1 = very poor, 10 = excellent): ST4-ST8 = 8 (range 7–9), ST1-ST3 = 7 (6–9), GPSTs/FY2s = 4 (2–5) and medical students = 8 (7–10). Further analysis of junior non-orthopaedic doctors' training experience showed that placement induction, organisation of formal teaching and opportunities for training out with formal sessions were rated as poor. However, content of delivered teaching was rated highly. Free text responses identified several barriers to training including being too busy on wards and no opportunity for protected teaching. Our study shows that junior non-orthopaedic trainees feel their training experience during orthopaedic placements is much poorer than orthopaedic trainees and medical students. Time constraints and less team based working patterns may detract from their teaching opportunities. In addition, junior doctors rotating through orthopaedic units now have a wider spectrum of career interests with heterogeneous training needs. Therefore, orthopaedic departments may need to adopt a more targeted training programme that recognises individual training needs if junior doctor training is to improve

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint. Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances

Cardiovascular disease is now the leading cause of morbidity and mortality worldwide. Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon. A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently. The intraoperative measurements were compared with their baseline readings and their stress response, assessed using the Bruce protocol. Many trends were noted in this pilot study. All of the surgeons had higher BP and HR readings on operating days compared to baseline. The physiological parameters normalised by one hour post-theatre list in all subjects. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating. We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers

Procedure Based Assessments (PBAs) are one type of Workplace Based Assessment (WBA) introduced recently to orthopaedic training in the UK. They play an increasing role in the assessment of a trainee's surgical competence. The study aims to determine the most valuable aspects of a PBA to a trainee, and the changes trainees suggest to improving the use of PBAs. A link to an online questionnaire was sent by email via the eLogbook system to all orthopaedic trainees in the UK with a National Training Number (NTN). The free text responses were coded and categorised. Analysis of results was conducted using the online survey software and Microsoft Excel. Of 668 responses, 616 met the inclusion criteria, making a response rate of 66% of all trainees with a NTN in the UK. There was a broad, representative spread of seniority and of geographical location. Trainees found the verbal feedback gained from their trainer to be most valuable (47%), followed by the assessment of competence (21%). Trainees identified the PBA form itself as the most important area for change (52.4%). This included increased numbers of PBAs (17.5%), more specific to the procedure (8.6%), more user friendly (15%), more levels of competence (4.5%) and a generic PBA (3.4%). Further suggestions included changing the role of PBAs, with 8.2% suggesting discontinuing their use entirely. Improving trainer investment in the use of PBA was also highlighted. Trainees value PBAs to gain formal feedback more than their use as evidence of competence in a procedure. There are a number of changes suggested by trainees that could improve the use and effectiveness of PBAs, and we have incorporated these into recommendations made by the British Orthopaedic Trainees’ Association, which should inform the debate on the further development of this assessment tool, and on WBAs in general

Abstract. Objectives. Hip instability following total hip arthroplasty in treatment of intracapsular neck of femur fractures is reported at 8–11%. Utilising the principle of a small articulation to minimize the problems of wear coupled with a large articulation, dual-mobility total hip arthroplasty prostheses stabilise the hip further than conventional fixed-bearing designs. The aim of this study is to compare the rate of dislocation and complication between standard fixed-bearing and dual-mobility prostheses for the treatment of intracapsular neck of femur fractures. Methods. A four-year retrospective review in a large district general hospital was completed. All cases of intracapsular neck of femur fractures treated with total hip arthroplasty were identified through the theatre logbooks. Patient's operative and clinical notes were retrospectively reviewed to collect data. Results. A total of 91 patients underwent total hip arthroplasty for intracapsular neck of femur fracture in the four-year period. 61.5% were dual-mobility design versus 28.5% had fixed-bearing implants. There were no statistical differences between patient group characteristics. Choice of implant was dependent on surgeon preference. There was a 0.0% dislocation rate in the dual-mobility group versus 8.6% in the fixed-bearing prosthesis group. All dislocations occurred in patients who underwent total hip arthroplasty with 36.0mm fixed-bearing prosthesis via posterior surgical approach. There was no statistical difference in mortality between both groups. Conclusion. There was an increasing trend of towards the use of dual-mobility prosthesis for fractured neck of femur within this department with excellent outcomes. Dual-mobility designs provide reduced dislocation rates in total hip arthroplasty in intracapsular neck of femur fractures compared to standard fixed-bearing designs at this institution. The authors recommend that all orthopaedic staff consider the use of dual-mobility prostheses in suitable patients and ensure trainees are suitably trained in use of dual-mobility designs. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Summary Statement. Uptake of robotically-assisted orthopaedic surgery may be limited by a perceived steep learning curve. We quantified the technological learning curve and 5 surgeries were found to bring operating times to appropriate levels. Implant positioning was as planned from the outset. Introduction. Compared to total knee replacement, unicondylar knee replacement (UKR) has been found to reduce recovery time as well as increase patient satisfaction and improve range of motion. However, contradictory evidence together with revision rates concern may have limited the adoption of UKR surgery. Semi-active robotically-assisted orthopaedic tools have been developed to increase the accuracy of implant position and subsequent mechanical femorotibial angle to reduce revision rates. However, the perceived learning curve associated with such systems may cause apprehension among orthopaedic surgeons and reduce the uptake of such technology. To inform this debate, we aimed to quantify the learning curve associated with the technological aspects of the NavioPFS™ (Blue Belt Technologies Inc., Pittsburgh, USA) with regards to both operation time and implant accuracy. Methods. Five junior orthopaedic trainees volunteered for the study following ethical permission. All trainees attended the same initial training session and subsequently each trainee performed 5 UKR surgeries on left-sided synthetic femurs and tibiae (model 1146–2, Sawbones-Pacific Research Laboratories Inc, Vashon, WA, USA). A few days lapsed between surgeries, which were all completed in a two week window. Replica Tornier HLS Uni Evolution femoral and tibial implants (Tornier, France) were implanted without cementation. Each surgery was videoed and timings taken for key operation phases, as well as the overall operative time. A ball point probe with four reflective spherical markers attached was used to record the position of manufactured divots on the implant, which allowed the 3D position of the implant to be compared to the planned position. Absolute translational and rotational deviations from the planned position were analysed. Results. Total surgical time decreased significantly with surgery number (p < 0.001) from an initial average of 85 minutes to 48 minutes after 5 surgeries. All stages, except the cutting tool set up, demonstrated a significant difference in operative time with increasing number of surgeries performed (all p < 0.05) with the cutting phase decreasing from 41 to 23 minutes (p < 0.001). The translational and rotational accuracy of the implants did not significantly vary with surgery number. Discussion and Conclusion. The accuracy in implant position obtained by trainee surgeons on synthetic bones were similar to published data for experienced orthopaedic surgeons on other systems on cadavers. Whilst cadaver operations increase the complexity of operation, this should not theoretically affect the robotic system in preventing innaccurate implantation. Moreover, the fact that this accuracy was obtainable on the first surgery clearly demonstrates the system's ability in ensuring accurate implantation. Five surgeries dramatically reduced the total operative time, and moreover, the trend suggests that more surgeries would further decrease the total operation time. It was not the intention of the study to compare absolute trainee times on synthetic bones to surgeons with cadavers, but the learning curve of the protocol and technology suggests a halving of the operation time after 5 sessions would not be unrealistic

Object. The aim of this study was to investigate the impact of the COVID-19 pandemic on the management and outcome of patients with neck of femur fractures. Methods. Data was collected for 96 patients with neck of femur fractures who presented to the emergency department between March 1, 2020 and May 15, 2020. This data set included information about their COVID-19 status. Parameters including inpatient complications, hospital quality measures, mortality rates, and training opportunities were compared between the COVID-19 positive and COVID-19 negative groups. Furthermore, our current cohort of patients were compared against a historical control group of 95 patients who presented with neck of femur fractures before the COVID-19 pandemic. Results. Seven (7.3%) patients were confirmed COVID positive by RT-PCR testing. The COVID positive cohort, when compared to the COVID negative cohort, had higher rates of postoperative complications (71.4% vs 25.9%), increased length of stay (30.3 days vs 12 days) and quicker time to surgery (0.7 days vs 1.3 days). The 2020 cohort compared to the 2019 cohort, had an increased 30-day mortality rate (13.5% vs 4.2%), increased number of delayed cases (25% vs 11.8%) as well as reduced training opportunities for Orthopaedic trainees to perform the surgery (51.6% vs 22.8%). Conclusions. COVID-19 has had a profound impact on the care and outcome of neck of femur fracture patients during the pandemic with an increase in 30-day mortality rate. There were profound adverse effects on patient management pathways and outcomes while also affecting training opportunities

Introduction. The transition from resident to registrar constitutes a steep learning curve in most medical practitioners’ careers, regardless of speciality. We aimed to determine whether a six-week orthopaedic surgical skills course could increase resident skills and confidence prior to transitioning to orthopaedic registrar within the Gold Coast University Hospital, Queensland, Australia. Materials. Unaccredited registrars, orthopaedic trainees, and orthopaedic consultants, through a departmental peer reviewed process and survey, developed a six-session course (“Registrar Academy”) that included basic knowledge and essential practical skills training for residents with an interest in becoming orthopaedic registrars. This course was implemented over a 3-month period and assessed. Mixed method quantitative and qualitative evidence was sought via a 14-item and 18-item Likert scale questionnaire coupled with open-ended questions. Ethical approval was granted by our institutions Human Research and Ethics Comittee, reference no.: HREC/16/QGC336. Results/Discussion. Results were qualitatively synthesised using quantitative and qualitative data. Thirteen residents participated in the course. All residents agreed to statements indicating they felt unprepared to work as an orthopaedic registrar and were not confident in performing various core tasks required. After completing the course, residents indicated greater confidence or comfort in all these areas and felt better prepared for the transition to registrar. There was broad approval of the course among participants. Every participant who completed the final questionnaire agreed or strongly agreed that they enjoyed the course and that it taught usable, reproducible practical skills and increased their orthopaedic knowledge. This group also uniformly agreed or strongly agreed that the course improved their patient care and patient safety. Conclusion. Residents feel unprepared for their transition to orthopaedic registrar and lack confidence in several core competencies. A supplemental “Registrar Academy” within an institution is an effective way to improve knowledge, confidence, and practical skills for residents wishing to transition to a registrar position