Aims. This Delphi study assessed the challenges of diagnosing soft-tissue knee injuries (STKIs) in acute settings among orthopaedic healthcare stakeholders. Methods. This modified e-Delphi study consisted of three rounds and involved 32 orthopaedic healthcare stakeholders, including physiotherapists, emergency nurse practitioners, sports medicine physicians, radiologists, orthopaedic registrars, and orthopaedic consultants. The perceived importance of diagnostic components relevant to STKIs included patient and external risk factors, clinical signs and symptoms, special clinical tests, and diagnostic imaging methods. Each round required scoring and ranking various items on a ten-point Likert scale. The items were refined as each round progressed. The study produced rankings of perceived importance across the various diagnostic components. Results. In Round 1, the study revealed widespread variability in stakeholder opinions on diagnostic components of STKIs. Round 2 identified patterns in the perceived importance of specific items within each diagnostic component. Round 3 produced rankings of perceived item importance within each diagnostic component. Noteworthy findings include the challenges associated with accurate and readily available diagnostic methods in acute care settings, the consistent acknowledgment of the importance of adopting a patient-centred approach to diagnosis, and the transition from divergent to convergent opinions between Rounds 2 and 3. Conclusion. This study highlights the potential for a paradigm shift in acute STKI diagnosis, where variability in the understanding of STKI diagnostic components may be addressed by establishing a uniform, evidence-based framework for evaluating these injuries. Cite this article: Bone Jt Open 2024;5(11):984–991

This project hoped to evaluate a new role, encompassing an in-hours registrar physician being based on the orthopaedic wards for advice, patient reviews, and patient journey optimisation. This service aimed to provide input for all patients who required them outwith the already established ortho-geriatric service. The success of this role was assessed through feedback questionnaires, as well as through the auditing of functional indicators such as the burden on the on-call orthopaedic registrar and other departments for advice from junior doctors, plus the number of medical emergencies. The survey received a total of 42 responses from various staff roles. All respondents thought the role had improved patient care or the functioning of the department. Respondents thought the role primarily enhanced patient care and safety and led to increased support for junior doctors and nursing staff. Data showed a 44% reduction in medical emergency calls since the role began. Total calls outwith the department for medical support reduced by 100% in hours and 50% out of hours when analysed over 22 days. Over a 14 day period, calls to the on-call orthopaedic registrar also reduced by 100% in hours, with no significant difference out of hours. This role has improved patient care and safety and allowed faster medical support with reduced impact on orthopaedic and general medical services. Feedback has been very positive from all staff. The major limitation is lack of 24 hour support. Next steps will include expanding the role, as well as introduction of framework for professional development

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

Orthopaedic surgery is a practical surgical specialization field, the exit exam for registrars remains written and oral. Despite logbook evaluation and surgical work-based assessments, the question remains: can registrars perform elective surgery upon qualification? In South Africa, obstacles to elective surgical training include the trauma workload, financial constraints, fellowships and the Covid pandemic. In hip and knee arthroplasty, new approaches like the direct anterior approach (DAA) and robotic-assisted knee surgery also contributed to the dilution of cases available for registrar training. There are concerns that orthopaedic registrars do not perform enough cases to achieve surgical proficiency. Review of the last 4 years of registrar logbooks in hip and knee arthroplasty surgery performed in a single tertiary academic hospital in South Africa. We included all primary total hip replacements (THR), total knee replacements (TKR) and hemiarthroplasties (HA) done for neck of femur (NOF) fractures between 1 April 2019 and 30 March 2023. Differentiation between registrar assisting, registrar performing with consultant supervision and registrar performing independent surgery was done. 990 hip arthroplasties (472 Primary THR, 216 NOF THR, 302 NOF HA) and 316 Primary TKR were performed during the study period. In primary elective THR the posterior approach was dominant and used in 76% of cases. In NOF THA the DAA was dominant used in 98% of cases. Primary TKR robotic-assisted technologies was used in 27% (n=94) cases. Registrars as the primary surgeon were the highest in NOF THA at 70% of cases and the lowest performing TKR at 25%. During 3-month rotations, an average registrar performed 12 (2 TKR and 10 THR) and assisted in 35 (10 TKR and 25 THR) cases. Despite the large number of arthroplasties operations being performed over the last 4-year period, the surgical cases done by registrars are below, the proposed minimal cases to provide surgical proficiency during their training period

Alcohol hand rubs, endorsed by WHO and NICE guidelines, are integral to modern surgical practices. Our objective was to assess how different scrubbing methods impact overall water usage by the surgical team, shedding light on variations among team members and their environmental implications. Over three consecutive arthroplasty lists spanning a week, water usage during scrubbing was observed for the operating team. Blinding all team members, including the anesthetist, consultant surgeon, orthopaedic registrar, orthopaedic SHO, and scrub nurse, during water usage calculations was implemented. Automated taps, using motion sensors, posed a challenge due to variable water quantity, necessitating water flow calculations per sensor movement. The senior surgeon, with over 20 years of experience, follows a traditional approach, starting with a morning prescrub and using an alcohol tub for each case, except when hands are soiled. We observed a total of 14 cases of lower limb primary arthroplasty. The cumulative water usage for scrubbing by the entire team was 193 liters, yielding a mean of 13.8 liters (±1.85) per case. The anaesthetist demonstrated the most conservative water usage, utilizing a total of 11.85 liters with a mean of 0.84 liters per case. Notably, alcohol rub was employed for half of the observed time, contributing to this efficient use. The senior operating surgeon used a total of 15.6 liters, averaging 1.1 liters per case. In contrast, the SHO and the registrar exhibited the highest water consumption, totaling 121.6 liters and yielding a mean of 5.7 liters per case. The nurses’ collective water usage for scrubbing amounted to 44.8 liters. Adopting alcohol rub, as endorsed by WHO, results in a remarkable 10-fold reduction in water usage, aligning with global health guidelines. This highlights significant potential for resource conservation in surgical procedures, presenting a practical and environmentally conscious approach to surgical scrubbing practices

Introduction. The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison. Methods. Patients over the age of 16 years undergoing an elbow CT scan within one week of a documented elbow dislocation between 1st June 2010 and 1st June 2014 were included in the study. Three orthopaedic registrars independently reviewed both the initial dislocation and immediate post reduction plain radiographs to identify any associated bony injuries. This radiograph review was repeated by each registrar after two weeks. The incidence of associated injuries as well as the inter- and intra-observer variability was calculated. Results. 28 patients were included in the study. 54% of the patients were female and the mean age was 45 years (range 16 to 90 years). The incidence of a radial head fracture was 54%, coronoid fracture 43% and epicondyle avulsion 18% on CT. The inter-observer reliability was only shown to be fair amongst registrars and the intra-observer variability moderate. Conclusions. Computerised tomography is a useful adjunct in the assessment of associated osseous injuries following an elbow dislocation due to the presence of a high number of injuries. Plain radiographs alone have been shown to have only a fair and moderate inter and intra-observer variability respectively, therefore a low threshold to obtain further 3D imaging should be practised. Level of Evidence. IV

Frequently, radiological data is transferred verbally between ED/GP/LMO to the Orthopaedic registrar. Given the different medical backgrounds and presentation skills there is often a limit to the verbal description of the radiographs. The aim of this study is to determine the feasibility and benefits of concurrently using picture messaging of X-rays to enhance communication between ED and Orthopaedic Registrars to optimise patient care. The X-rays of 40 patients referred to orthopaedics OPD or admitted from the ED were photographed and retrospectively reviewed on a mobile phone screen (240 × 320) by an orthopaedic registrar along with a printout of the patient history and verbal description of the x-ray as interpreted by the ED staff. No further information was provided to the registrar. A questionnaire was completed to subjectively and objectively evaluate the therapeutic benefit of the image review. Patient(tm)s management was compared to management plans after image review and differences were attributed to the visual inspection of the x-rays on the mobile phone. Concurrent to the retrospective review, the ED is currently trialling this with a Sony-Erickson K750i. After hours orthopaedic cases are sent via MMS to the registrar prior to consultation. In the emergency department, 10% of patients who presented with a fracture were reviewed in person by an orthopaedics registrar and none were admitted straight from ED whilst two were admitted following review at the OPD. X-rays of 40 patients were reviewed in this study. Twenty-seven patients presented with a fracture and four with islocations. When the clinical data was reviewed alongside images of x-rays by an orthopaedic registrar, a difference in management plans were observed in 25% of cases and 7.5% where surgical intervention would yield a better result. Twenty-six of the twenty-seven fractures and four dislocations were successfully visualised on the MMS. In 18 cases, picture messaging provided additional information compared to verbal report alone. The limiting factor in picture messaging was the resolution and size of the radiograph. Ease of operation and portability was found to be satisfactory by both ED and Orthopaedic staff. Equipping the ED with the phone has enhanced communication with the orthopaedics department and increased the potential for optimising patient care. This will be formally assessed through questionnaires after 12 months trial of the phone. Picture messaging is an inexpensive way of utilising technical advancements to improve patient care. Consistent with current literature, the quality of images was not sufficient as a diagnostic tool but rather a screening tool. Picture messaging is valuable practically and educationally and enhances the consultation and teaching process whilst encompassing medical staff who have limited skills in radiological description

The regenerative potential of bone is enormous, and it is possible to lengthen limbs by bone distraction. However, there remains a major risk of fracture after lengthening the bone. Previous studies have described how the pixel value ratio may be used for determining the time for frame removal. The aim of this study was to investigate the intrarater and the interrater reliability of pixel value scores from radiographs in tibial lengthening prior to frame removal. Moreover, the study aimed to determine the overall number of X- rays obtained during circular frame treatment. Retrospective study. Patients treated with tibial lengthening by a circular frame at Aalborg University Hospital from January 1st 2000 to December 31st 2017 and a minimum of 12 months after frame removal were included. The bone was divided in proximal-, regenerate- and distal bone zone. These 3 zones were in AP x-ray divided in an anterior and posterior zone and in sagittal X-ray medial and lateral zone producing 6 zones in which the pixel value was measured. Pixel value ratio was calculated as: (Proximal pixel value+Distal pixel value)/2/Regenerate pixel value. Interrater correlations were calculated from measurements obtained by an orthopaedic registrar and an orthopaedic specialist. Intrarater correlation was calculated from repeated measurements obtained by an orthopaedic specialist. Mean duration of circular frame treatment was: 6 (+-3) months. Median number of x-ray controls during frame treatment were: 9 (+-4). Out of 90 tibial lengthening it was only possible to measure pixel value in all six areas of interest on 20 lengthening prior to frame removal. Major reasons for inability to obtain measurements were metal hardware crossing the areas of bone interest on x-rays. The mean (95 % confidence intervals) pixel ratios values were: 1) lateral: 0.96 (0.93–1.00); 2) medial: 0.95 (0.92–0.99); 3) anterior: 0.94 (0.90–0.97); 4) posterior: 0.96 (0.93–0.99). The mean (95 % confidence intervals) inter ratter ICC estimates were: 1) lateral: 0.8 (0.5–0.9); 2) medial: 0.8 (0.4–0.9); 3) anterior: 0.4 (−0.5–0.8); 4) posterior: 0.6 (0.1–0.9). The mean (95 % confidence intervals) intra ratter ICC estimates were: 1) lateral: 1.0 (0.9–1.0); 2) medial: 1.0 (1.0–1.0); 3) anterior: 0.9 (0.9–1.0); 4) posterior: 1.0 (1.0–1.0). Out of the 20 lengthening examined one fracture occurred in the bone regenerate after frame removal. Prospective studies are warranted to determine whether the pixel value ratio can be used as an indicator for frame removal

Aim: To describe a radiographic biomechanical classification of tibial plateau fractures which dictates treatment. To compare the intra- and interobserver reliability and reproducibility of this, the Chertsey (C1-3) classification, and the Schatzker (SK1-6) classification. Method: This classification system has been used at this institution for 8 years by the orthopaedic trauma consultants and consists of C1 – valgus fractures, C2 – Varus fractures and C3 axial fractures. Our treatment regime is based on this classification and results presented in a sperate study. These consultants were excluded from the study on reliability and reproducibility. 2 Orthopaedic consultants, 2 orthopaedic registrars and 2 radiologists were selected randomly to classify 30 sets of AP and Lateral radiographs, of randomly selected patients treated in this institution with tibial plateau fractures, consisting of 9 SK1-3/C1, 8 SK4/C2 and 13 SK5,6/C3 fractures, and again with the same radiographs in a random order 1 month later. Radiographs of fractures treated conservatively were excluded. Statistical analysis included Kappa concordance according to Landis and Koch, and the Mann-Whitney U test. Results: The Schatzker system was only moderately reliable (K=0.66), and the Chertsey classification system significantly more reliable (K=0.82) (p=0.03) with regards to interobserver reliability. Excellent reproducibility (intra-observer reliability) was seen amongst all observers. The consultant orthopaedic surgeons were significantly more reliable than the radiologists, but not the orthopaedic registrars. No particular fracture type in any classification proved to be significantly more difficult to classify. Conclusion: We present a classification used in our institution based on plain radiographs, which depicts investigations and treatment. The Chertsey classification is significantly more reliable between observers than the Schatzker classification and is reproducible

Computer assisted total knee arthroplasty helps in accurate and reproducible implant positioning, bony alignment, and soft-tissue balancing which are important for the success of the procedure. In TKR, there are two surgical techniques one is measured resection in which bony landmarks are used to guide the bone cuts and the other is gap balancing which equal collateral ligament tension in flexion and extension is done before and as a guide to final bone cuts. Both these procedures have their own advantages and disadvantages. We retrospectively collected the data of 128 consecutive patients who underwent computer-assisted primary TKA using either a gap-balancing technique or measured resection technique. All the operations were performed by a single surgeon using computer navigation system available during a period between June 2016 to October 2016. Inclusion criteria were all patients requiring a primary TKA, male or female patients, and who have given informed consent for participation in the study. All patients requiring revision surgery of a previous implanted TKA or affected by active infection or malignancy, who presented hip ankylosis or arthrodesis, neurological deficit or bone loss or necessity of more constrained implants were excluded from the study. Two groups measured resection and gap balancing was randomly selected. At 1-year follow-up, patients were assessed by a single orthopaedic registrar blinded to the type of surgery using the Knee Society score (KSS) and functional Knee Society score (FKSS). Outcomes of the 2 groups were compared using the paired t test. All the obtained data were analysed. Statistical analysis was performed using SPSS 11.5 statistical software (SPSS Inc. Chicago). Inter-class correlation coefficient (ICC) and paired t-test were used and statistical significance was set at P = 0.05. In the measured resection group, the mean FKSS increased from 48.8769 (SD, 2.3576), to 88.5692 (SD, 2.7178) respectively. In the gap balancing group, the respective scores increased from 48.9333 (SD, 3.6577) to 89.2133(SD, 7.377). Preoperative and Postoperative increases in the respective scores were slightly better with the gap balancing technique; the respective p values were 0.8493 and 0.1045. The primary goal of TKA is restoration of mechanical axis and soft-tissue balance. Improper restoration leads to poor functional outcome and premature prosthesis loosening. Computer navigation enables precise femoral and tibial cuts and controlled soft-tissue release. Well balanced and well aligned knee is important for good results. Mechanical alignment and soft-tissue balance are interlinked and corrected by soft tissue releases and precise proximal tibial and distal femoral cuts. The 2 common techniques used are measured resection and gap balancing techniques. In our study, knee scores of the 2 groups at 1-year follow-up were compared, as most of the improvement occurs within one year, with very little subsequent improvement. Some surgeons favour gap balancing technique, as it provides more consistent soft-tissue tension in TKA

Aims

The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

Paediatric distal radial and forearm fractures account for 37.4% of all fractures in children. We present our 2.5-year results of a novel safe approach to the treatment of simple distal radial and diaphyseal fractures using intranasal diamorphine and entonox in a designated fracture reduction room in the emergency department. All simple fractures of the distal radius and forearm admitted to our ED between March 2012 and August 2014 that could be reduced using simple manipulation techniques were included in this study. These included angulated diaphyseal fractures of the forearm, angulated metaphyseal fractures of the distal radius and Salter Harris types I and II without significant shortening. All children included were given intranasal diamorphine as well as entonox. The orthopaedic registrar on call performed all reductions. 100 children had their distal radius or forearm fracture reduced in the emergency department using entonox and diamorphine analgesia and had a same day discharge. Average age was 10 years (range 2.20–16.37 years). No complications were reported regarding the use of the analgesia and all children and parents were pleased with their treatment not requiring a hospital admission. The mean initial dorsal angulation of all fracture types was 28.05° degrees (23.91–32.23 95% CI) which was reduced to 7.03° (5.11–8.95 95% CI) post manipulation. There were 9 cases lost to follow up. Two cases lost the initial reduction of the fracture on subsequent clinic follow up and underwent internal fixation in theatre. The use of entonox and intranasal diamorphine is a safe, effective treatment of providing adequate analgesia for children with distal radial and forearm fractures to allow manipulation of displaced dorsally angulated fractures in the emergency department. By facilitating a same day discharge, over £45,000 was saved using this safe method of treatment

Purpose of Study. To investigate the level of Orthopaedic Residents' knowledge of safety techniques in the procedures involving the use of C-arm. Methods. A survey of evidence based questions regarding safety techniques in the use of C-arm was administered to 58 Orthopaedic Residents from three major tertiary hospitals. Results. Of the 58 questionnaires administered, 42 usable questionnaires were returned (a 72.4% response rate). Only 33% of orthopaedic residents have received some form of formal training on safety techniques in the use of a C-arm. 95% of orthopaedic residents protect themselves with a lead apron in every case that that involves the use of a C- arm. 62% of residents do not know that scattered radiation is as harmful as direct radiation. Conclusion. Most orthopaedic residents believe that they are responsible for their own safety, as well as, the safety of their patients and the theatre staff during procedures that involve the use of c-arm. A majority of orthopaedic residents however, lack the detailed knowledge of the safety techniques in the use a C-arm. This knowledge gap may lead to unnecessary exposure to ionising radiation. We therefore, propose a mandatory training on “ionising radiation and safety techniques” for orthopaedic registrars. NO DISCLOSURES

Background. The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. Purpose of Study. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics. Methods. Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis. Results. 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers. Conclusion. Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics. NO DISCLOSURES

The safe and effective management of orthopaedic patients out of hours requires the communication of radiographs between junior residents and their non-resident seniors. Despite stringent guidelines issued by the Caldecott Guardian on the transmission of patient sensitive data, there is no data describing actual exchanges in the literature. The objective was t describe current trends in the transmission of patient sensitive data between resident Orthopaedic juniors and their non-resident seniors out of hours. The method was a Questionnaire survey polling Orthopaedic registrars in North London. Seventy-six (76) trainees participated in the survey. Fifty Three (53) trainees received radiographs for review off site. Forty-eight (48) reported receiving patient radiographs for review to their personal email account. 48% of these trainees reported that the images contained patient sensitive information. 40% of the trainees who received images to their personal email had a NHS mail account which was not used. Remote access to patient radiographs improves patient management out of hours. Although there is some awareness of Caldecott guidelines for the handling of patient sensitive electronic data, compliance is extremely poor. We recommend that all trainees who routinely handle patient sensitive data remotely acquire a free NHS mail account for receiving patient radiographs

Purpose:. Paediatric forearm fractures are commonly seen and treated by closed reduction and plaster cast application in theatre. Historically, cast application has been subjectively evaluated for its adequacy in maintaining fracture reduction. More recently emphasis has been placed on objectively evaluating the adequacy of cast application using indicators such as the Canterbury index (CI). The CI has been used in predicting post-reduction, re-displacement risk of patients by expressing the casting and padding indices as a ratio. The CI has been criticized for not including cast 3 point pressure, fracture personality and lack of standardization of X-ray views as well as practical requirement of physical measurement using rulers. The aim of this study was to determine whether subjective evaluation of these indices, on intra-operative fluoroscopy and the day 1 to 7 postoperative X-ray, was accurate in predicting a patient's ultimate risk of re-displacement, following reduction and casting. Materials and Methods:. In total, 22 X-rays from 11 patients were evaluated by 20 orthopaedic registrars and 8 consultants, before and after a tutorial on the Canterbury index. Results:. Formal tutorial did not show an increased subjective predictive accuracy. No clear correlation could be demonstrated between CI and the clinical outcome. Conclusion:. Value of the CI in clinical practice is doubtful due to various confounding factors. The CI has been used due to lack of other available systems, and ideally a system should be sought which incorporates fracture personality, cast 3 point pressure and standardisation of X-Rays

Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

Aims

Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.