The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research

The role of dual consultant operating (DCO) in general orthopaedics has not been researched; where it has shown benefit in other specialties, there is a lack of information on how DCO affects the surgeons themselves. We wanted to explore the potential effects of DCO on stress, as a foundation for further research to guide support for our surgeons. We conducted a survey among orthopaedic consultants around New Zealand, containing questions pertaining to the demographics of respondents, their experience with DCO, what the expected risks and benefits of DCO would be, and provided two high-stress exemplar clinical scenarios where respondents were asked to rate their expected stress level at baseline, with a more junior consultant present, and with a more senior consultant present. We found 99% of respondents had been involved in DCO at some point in their careers, yet only 38% were involved in DCO on at least a monthly basis. Perceived benefits greatly outweighed potential risks: 95% felt DCO would decrease their stress, 91% felt it improved intraoperative decision making, and 89% felt it provided more enjoyment at work and enhanced collegiality. A decrease in perceived stress was seen from baseline with a more junior consultant available and a greater decrease in stress seen with a more senior consultant, particularly in a complex elective setting. All respondents felt there is benefit in DCO and the vast majority feel it has positive effects on stress levels. In a time where burnout is more prevalent, using tools such as DCO could be an effective way to decrease stress, enhance enjoyment and collegiality — challenging some key contributors to burnout — and support mentorship with further skill acquisition. This research provides a good base to pursue further qualitative and quantitative research into the area, with a view to addressing barriers to provision of regular DCO

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation

Introduction. A greater emphasis has been placed on fracture related infection (FRI) orthopaedic practice as a separate entity in recent years. Since the publication of the FRI consensus definition and guidelines, there has been an increase in the published literature on the topic and a move towards considering FRI as separate from general orthopaedic practice and as work that requires a more specialist approach. The aim of this study was to audit current FRI practice in the UK. Materials & Methods. Orthopaedic practice related to FRI in the UK was audited using a semi-structured questionnaire. Respondents were from a range of institutions, specialties and clinical roles to reflect the multi-disciplinary nature of treating FRI. The online tool SurveyMonkey was used to share the survey at the 2022 annual meeting of the British Limb Reconstruction Society. Twenty-one questions were asked in the following domains: scope of practice, theatre and clinic capacity, availability of the multidisciplinary team, renumeration for work and scope of FRI networks. Results. Of the 36 respondents, the majority (64%) worked in a major trauma centre. In the majority of cases, bone infection was managed by the limb reconstruction team (68%) although in most centres the wider team was often also involved including the general on call, the trauma team and the arthroplasty team. When referrals were made elsewhere, this was usually done to known individuals rather than established FRI networks. 80% of respondents said that there was a bone infection MDT in their unit and this usually met weekly. This usually included orthopaedics and microbiology but plastics in only 43% of cases and radiology in only 23% of cases. Most respondents said that the lack of funding and appropriate tariffs were the main barrier to FRI management locally (62%) and nationally (83%). Most respondents (83%) said that bone infection practice should be centralised. The overwhelming majority of this cohort (90%) said that patient outcomes would be improved by cases being managed in dedicated centres. Conclusions. There is variation in practice for the management of bone infection in the UK. This reflects the lack of clear national guidelines and the lack of established networks for management and onward referral. There is agreement that patient outcomes would be improved by more formal networks and specialised centres but also recognition that remuneration is a significant barrier to implementing change. This survey reflects practice in units with an interest in limb reconstruction and bone infection. Further work is needed to evaluate practice across district general hospitals in the UK and to build consensus around best practice and national strategies for improved care

Objective evaluations of resident performance can be difficult to simulate. A novel competency based surgical OSCE was developed to evaluate surgical skill. The goal of this study was to test the construct validity comparing previously validated Ottawa scores (O-scores) and Orthopaedic in-training evaluation scores (OITE). An OSCE designed to simulate typical general orthopaedic surgical cases was developed to evaluate resident surgical performance. Post-graduate year (PGY) 3–5 trainees have an encounter (interview and physical exam) with a standardized patient and perform a correlating surgery on a cadaver. Examiners evaluate all components of the treatment plan and provide an overall score on the OSCE and also provide an O-score on overall surgical performance. Convergent and divergent validity was assessed comparing OSCE scores to O-scores and OITE scores. SPSS was used for statistical analysis. ANOVA was used to compare PGY averages and Pearson correlation coefficients were calculated to compare OSCE versus O-score and OITE scores. A total of 96 simulated surgical cases were evaluated over a 3 year period for 24 trainees. There was a significant difference in OSCE scores based on year of training. (PGY3 − 6.06/15, PGY4 − 8.16/15 and PGY5 − 11.14/15, p < 0 .001). OSCE and O-scores demonstrated a strong positive correlation of +0.89 while OSCE and OITE scores demonstrated a moderate positive correlation of 0.68. OSCE scores demonstrated strong convergent and moderate divergent correlation. A positive trajectory based on level of training and stronger correlations with established, validated scores supports the construct validity of the novel surgical OSCE

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 . sd. s 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

Adverse events (AEs) following spine surgery are very common. It is important to monitor the incidence of AEs to ensure that appropriate practices are implemented to minimise AEs and improve patient outcomes. The Spine Adverse Events Severity System (SAVES) is a validated AE recording tool specifically designed for spine surgery and the Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) is a similar tool intended for general orthopaedic surgery. The main objective was to prospectively collect AE data from spine surgery patients using SAVES and OrthoSAVES and compare their viability and applicability for use. The longterm objective is to enhance patient safety by tracking AEs with a view towards potentially changing future healthcare practices to eliminate the risk factors for AEs. For a 10-week period in June-September 2015, three spine surgeons used SAVES to record AEs experienced by any elective spine surgery patients. In addition, a trained independent clinical reviewer with access to electronic records, medical charts, and allied health professionals (e.g. nurses, physioterhapists) used SAVES and OrthoSAVES to record AEs for the same patients. At discharge, the SAVES forms from the surgeons and SAVES and OrthoSAVES forms from the independent reviewer were collected and all AEs were recorded in a database. In 48 patients, the independent reviewer recorded a total of 45 AEs (4 intra-operative, 41 post-operative), compared to the surgeons who recorded a total of 8 AEs (2 intra-operative, 6 post-operative) (P2) were recorded by both the independent reviewer and surgeons. OrthoSAVES had the capacity to directly record 3 additional AEs that had to be included in the “Other” section on SAVES. SAVES and OrthoSAVES are valuable tools for recording AEs. Use of SAVES and OrthoSAVES has the potential to enhance patient care and safety by ensuring AEs are followed by the surgeon during their in-hospital stay and prior to discharge. Independent reviewers are more effective at capturing AEs following spine surgery, and thus, could be recruited in order to capture more AEs and maximise different complication diagnoses in alignment with proposed diagnosis-based funding models. The next step is to analyse AE data identified by the hospital discharge abstract to determine whether retrospective administrative coding can adequately record AEs compared to prospectively-collected AE data with SAVES/OrthoSAVES

To study the surgical outcome of multi-fragmentary, un-reconstructable radial head fractures managed acutely by a radial head prosthetic replacement, we retrospectively reviewed nineteen radial head fractures that were treated acutely with a radial head replacement, over a four-year period in three district general hospitals. Nineteen patients were clinically and radiologically assessed for this study. Functional assessment was performed with the Mayo elbow performance score (MEPS). No patient achieved full functional range of motion. The average range of flexion was 110° (range 80° to 120°), average extension deficit of 35° (range 30° to 45°), average pronation was 35° (range 0° to 65°), and average supination was 50° (range 30° to 85°). Complications included implant removal due to loosening (n=1), elbow stiffness (n=2), and instability (n=1), the latter case requiring a revision of the radial head prosthesis. Some degree of persistent discomfort was noticed in all cases. Five patients were tolerant of the final functional outcome. The average Mayo elbow score was 68/100 (range 55 to 80). One patient had an intra-operative fracture of the radial metaphysis during insertion of the implant. Conclusions. Radial head replacement in general orthopaedic, low volume practice failed to achieve satisfactory results. Contrary to popular belief, it is a technically demanding operation, for which surveillance should be continued for a minimum of one year. Strict indications for prosthetic replacement should be followed and implant selection has yet to be proven to make a significant positive contribution. Our review highlights the need for a stricter adherence to indications; surgery should not be under-estimated and devolved to trainees, and our understanding of the radial axis of the elbow and forearm remains relatively rudimentary

Chris Hani Baragwanath Hospital is situated in the South Western part of Johannesburg and is one of the largest acute hospitals in the world, serving a population of more than 3.5 million people. The hospital has a total of 2964 beds of which 232 beds are orthopaedic, including paediatric orthopaedics. The orthopaedic division at this tertiary level hospital comprises six units, namely; Upper Limb Trauma, Lower Limb Trauma, Spine Unit, Paediatric Orthopaedics, Sports and General Orthopaedics, and Arthroplasty/Tumour & Sepsis Unit. This review seeks to elicit the total number of patients seen with orthopaedic conditions and the spectrum thereof in and around Soweto. This is the first review of its kind done at The Chris Hani Baragwanath Hospital, Orthopaedic division, to date. Purpose:. The purpose of this audit is to identify the orthopaedic related health events that occur within the Soweto population being serviced by the Chris Hani Baragwanath Hospital, and in doing so be used as a tool to improve orthopaedic related patient care and outcomes in public health services. Method:. A retrospective review was conducted for a period of one year. This included all orthopaedic admissions, theatre cases performed, and outpatient assessments. Statistics were taken from registers incorporating OPD, Wards, Casualty and theatre. Results of the study:. For the period of the review there were more than 3000 orthopaedic admissions from the emergency unit. Theatre records show that approximately 4000 orthopaedic theatre cases were performed at Chris Hani Baragwanath Hospital. This consisted of more than 75 different types of operative procedures. The majority were hand procedures and the bulk of elective procedures were for total hip replacements. There were more than 28000 patients reviewed at the outpatients department for the year being reviewed. Conclusion:. This analysis outlines the spectrum of orthopaedics seen at Chris Hani Baragwanath Hospital, ranging from admissions to theatre cases performed. The result of which can be used to improve the quality of patient care, reduce elective procedure waiting lists, as well as be used as a tool for future research

During the development and early use of the First Generation of Universal Total Knee Replacement Instruments, those instruments supplied with the PCA knee and also available for use with the Kinematic and Total Condylar knees, David Hungerford and I noticed our imperfection in balancing some varus and valgus deformed total knee patients. We decided to start ligament tightening procedures to address this problem. I became impressed with the potential difficulty of simply grasping the medial capsular ligamentous sleeve and pulling it distally on the proximal tibia so that it could be stapled in place. I thought that use of a suture and then incorporation of that suture with a staple or screw could enhance the fixation. The tissue we were working with and are now talking about is rather thin, 1mm to 2mm, flat and broad with longitudinal fibers running in a caudad-cephalad direction. I wanted some way to grab these longitudinal fibers and exert a distal pull without having the suture material pull through. This suggested the use of a locking loop, analogous to what I had seen in my training when locking stitches were commonly used on different layers of wound closure. I developed in my head the picture of a row of locking loops and then saw the cross-over to the other side which revealed the entire structure with trailing tails. At this writing, I am uncertain of the year, but I am thinking it was 1982. Soon after that I illustrated it with OR suture thru paper and then began using it in surgery. I felt that publication would require studies of relative pull-out strength, and we added an injection study to look at possible influence of the tissue vascularity. For tensile strength we used #5 Ethibond in bovine xenograft material, stapled and sewn to wood. In summary, different from individual stitches or stapling without stitching, The K-stitch fails at the suture material and not by pulling the tissue. This statement is true when the suture reasonably matches the heft or thickness and strength of the soft tissue. Otherwise one is dealing with suture that is overpoweringly stronger than the tissues being fixed or held. Clearly this stitch has found common application in Achilles tendon repair and a wide variety of other applications. My own most common use is with re-attachment of the gluteus minimus tendon after an anterolateral total hip exposure. I imagine that this suture is used or at least known by all orthopaedic surgeons with one exception, spine surgeons. I just do not see an application in their surgery. However, some of the younger ones will know it from their general orthopaedic training. A video is shown of the technique and it is emphasised that the suture need not be used so that it loops the edge of a tendon. It may just as easily and helpfully be used on a broader surface as shown

Introduction. Our clinic has started to use MAZOR's Spine-Assist(r) robotic device in routine spinal surgery practice since 2006. The use of this system is diverse and now applicable for Vertebroplasty, Biopsy procedures and different techniques of Spinal fusion. During this time our clinic performed near 150 robotic assisted surgeries. Amongst its benefits the system allows the reduction of the duration of fluoroscopic exposure in the OR, better accuracy due to computerized assisted planning and navigation, avoidance of human caused complications and a less traumatic procedure for the patient. On the other hand, the duration of the procedure is prolonged, the wound is subdued to a longer exposure in cases of the open surgery, and the operational cost is higher and requires a good trained medical staff. Materials and Methods. In the last 2 years we have performed 56 robotic assisted Vertebroplasty procedures (research group). At the same time we have performed 44 non assisted Vertebroplasty procedures. There was a significant difference in the fluoroscopic time and subsequent exposure time to radiation between the groups: in the research group we used only an average of 3 seconds of staff fluoroscopic exposure (an average of 5 fluoroscopic images) compared to an average of 11 seconds of exposure (an average of 24 fluoroscopic images). Furthermore, we have successfully inserted more than 400 pedical screws with less than 1mm accuracy from planning, out which only 8 were misplaced. Subsequently we have also performed 16 biopsies, which were effective as CT based biopsies. The average duration of a surgical procedure without the use of the system in 1 level fusion was 82 min. With the use of the system the average time was 106 min. The operational cost with the use of the system was about 1,000 ∊ more expensive. Furthermore, the use of the system required performing of an additional CT scan with 1 mm slices, which caused an additional exposure to patient radiation. Results. Robotic assisted spinal surgery is a new and safe approach aiming to dramatically shorten the duration of fluoroscopic exposure of the staff and surgeon thus reducing the exposure to radiogenic dose. This novel procedure, promotes a better accuracy with regard to Vertebroplasty, Spinal fusion, insertion of Pedical Screws and also for biopsies procedures. We continue to broaden the usage of the robotic assisted device to other fields of spinal surgery and to general orthopaedic surgery. However, we have to resolve some issues such as cost, operation time and less fluoroscopic exposure for the patient

Introduction. The Western Infirmary/Gartnavel General Hospital orthopaedic department is geographically located next to the Beatson Oncology Centre, a specialist regional oncology unit. Pathological femoral fractures are the commonest reason for surgical intervention in patients referred from the Beatson and we have used them as a model to establish the demographic data, referral patterns, treatment results, and survival characteristics in such a group of patients. Methods. We have collected prospective data for the last 4 years on referrals from patients under the care of oncology services. Results. 52 patients with 53 pathological fractures and 2 impending pathological fractures of the femur during a 4 year period have been treated with a surgical intervention. The surgery included locked reconstruction femoral nailing, long stem hemiarthroplasty with distal locking and proximal femoral replacement with or without acetabular augmentation/reconstruction. 34 patients were female, 18 were male reflecting the most common primary diagnosis of breast carcinoma (30 patients). The mean age was 64 years (range 31 to 82). Post-operative complications include one death at 48 hours, 4 pulmonary emboli, a symptomatic DVT and one sciatic nerve palsy. No dislocations have occurred and there have been no implant failures at a mean of 1.2 years (range 2-26 months). We present survival characteristics based on primary tumour type and indicators of poor prognosis. Discussion. The benefits of timely orthopaedic intervention in patients with pathological fractures is well established and this study provides further insight to aid informed decisions and provides information on surgical provision required

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

Aims

Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays.

Aims

Calcium sulphate (CaSO₄) is a resorbable material that can be used simultaneously as filler of a dead space and as a carrier for the local application of antibiotics. Our aim was to describe the systemic exposure and the wound fluid concentrations of vancomycin in patients treated with vancomycin-loaded CaSO₄ as an adjunct to the routine therapy of bone and joint infections.

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.