Novel immersive virtual reality (IVR) technologies are revolutionizing medical education. Virtual anatomy education using head-mounted displays allows users to interact with virtual anatomical objects, move within the virtual rooms, and interact with other virtual users. While IVR has been shown to be more effective than textbook learning and 3D computer models presented in 2D screens, the effectiveness of IVR compared to cadaveric models in anatomy education is currently unknown. In this study, we aim to compare the effectiveness of IVR with direct cadaveric bone models in teaching upper and lower limb anatomy for first-year medical students. A randomized, double-blind crossover non-inferiority trial was conducted. Participants were first-year medical students from a single University. Exclusion criteria included students who undertook prior undergraduate or graduate degrees in anatomy. In the first stage of the study, students were randomized in a 1:1 ratio to IVR or cadaveric bone groups studying upper limb skeletal anatomy. All students were then crossed over and used cadaveric bone or IVR to study lower limb skeletal anatomy. All students in both groups completed a pre-and post-intervention knowledge test. The educational content was based on the University of Toronto Medical Anatomy Curriculum. The Oculus Quest 2 Headsets (Meta Technologies) and PrecisionOS Anatomy application (PrecisionOS Technology) were utilized for the virtual reality component. The primary endpoint of the study was student performance on the pre-and post-intervention knowledge tests. We hypothesized that student performance in the IVR groups would be comparable to the cadaveric bone group. 50 first-year medical students met inclusion criteria and were computer randomized (1:1 ratio) to IVR and cadaveric bone group for upper limb skeletal anatomy education. Forty-six students attended the study, 21 completed the upper limb modules, and 19 completed the lower limb modules. Among all students, average score on the pre-intervention knowledge test was 14.6% (Standard Deviation (SD)=18.2%) and 25.0% (SD=17%) for upper and lower limbs, respectively. Percentage increase in students’ scores between pre-and post-intervention knowledge test, in the upper limb for IVR, was 15 % and 16.7% for cadaveric bones (p = 0. 2861), and for the lower limb score increase was 22.6% in the IVR and 22.5% in the cadaveric bone group (p = 0.9356). In this non-inferiority crossover randomized controlled trial, we found no significant difference between student performance in knowledge tests after using IVR or cadaveric bones. Immersive virtual reality and cadaveric bones were equally effective in skeletal anatomy education. Going forward, with advances in VR technologies and anatomy applications, we can expect to see further improvements in the effectiveness of these technologies in anatomy and surgical education. These findings have implications for medical schools having challenges in acquiring cadavers and cadaveric parts

Novel immersive virtual reality (IVR) technologies are revolutionizing medical education. Virtual anatomy education using head-mounted displays allows users to interact with virtual anatomical objects, move within the virtual rooms, and interact with other virtual users. While IVR has been shown to be more effective than textbook learning and 3D computer models presented in 2D screens, the effectiveness of IVR compared to cadaveric models in anatomy education is currently unknown. In this study, we aim to compare the effectiveness of IVR with direct cadaveric bone models in teaching upper and lower limb anatomy for first-year medical students. A randomized, double-blind crossover non-inferiority trial was conducted. Participants were first-year medical students from a single University. Exclusion criteria included students who undertook prior undergraduate or graduate degrees in anatomy. In the first stage of the study, students were randomized in a 1:1 ratio to IVR or cadaveric bone groups studying upper limb skeletal anatomy. All students were then crossed over and used cadaveric bone or IVR to study lower limb skeletal anatomy. All students in both groups completed a pre-and post-intervention knowledge test. The educational content was based on the University of Toronto Medical Anatomy Curriculum. The Oculus Quest 2 Headsets (Meta Technologies) and PrecisionOS Anatomy application (PrecisionOS Technology) were utilized for the virtual reality component. The primary endpoint of the study was student performance on the pre-and post-intervention knowledge tests. We hypothesized that student performance in the IVR groups would be comparable to the cadaveric bone group. 50 first-year medical students met inclusion criteria and were computer randomized (1:1 ratio) to IVR and cadaveric bone group for upper limb skeletal anatomy education. Forty-six students attended the study, 21 completed the upper limb modules, and 19 completed the lower limb modules. Among all students, average score on the pre-intervention knowledge test was 14.6% (Standard Deviation (SD)=18.2%) and 25.0% (SD=17%) for upper and lower limbs, respectively. Percentage increase in students’ scores between pre-and post-intervention knowledge test, in the upper limb for IVR, was 15 % and 16.7% for cadaveric bones (p = 0. 2861), and for the lower limb score increase was 22.6% in the IVR and 22.5% in the cadaveric bone group (p = 0.9356). In this non-inferiority crossover randomized controlled trial, we found no significant difference between student performance in knowledge tests after using IVR or cadaveric bones. Immersive virtual reality and cadaveric bones were equally effective in skeletal anatomy education. Going forward, with advances in VR technologies and anatomy applications, we can expect to see further improvements in the effectiveness of these technologies in anatomy and surgical education. These findings have implications for medical schools having challenges in acquiring cadavers and cadaveric parts

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

While surgeon-industry relationships in orthopaedics have a critical role in advancing techniques and patient outcomes, they also present the potential for conflict of interest (COI) and increased risk of bias in surgical education. Consequently, robust processes of disclosure and mitigation of potential COI have been adopted across educational institutions, professional societies, and specialty journals. The past years have seen marked growth in the use of online video-based surgical education platforms that are commonly used by both trainees and practicing surgeons. However, it is unclear to what extent the same COI disclosure and mitigation principles are adhered to on these platforms. Thus, the purpose of the present study was to evaluate the frequency and adequacy of potential COI disclosure on orthopaedic online video-based educational platforms. We retrospectively reviewed videos from a single, publicly-accessible online peer-to-peer orthopaedic educational video platform (VuMedi) that is used as an educational resource by a large number of orthopaedic trainees across North America. The 25 highest-viewed videos were identified for each of 6 subspecialty areas (hip reconstruction, knee reconstruction, shoulder/elbow, foot and ankle, spine and sports). A standardized case report form was developed based on the COI disclosure guidelines of the American Academy of Orthopaedic Surgery (AAOS) and the Journal of Bone and Joint Surgery. Two reviewers watched and assessed each video for presentation of any identifiable commercial products or brand names, disclosure of funding source for video, and presenter's potential conflict of interest. Additionally, presenter disclosures were cross-referenced against commercial relationships reported in the AAOS disclosure database to determine adequacy of disclosure. Any discrepancies between reviewers were resolved by consensus wherever possible, or with adjudication by a third reviewer when necessary. Out of 150 reviewed videos, only 37 (25%) included a disclosure statement of any kind. Sixty-nine (46%) videos involved the presentation of a readily identifiable commercial orthopaedic device, implant or brand. Despite this, only 13 of these (19%) included a disclosure of any kind, and only 8 were considered adequate when compared to the presenter's disclosures in the AAOS database. In contrast, 83% of the presenters of the videos included in this study reported one or more commercial relationships in the AAOS disclosure database. Videos of presentations given at conferences and/or academic meetings had significantly greater rates of disclosure as compared to those that were not (41% vs 14%; p=0.004). Similarly, disclosures associated with conference/meeting presentations had significantly greater rates of adequacy (21% vs 7%; p=0.018). Even so, less than half of the educational videos originating from a conference or meeting included a disclosure of any kind, and only about half of these were deemed adequate. No differences were seen in the rate of disclosures between orthopaedic subspecialties (p=0.791). Online orthopaedic educational videos commonly involve presentation of specific, identifiable commercial products and brands, and the large majority of presenters have existing financial relationships with potential for conflict of interest. Despite this, the overall rate of disclosure of potential conflict of interest in these educational videos is low, and many of these disclosures are incomplete or inadequate. Further work is needed to better understand the impact of this low rate of disclosure on orthopaedic education both in-training and in practice

Aging of Population – Baby Boomers, Millennials, Generation X. Burden of TJR in USA – Estimated ∼ 4 million US adults currently live with TKR (4.2% of the population aged 50 or older) – Females (4.8%); Males (3.4%). Prevalence increased with increasing age. Estimated lifetime risk of primary TKR – 7.0% for males, 9.5% for females. Changes in Resident Education – Resident Work Hour Restrictions. Changes in Fellowship Education – Presumed shortage of fellowship trained arthroplasty surgeons, BWH Data. Changes in Healthcare Paradigm – Hospital – Margin/Mission, Efficiency, Contribution Margin, Ambulatory Centers. Academic/Community Practice – Revenue Driven, Diminished Education/Research Incentive. Arthroplasty Education – Time Restraints, Surgical Volume, Exposure to Options – CR/CS TKR, Revision TKR/THR, Femoral Cementing in THR. “Mind's EYE”. CME Training/Evidence-Based Medicine. Learn Basic Principles of Arthroplasty. “Be Neither the First nor Last to Embrace a New Technology”. “Always Act in the Best Interests of Your Patient”

Aims. The COVID-19 pandemic has had a significant impact on the provision of orthopaedic care across the UK. During the pandemic orthopaedic specialist registrars were redeployed to “frontline” specialties occupying non-surgical roles. The impact of the COVID-19 pandemic on orthopaedic training in the UK is unknown. This paper sought to examine the role of orthopaedic trainees during the COVID-19 and the impact of COVID-19 pandemic on postgraduate orthopaedic education. Methods. A 42-point questionnaire was designed, validated, and disseminated via e-mail and an instant-messaging platform. Results. A total of 101 orthopaedic trainees, representing the four nations (Wales, England, Scotland, and Northern Ireland), completed the questionnaire. Overall, 23.1% (23/101) of trainees were redeployed to non-surgical roles. Of these, 73% (17/23) were redeployed to intensive treatment units (ITUs), 13% (3/23) to A/E, and 13%(3/23%) to general medicine. Of the trainees redeployed to ITU 100%, (17/17) received formal induction. Non-deployed or returning trainees had a significant reduction in sessions. In total, 42.9% (42/101) % of trainees were not timetabled into fracture clinic, 53% (53/101) of trainees had one allocated theatre list per week, and 63.8%(64/101) of trainees did not feel they obtained enough experience in the attached subspecialty and preferred repeating this. Overall, 93% (93/101) of respondents attended at least one weekly online webinar, with 79% (79/101) of trainees rating these as useful or very useful, while 95% (95/101) trainees attended online deanery teaching which was rated as more useful than online webinars (p = 0.005). Conclusion. Orthopaedic specialist trainees occupied an important role during the COVID-19 pandemic. COVID-19 has had a significant impact on orthopaedic training. It is imperative this is properly understood to ensure orthopaedic specialist trainees achieve competencies set out in the training curriculum. Cite this article: Bone Joint Open 2020;1-11:676–682

Purpose:. Total knee and hip arthroplasty is a commonly performed surgical procedure. As the population ages the numbers of these procedures are predicted to increase. Maximizing patient outcomes and decreasing healthcare delivery costs will be essential to creating a higher value U.S. healthcare system. The purpose of our study was to analyze the effect of a multidisciplinary preoperative education program (Joint Academy) on various outcomes that effect overall cost of primary hip and knee arthroplasty. Methods:. A retrospective review of 904 patients' charts that underwent primary total hip and knee arthroplasty from October 1, 2010 to September 31, 2011 at a single institution was performed. We then compared 102 patients who did not have preoperative education to 802 patients who did have preoperative education through the Joint Academy (JA). We looked at patient length of stay (LOS), discharge disposition, and internal hospital cost. Linear regression was performed on all data to look for statistical significance. Results:. We found that those patients that participated in JA had a length of stay that was 2.12 days less than those that did not participate in the Joint Academy. We also found that in the JA group, patients were 62% more likely to be discharged to home versus patients in the non-JA group. We also found that the JA group had lower internal hospital costs; with the JA group on average costing $1,493 less than the non-JA group. All referenced findings were statistically significant. Conclusion:. When looking at future global or episodic payment plans in the future all costs of care delivery will be scrutinized. To our knowledge internal hospital costs have not been evaluated in any other studies in regards to preoperative patient education. The decrease in variable costs seen at our institution with JA patients may help justify the benefit of allocating resources to preoperative patient education programs and in turn decrease the overall cost of hip and knee arthroplasty. Significance: The Joint Academy decreased patient length of stay, improved their chances of discharge to home, and decreased internal hospital costs. Multidisciplinary preoperative patient education may provide a cost efficient means to reduce overall healthcare cost and improve a patient's ability to return home more quickly

We share our experiences in designing a complete simulator prototype and provide the technological basis to determine whether an immersive medical training environment for vertebroplasty is successful. In our study, the following key research contributions were realised: (1) the effective combination of a virtual reality surgical simulator and a computerised mannequin in designing a novel training setup for medical education, and (2) based on a user-study, the quantitative evaluation through surgical workflow and crisis simulation in proving the face validity of our immersive medical training environment. Medical simulation platforms intend to assist and support surgical trainees by enhancing their skills in a virtual environment. This approach to training is consistent with an important paradigm shift in medical education that has occurred over the past decade. Surgical trainees have traditionally learned interventions on patients under the supervision of a senior physician in what is essentially an apprenticeship model. In addition to exposing patients to some risk, this tends to be a slow and inherently subjective process that lacks objective, quantitative assessment of performance. By proposing our immersive medical simulator we offer the first shared experimental platform for education researchers to design, implement, test, and compare vertebroplasty training methods. We collected feedback from two expert and two novice residents, on improving the teaching paradigm during vertebroplasty. In this way, this limits the risks of complications during the skill acquisition phase that all learners must pass through. The complete simulation environment was evaluated on a 5-pt Likert scale format: (1) strongly disagree, (2) disagree, (3) neither agree nor disagree, (4) agree, and (5) strongly agree. When assessing all aspects of the realism of the simulation environment, specifically on whether it is suitable for the training of technical skills team training, the participating surgeons gave an average score of 4.5. Additionally, we also simulated a crisis simulation. During training, the simulation instructor introduced a visualisation depicting cement extravasation into a perivertebral vein. Furthermore, the physiology of the computerised mannequin was influenced by the instructor simulating a lung embolism by gradually lowering the oxygen saturation from 98% to 80% beginning at a standardised point during the procedure. The simulation was stopped after the communication between the surgeon and the anaesthetist occurred which determined their acknowledgment that an adverse event occurred. The realism of this crisis simulation was ranked with an average score of 4.75. To our knowledge this is the first virtual reality simulator with the capacity to control the introduction of adverse events or complication yielding a wide spectrum of highly adjustable crisis simulation scenarios. Our conclusions validate the importance of incorporating surgical workflow analysis together with virtual reality, human multisensory responses, and the inclusion of real surgical instruments when considering the design of a simulation environment for medical education. The proposed training environment for individuals can be certainly extended to training medical teams

Introduction. The advent of ambulatory total joint replacements has called for measures to reduce postoperative length of stay, while improving patient function and postoperative satisfaction. This prospective, randomized trial evaluated the efficacy of one-on-one preoperative physical therapy (PT) education with a supplemental web-based PT web-portal on discharge disposition, postoperative function and patient satisfaction after total joint replacement. Materials & Methods. Between February and June 2015, 126 patients underwent unilateral total knee (n=63) or total hip arthroplasty (n=63). All patients attended a group preoperative education (preopEd) class [standard of care] and were subsequently randomized into two groups. One group received no further education as per the standard of care [control; TKA= 31; THA=32] and the other received an in-person one-on-one preoperative PT education session (preopPTEd) as well as access to a web-portal during the postoperative period [experimental; TKA=32; THA=31]. Discharge disposition was attained from hospital records. Patient satisfaction and WOMAC scores were evaluated by a series of patient administered questionnaires. Results. The group that received preopPTEd trended towards a reduction in hospital length of stay compared to the current standard of care (2.4 days vs. 2.6 days; p=0.077). However, the group that received preopPTEd met the postoperative functional discharge requirements significantly faster (1.6 days vs. 2.7 days, respectively; p<0.001) and required fewer postoperative PT visits (3.3 vs. 4.4 visits respectively; p<0.001) than those who did not. With respect to satisfaction, patients who received the preopPTEd felt they were better prepared to leave the hospital postoperatively and were overall more satisfied with their postoperative education (p<0.001 and p<0.001, respectively). The majority (69.8%) of patients who did not receive preopPTEd reported that they would have benefitted from additional preopPTEd. There were no clinically relevant improvements in the WOMAC subscores or total score between the groups. All findings were consistent in both the TKA and THA sub-groups. Conclusion. Patients who received the preopPTEd required fewer PT visits and met the postoperative functional PT discharge criteria faster than those who did not. Patients who received preopPTEd also reported being better prepared to leave the hospital after surgery and better overall satisfaction compared to the current standard of care. The one-on-one preoperative PT education session with supplemental web-portal education pathway may be an adjunct to help reduce postoperative length of stay for ambulatory total joint replacements

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

Background. Patterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described however most of the existing literature focuses on opioid naive patients. We sought to describe the effect of an educational intervention on prescribing for opioid tolerant patients. Methods. As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid tolerant patients undergoing primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA). Opioid prescribing data was standardized to mean morphine equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. Results. A total of 508 opioid tolerant patients underwent TKA and 342 opioid tolerant patients underwent THA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 (P=0.005)in TKA patients and 594 mean MME (28%) from 2,159 to 1,565 (P=0.003) in THA patients. There were no readmissions for pain control during the study period. Conclusions. This study demonstrates an educational intervention is associated with decreased opioid prescribing to opioid tolerant arthroplasty patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care. Level of Evidence. Level III, retrospective cohort study. Keywords. Primary Arthroplasty; Opioid Tolerant; Analgesics, Opioid; Practice Patterns, Physicians; Quality Improvement; Pain, Postoperative

Current fracture-clinic models, especially in the advent of reductions in junior doctors hours, may limit outpatient trainee education and patient care. We designed a new model of fracture-clinic, involving an initial consultant led case review focused on patient management and trainee education. Prospective outcomes for all new patients attending the redesigned fracture-clinic over a 3-week period in 2010 (n=240) were compared with the traditional clinic in the same period in 2009(n=296). Trainees attending the fracture clinic completed a Likert questionnaire (1 [strongly dissagree] − 5 [strongly agree]) assessing the adequacy of education, support, staff morale & standards of patient care. The percentage of cases given consultant input increased significantly from 33% in 2009 to 84% in 2010 (p< 0.0001), while the proportion of patients requiring physical review by a consultant fell by 21% (p< 0.0001). Return rates were reduced by 14.3% (p< 0.013) & utilization of the nurse lead fracture clinic improved by 10.1% (p< 0.0028). These improvements were most marked in the target group ?StR2 (24.2% & 22.3% respectively). There were significant improvements in staff perception of their education from 2 to 4.75 (p< 0.0001), provision of senior support from 2.38 to 4.5 (p=0.019), morale from 3.68 to 4.13 (p=0.0331) & their overall perception of patient care from 3.25 to 4.5 (p=0.0016). A&E staff found the new style clinic educational, practice changing & that it improved interdisciplinary relations, but did not interfere with their A&E duties. Our model of fracture-clinic redesign has significantly enhanced consultant input into patient care without additional funding. In addition, we have demonstrated increased service efficiency and significant improvements in staff support, morale and education. In the face of current economic and training challenges, we recommend this new model as a tool for enhancing patient and trainee experiences

The Accreditation Council of Graduate Medical Education (ACGME) has formalized a limit of 16 consecutive duty hours for first year and 20 hours for intermediate level trainees, while maintaining a maximum of 80 duty hours per week despite social pressure to further reduce this limit. Deterioration in cognitive and technical performance secondary to fatigue is the basis for the 16 hour rule, along with the notion that “strategic napping” be strongly encouraged for trainees that must remain for longer shifts. For more senior trainees, graduated independence and responsibility are recognized as important to prepare for the independent practice of medicine. Yet, a reduction of nearly 7000 hours, or the equivalent of 2 years of surgical education and experience, results from the 80-hour duty limitation compared to surgical training of two decades ago. The contention is that duty hours must be constrained to optimize patient safety and the learning environment, but it is unclear whether mastery of the necessary cognitive and technical competencies can be achieved in such a constricted time period. Another worrisome by-product of legislated duty hour limitations is the unintended encouragement of a “shift worker” mentality and erosion of the ethos of professionalism among trainees. Effective mentoring takes on critical importance in this challenging environment, yet productive mentoring may be counter to learned adaptive behaviours and instinctive personality traits of some accomplished surgeon educators. Fostering effective mentors in academic surgery requires us to develop behaviors that are conducive to the mentoring process. As our trainees struggle to achieve mastery of a surgical discipline within a prescribed and constricted time period, we must consider a competency-based system of surgical education rather than one that is time-defined. Likewise, the personal and professional growth of our trainees in this system, as well as the succession planning for our specialty, are dependent upon the creation of an environment conducive to effective mentoring in academic orthopaedics

Enhanced recovery programmes have improved outcomes following elective arthroplasty surgery. Most studies assess whole advanced recovery programmes. There are few studies assessing the role of patient education. We therefore assessed our outcomes. As part of our enhanced recovery programme at Wrexham Maelor Hospital, all patients are offered the chance to attend ‘joint school’, a preoperative education class. Not all patients attend these sessions allowing comparison of outcomes in these two groups using our prospectively collected database of outcome measures. Between April 2009 and March 2013, 915 patients underwent elective hip or knee arthroplasty. Revision cases were excluded, leaving 567 knee replacements, 315 hip replacements and 27 unicompartmental knee replacements. In patients undergoing knee replacement, those attending joint school had shorter length of stay (4.38 vs 4.85 days, p=0.145) and better Oxford Knee Score at 6 months (p=0.026) and two years (p=0.035). Patients undergoing total hip arthroplasty had a statistically significantly shorter length of stay (3.64 vs 4.54 days, p=0.011); increased frequency of mobilising on the day of surgery (28.1% vs 22.6%, p=0.203) and higher Oxford Hip Scores (non-significant) if they attended joint school. Our retrospective analysis demonstrates that preoperative education for patients undergoing elective total hip arthroplasty produces significantly shorter lengths of stay. There are also effects on mobilisation and outcome scores. These effects are also seen in knee arthroplasty. These results will have clinical and financial implications. Assessing cost of saved bed days alone, joint school saves the trust over £10,000 per year

Fluoroscopic guidance is common in interventional pain procedures. In spine surgery, injections are used for differential diagnosis and determination of indication for surgical treatment as well. Fluoroscopy ensures correct needle placement and accurate delivery of the drug. Also, exact documentation of the intervention performed is possible. However, besides the patient, interventional pain physicians, surgeons and other medical staff are chronically exposed to low dose scatter radiation. The long-term adverse consequences of low dose radiation exposure to the medical staff are still unclear. Especially in university hospital settings, where education of trainees is performed, fluoroscopy time and total radiation exposure are significantly higher than in private practice settings. It remains a challenge for university hospitals to reduce the fluoroscopic time while maintaining the quality of education. Multiple approaches have been made to reduce radiation exposure in fluoroscopy, including the wide spread use of pulsed fluoroscopy, or rarely used techniques like laser guided needle placement systems. The Zero-Dose-C-Arm-Navigation (ZDCAN) allows an optimal positioning of the c-arm without exposure to radiation. For training purposes, relevant anatomical structures can be highlighted for each interventional procedure, so injection needles can be best positioned next to the target area. The Zero-Dose-C-Arm-Navigation (ZDCAN) module was developed to display a radiation free preview of the expected fluoroscopic image of the spine. Using an optical tracking system and a registered 3D-spine model, the expected x-ray image is displayed in real-time as a projection of the model. Additionally, selected anatomical structures including nerve roots, facet joints, vertebral discs and the epidural space, can be displayed. A seamless integration of the ZDCAN in a c-arm system already used in clinical practice for years could be achieved. For easy use, a tool was developed allowing the admission and use of regular single-use syringes and spinal needles. Accordingly, these can be used as pointers in the sterile area, a sterilization of the whole tool after every single injection is not required. We evaluated the efficiency and accuracy of this procedure compared to conventional fluoroscopically guided interventional procedures. In sawbones of the lumbar spine, facet joint injections (N = 50), perineural injections (N = 46) and epidural injections (N = 20) were performed. Highlighting the target area in the radiation free preview model, an optimal positioning of the c-arm could be achieved even by unskilled medical staff. The desired anatomical structures could be identified easily in the x-rays taken, as they were displayed in the 3D model aside. As already seen evaluating a previous version of the ZDCAN module for the lower limb, the total number of x-ray images taken could be reduced significantly. Compared to the conventional group, the number of x-ray images required for facet joint injections could be reduced from 12.5 (±1.1) to 5.7 (±1.1), from 5.4 (±1.8) to 3.8 (±1.3) for perineural injections and from 4.1 (±0.9) to 2.1 (±0.3) for epidural injections. Total radiation time was reduced accordingly. Likewise, the mean time needed for the interventional procedure could be reduced from 168.3 s (±19.1) to 131.4 s (±16.8) for facet joint injections, was unchanged from 97.7 s (±26.0) to 104.7 s (±31.0) for perineural injections and from 60 s (±14.9) to 52 s (±7.1) for epidural injections. The ZDCAN is a powerful tool advancing conventional fluoroscopy to another level. Using the radiation free preview model, the c-arm can easily be positioned to show the desired area. The accentuated display of the target structures in the preview model makes the introduction to fluoroscopy guided interventional procedures easier. This feature might reduce the learning curve to achieve better clinical results with lower radiation dose exposure. Thus, the ZDCAN can be a tool to improve education in university hospital settings for physicians as well as for medical staff while reducing radiation dose exposure in general use

The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club. The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions. It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development

Introduction. Fractures of the distal radius are one of the most common extremity fractures encountered in A&E departments and general adult fracture clinics. Over the last 10 years the rate of operation for distal radial fractures has been steadily increasing. Staff within our unit felt that formal teaching, particularly of new medical staff, with regards to fracture reduction and appropriate cast application could result in a reduction in operation rates. Methods. Retrospective data was extracted from FORD (Fracture Outcome and Research Database). Data included: the number of fractures in a 6 month period, number of fractures undergoing ORIF in that period, fracture configuration, patient demographics, and mechanism of injury. All patients undergoing ORIF had their radiographs assessed by 2 separate reviewers. Information regarding adequate fracture reduction, adequate cast application (using Gap Index calculation), and appropriate plaster cast moulding was recorded. Formal teaching was then given to the next group of medical staff rotating through the unit, and the same data was collected prospectively for that 6 month period. Exclusion criteria included bilateral injuries, and polytrauma patients. Results. A total of 1712 distal radial fractures were treated in our unit over the 12 month period, with 71 undergoing ORIF in the first 6 months and 37 in the second 6 months. Our study found that formal teaching and education of medical staff significantly reduced the operation rate for distal radial fractures in our unit. This effect was most significant for extra-articular, dorsally angulated fractures of the distal radius. Conclusion. In today's busy hospital environment it is sometimes all too easy to overlook the training of junior medical staff, our study proves that just 1 hour of basic training at the beginning of an attachment can have significant benefits to both the unit and, more importantly, the patients

Surgeons must explain the risk of complications to prospective patients and get informed consent. If a complication that occurred was omitted in the process or given the wrong risk level, culpability of the surgeon is judged in court against what a “reasonable patient” would like to know to give or refuse consent. ObjectivesThe concept “reasonable patient” is widely used, no attempt has been made to define it objectively. We assessed insight of patients, presumed “reasonable”, about risks of certain complications after they underwent one of five orthopaedic procedures. Questionnaire was administered with procedures: femur IMN, tibia IMN, ankle ORIF, distal radius ORIF and hip arthroplasty. Four common/serious complications were chosen per procedure, and matched against life events with documented risk levels. There were 230 participants 163 males and 67 females. We found 19.1% of patients above age 40 and 33.3% with tertiary education wouldn't accept nerve injury as reported in literature. With infection risk, 18.1% above 40 and 52.9% with pre-tertiary education would not accept. All patients below 40 and 7.4% pre-tertiary education wouldn't accept the risk of death as reported. However, 37.1% above 40 and 76.9% with pre-tertiary education would accept that risk at a higher level. It is hard to predict what risk of complication a patient may accept. This study highlights that some patients will not accept risks as reported in literature, even though they need the procedure. Therefore, surgeons need to explain complications fully, so that patients knowingly accepts or refuses consent. The subset of patients who are not willing to accept any level of risk, should be the subject of another study

Introduction. With advances in mobile application, digital health is being increasingly used for remote and personalised care. Patient education, self-management and tele communication is a crucial factor in optimising outcomes. Aims. We explore the use of a smartphone app based orthopaedic care management system to deliver personalised surgical experience, monitor patient engagement and functional outcomes of patients undergoing knee arthroplasty. Results. Over a 12-month period, 124 patients listed for knee arthroplasty were offered access to the app. Average patient age was 65.4 years (range 49 to 86). 13(10.4%) patients were over 80 years. Compliance with app usage was 86.4%. Compliance with post-operative exercises increased following a message through the app. The mean Oxford knee score improved from a pre-op value of 17 to 35 at a mean follow-up of 6 months. Mean numeric rating scale pain score reduced from 7 pre-operatively to 3 at the latest follow-up. 58 patients (46.7%) used the communication feature on the app (text messages, photos, video consultations), reducing telephone calls and patient foot fall in the hospital. Patient satisfaction with the app was very high. Conclusion. We found the virtual care system to be effective in providing patient education, prehabilitation and post-operative rehabilitation along with being an effective channel of communication between patients and the hospital team. Patient satisfaction and compliance was very high