The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe.

Background

Previous research in people with musculoskeletal low back pain (MLBP) in primary care shows that a reliable and valid measure of consultation-based reassurance enables testing reassurance against patient' outcomes. Little is known about the role of reassurance in people with MLBP consulting spinal surgeons, especially in cases where surgeons recommend not to have surgery. There might be several reasons to exclude surgery as a treatment option, that range from positive messages about symptoms resolving to negative messages, suggesting that all reasonable avenue of treatment have been exhausted.

AIM to explore patient's experience of consultation-based reassurance in people with MLBP who have been recently advised not to have surgery.

Patients with neurogenic claudication from lumbar canal stenosis non-responsive to non-surgical treatment are usually managed with spinal decompression with or without fusion. Flexion at stenotic segments relieves symptoms by increasing canal cross-sectional area, intervertebral foraminal height. Interspinous spacers work by causing flexion at the treated segement. We used COFLEX¯ [Paradigm Spine] a titanium interspinous spacer along with interlaminar decompression where indicated.

To compare the clinical and radiological results of patients undergoing interlaminar decompression with or without use of COFLEX¯.

Pre and post-operative assessment and comparison of clinical outcomes of Oswestry disability index(ODI), Visual analog Scale(VAS), Short Form-36(SF-36) and radiological outcomes of disc heights of operated and adjacent levels, intervertebral foraminal heights, sagittal angles of the operated segment.

All consecutive patients undergoing spinal decompression at one or more levels from Jan to Dec 2008 were included. Patients with clinically symptomatic back pain for a duration longer than claudication pain were offered interspinous spacer at L4/5 level or above.

In first group(n-20), patients were treated with inter-laminar decompression and COFLEX¯ with a standard posterior approach. In second group(n-25) inter-laminar decompression for the involved segment was performed. All patients are on follow-up.

Clinical and radiological outcomes were compared at 6 months and 1 year.

Statistically significant(p<0.001) improvements in ODI, VAS(back), VAS(leg) and SF-36 in patients in whom COFLEX¯ was used. Radiological parameters also showed significant improvements(p<0.05).

Use of COFLEX¯ spacer is justified in patients with symptomatic disc degeneration with neurogenic claudication when treated operatively.

Introduction

Displaced distal radius fractures in children have been treated in above elbow plaster casts since the last century. Cast index has been calculated previously, which is a measure of the sagittal cast width divided by the coronal cast width measurement at the fracture site. This indicates how well the cast was moulded to the contours of the forearm. We retrospectively analysed the cast index in post manipulation radiographs to evaluate its relevance in redisplacement or reangulation of distal forearm fractures.

There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p < 0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients.

Recent reports suggest that long-term alendronate therapy may result in an unusual pattern of femoral subtrochanteric fracture. We aimed to determine if the presence of a specific radiographic feature in patients on alendronate could be used to predict an impending insufficiency fracture and thereby prevent its occurrence through further investigations and prophylactic fixation in high-risk patients.

Sixty-two subtrochanteric fractures treated surgically from 2001 to 2007 were reviewed and radiographs of 25 low-energy fractures were independently evaluated. Incidence of alendronate therapy, clinical data, and other investigations like bone mineral density (BMD) scans were recorded.

Seventeen fractures (68%) were associated with alendronate therapy. Hypertrophy of the lateral cortex of the femur with splaying of the fracture ends was noted in 70.1% of patients on alendronate; initial radiographs were not available in 17.6% and 11.8% had stress fractures identified by bone scan. None of the fractures in the non-alendronate group had this pattern. The fracture configuration in the alendronate group suggested that an ellipsoid thickening in the lateral cortex had been present prior to fracture. Indeed, 6 patients on alendronate (35.3%) had pre-existing radiographs as early as 3 years prior to fracture and all had this feature. Four of them had bone scans, which confirmed a stress fracture. Hip pain was often associated with this radiographic sign but may not be specific as patients were already on follow-up for other musculoskeletal conditions. BMD scans were not predictive of an impending fracture as they were mostly in the osteopaenic range. Only 50% with proven stress fractures had prophylactic fixation, while the remainder sustained overt fractures.

Alendronate-related subtrochanteric fractures are associated with a specific pre-existing radiographic abnormality. We recommend that all patients on long-term alendronate - particularly those with hip pain or a previous subtrochanteric fracture - be routinely followed-up with plain radiographs of the pelvis. If an ellipsoid feature is noted in the subtrochanteric region, further investigations like bone scan or MRI should be sought. Patients with evidence of stress fracture should be strongly considered for prophylactic operative fixation. We believe this is a cost-effective strategy to prevent subtrochanteric insufficiency fractures in patients on alendronate.

We report the outcome of 135 knees with medial compartment osteoarthritis treated by Oxford meniscal-bearing unicompartmental arthroplasty. They have been performed in a Distict General hospital by a single surgeon. All the knees had an intact anterior cruciate ligament, a correctable varus deformity and the lateral compartment was uninvolved or had minor osteoarthritic changes. At review 29 knees were in patients who had died and 106 were in those who were still living. The mean elapsed time since operation was 5.82 years (range 2–12 yrs).

Using revision as the end point the outcome for every knee was established. Five knees have been revised, giving a cumulative prosthetic survival rate at ten years of 94.04% (95% confidence interval 84.0 to 97.8). The causes for revision were aseptic loosening in three, progressive valgus deformity in one and dislocation of the bearing in one. Knee rating and patient function were assessed using the modified Knee Society Scoring system. The mean Knee score was 92.2 (51–100), and mean Functional score was 76.2 (51–100). 90% of the patients did not require blood transfusion. Two patients had deep vein thrombosis and three knees had superficial wound infection that responded to antibiotics. Intraoperatively, one patient had fracture of the proximal tibia which was fixed with two partially threaded cancellous screws.

92% of patients were fully satisfied with the procedure and 91% of them said that they would undergo a similar procedure in the opposite knee.

The implant survival is comparable to that reported by the designers of the prosthesis and not significantly different from those for total knee replacement. Uni-compartmental knee replacement with all its advantages offers a viable alternative in patients with medial gonarthrosis. Appropriate patient selection and good surgical technique are the key factors.

We report the outcome of 135 knees with anteromedial osteoarthritis in which the Oxford meniscal-bearing unicompartmental arthroplasty was inserted in a district general hospital by a single surgeon. All the knees had an intact anterior cruciate ligament, a correctable varus deformity and the lateral compartment was uninvolved or had only minor osteoarthritis. The mean follow-up was 5.82 years (2 to 12).

Using revision as the end-point, the outcome for every knee was established. Five knees have been revised giving a cumulative rate of survival of the prosthesis at ten years of 94.04% (95% confidence interval 84.0 to 97.8). Knee rating and patient function were assessed using the modified Knee Society scoring system. The mean knee score was 92.2 (51 to 100) and the mean functional score 76.2 (51 to 100).

The survival of the implant is comparable to that reported by the designers of the prosthesis and not significantly different from that for total knee replacement. Unicompartmental knee replacement offers a viable alternative in patients with medial osteoarthritis. Appropriate selection of patients and good surgical technique are the key factors.

Aims: To evaluate the outcome of 135 Oxford Unicompartmental Knee replacements with regards to knee function and implant survival. Methods: 135 Oxford unicompartmental knee replacements were performed by a single surgeon between 1989–2000. Indication was anteromedial knee osteoarthritis with a correctable varus deformity and intact anterior cruciate ligament. The patients were evaluated in clinic both clinically & radiologically. Modiþed Knee Society Score was used to evaluate knee function. X-rays were performed to look for implant loosening and progression of arthritis. Results: 29 patients died and 5 were too ill to attend clinic. A total of 5 revisions were carried out. There were 53 male and 43 females. 74% patients were betweem 60 Ð 80 yrs. Follow up ranged from 1–11 yrs with a mean follow up of 5.2 yrs. 88% patients had range of movement of more than 105 degrees. The mean Total Knee Score was 92 and the mean functional knee score was 76. Blood transfusion was not necessary in 90% of patients. Superþcial wound infection was noted in 2 cases and hematoma formation in 4 cases. Tibial component loosening was the cause for revision. Conclusions: 1. With appropriate patient selection Oxford unicompartmental knee is a reliable treatment option for anteromedial osteoarthritis of the knee. 2. It offers long term relief of symptoms and good knee function in a high percentage of cases. 3. Implant survival is comparable to total knee replacement and to the series reported by the designers.

Many surgical approaches at decompression have been attempted for the thoracic outlet syndrome (TOS), but only the transaxillary and supraclavicular routes carry the best outcomes. More recently, a selective and tailored approach via the supraclavicular route has been favoured. We performed a retrospective review between 1978 and 1998, and report the outcome of the ‘’two surgeon approach’’ for TOS via the supraclavicular method.

An orthopaedic and vascular surgeon jointly conducted 30 operations for disabling symptoms relating to TOS in 27 patients (21F, 6M), mean age of 29 yrs (range 18–63 yrs), having performed the preoperative assessment in conjunction with a neurologist. In all cases, it was essential that patient selection for surgery was determined on clinical grounds rather than the presence of a cervical rib. Anterior scalenectomy was performed via the supraclavicular route except in one case where the infraclavicular route was utilised. Additional surgical procedures were carried out according to the underlying abnormalities, i.e. excision of cervical rib or band or medial scalenectomy. The first rib was always spared.

At mean follow-up of 37 mths (range 3-228 mths), 26/30 sides (87%) had excellent or good results. The results were fair or poor in three cases where scalenec-tomy alone was performed. There were no major complications and no patients required a re-operation. 24 patients (89%) returned to their previous lifestyle or occupation.

Our results suggest that, with a multidisciplinary assessment and two-surgeon team, good to excellent surgical outcomes can be achieved via the supraclavicular route without resection of the first rib. Instead of the current practise of routine transaxillary first rib resection, we recommend decompression via this approach with further procedures tailored to the abnormality identified.

In a prospective study of 14 patients undergoing total hip replacement we have used dual-energy X-ray absorptiometry (DEXA) to investigate remodelling of the bone around two different designs of cementless femoral prosthesis. The bone mineral density (BMD) was measured at 12-weekly intervals for a year. Eight patients (group A) had a stiff, collarless implant and six (group B) a flexible isoelastic implant.

Patients in group A showed a decrease in BMD from 14 weeks after operation. By 12 months, the mean loss in BMD was 27%, both medially and laterally to the proximal part of the implant. Those in group B showed an overall increase in BMD which reached a mean of 12.6% on the lateral side of the distal portion of the implant.

Our results support the current concepts of the effects of stem stiffness and flexibility on periprosthetic remodelling.

We performed a prospective randomised controlled trial of a new mechanical method of prophylaxis for venous thrombo-embolism in 60 patients undergoing knee replacement surgery. The method uses the A-V Impulse System to produce cyclical compression of the venous reservoir of the foot. The overall incidence of deep-vein thrombosis was 68.7% in patients receiving no prophylaxis and 50% in those using the device. The difference was not significant. There was, however, a reduction of the extent of thrombosis in the treated group. There were 13 major calf-vein thrombi and six proximal-vein thrombi in the control group compared with only five major calf-vein thrombi in the treated group. This difference was significant (p = 0.014). No patient developed clinical features of a pulmonary embolism.

A lesion similar to that described by Bankart in recurrent dislocation of the shoulder was seen in seven patients with recurrent dislocation of the peroneal tendons. Detachment of the periosteum had resulted in the formation of a false pouch on the surface of the lower end of the fibula; into this pouch the peroneal tendons could easily dislocate. Reattachment of the periosteum to drill holes in the fibula prevented dislocation, and this anatomical method of repair is described. This lesion is one of the causes of recurrent dislocation of the peroneal tendons.

The joint surfaces of 60 hips obtained from the cadavers of elderly Asians were studied to determine the incidence, the grade and the distribution of both non-progressive (age-related) and progressive degenerative changes. It was observed that in the Asian population of 40 to 90 years of age, non-progressive changes were common, being seen in 66% of the acetabular specimens and 50% of the femoral heads. Only one specimen of the 60 showed unexplained progressive degenerative change. We conclude that primary osteoarthritis of the hip is rare in Asians.

Four patients with lumbosacral fracture-dislocation are presented. The common mechanism of injury was hyperflexion with compression. A rotational element may be implicated in single facet dislocation. Although lumbosacral fracture-dislocations can be managed conservatively, the best method of treatment is open reduction and bone grafting as soon after injury as possible. Only this will ensure complete correction of the deformity and prevent later deterioration.