Excessive resident duty hours (RDH) are a recognized issue with implications for physician well-being and patient safety. A major component of the RDH concern is on-call duty. While considerable work has been done to reduce resident call workload, there is a paucity of research in optimizing resident call scheduling. Call coverage is scheduled manually rather than demand-based, which generally leads to over-scheduling to prevent a service gap. Machine learning (ML) has been widely applied in other industries to prevent such issues of a supply-demand mismatch. However, the healthcare field has been slow to adopt these innovations. As such, the aim of this study was to use ML models to 1) predict demand on orthopaedic surgery residents at a level I trauma centre and 2) identify variables key to demand prediction.

Daily surgical handover emails over an eight year (2012-2019) period at a level I trauma centre were collected. The following data was used to calculate demand: spine call coverage, date, and number of operating rooms (ORs), traumas, admissions and consults completed. Various ML models (linear, tree-based and neural networks) were trained to predict the workload, with their results compared to the current scheduling approach. Quality of models was determined by using the area under the receiver operator curve (AUC) and accuracy of the predictions. The top ten most important variables were extracted from the most successful model.

During training, the model with the highest AUC and accuracy was the multivariate adaptive regression splines (MARS) model, with an AUC of 0.78±0.03 and accuracy of 71.7%±3.1%. During testing, the model with the highest AUC and accuracy was the neural network model, with an AUC of 0.81 and accuracy of 73.7%. All models were better than the current approach, which had an AUC of 0.50 and accuracy of 50.1%. Key variables used by the neural network model were (descending order): spine call duty, year, weekday/weekend, month, and day of the week.

This was the first study attempting to use ML to predict the service demand on orthopaedic surgery residents at a major level I trauma centre. Multiple ML models were shown to be more appropriate and accurate at predicting the demand on surgical residents as compared to the current scheduling approach. Future work should look to incorporate predictive models with optimization strategies to match scheduling with demand in order to improve resident well being and patient care.

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery.

We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05.

Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 – 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique.

This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis.

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery.

We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05.

Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 - 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique.

This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis.

The primary objectives of this study were to: 1) identify risk factors for subsequent surgery following initial treatment of proximal humerus fractures, stratified by initial treatment type; 2) generate risk prediction tools to predict subsequent shoulder surgery following initial treatment; and 3) internally validate the discriminative ability of each tool.

We identified patients ≥ 50 years with a diagnosis of proximal humerus fracture from 2004 to 2015 using linkable health datasets in Ontario, Canada. We used procedural and fee codes within 30 days of the index fracture to classify patients into treatment groups: 1) surgical fixation; 2) shoulder replacement; and 3) conservative. We used intervention and diagnosis codes to identify all instances of complication-related subsequent shoulder surgery following initial treatment within two years post fracture. We developed logistic regression models for randomly selected two thirds of each treatment group to evaluate the association of patient, fracture, surgical, and hospital variables on the odds of subsequent shoulder surgery following initial treatment. We used regression coefficients to compute points associated with each of the variables within each category, and calculated the risk associated with each point total using the regression equation. We used the final third of each cohort to evaluate the discriminative ability of the developed risk tools (via the continuous point total and a dichotomous point cut-off value for “higher” vs. “lower” risk determined by Receiver Operating Curves) using c-statistics.

We identified 20,897 patients with proximal humerus fractures that fit our inclusion criteria for analysis, 2,414 treated with fixation, 1,065 treated with replacement, and 17,418 treated conservatively. The proportions of patients who underwent subsequent shoulder surgery within two years were 13.8%, 5.1%, and 1.3%, for fixation, replacement, and conservative groups, respectively. Predictors of reoperation following fixation included the use of a bone graft, and fixation with a nail or wire vs. a plate. The only significant predictor of reoperation following replacement was poor bone quality. The only predictor of subsequent shoulder surgery following conservative treatment was more comorbidities while patients aged 70+, and those discharged home following initial presentation (vs. admitted or transferred to another facility) had lower odds of subsequent shoulder surgery. The risk tools developed were able to discriminate between patients who did or did not undergo subsequent shoulder surgery in the derivation cohorts with c-statistics of 0.75–0.88 (continuous point total), and 0.82–0.88 (dichotomous cut-off), and 0.53–0.78 (continuous point total) and 0.51–0.79 (dichotomous cut-off) in the validation cohorts.

Our results present potential factors associated with subsequent shoulder surgery following initial treatment of proximal humerus fractures, stratified by treatment type. Our developed risk tools showed good to strong discriminative ability in both the derivation and validation cohorts for patients treated with fixation, and conservatively. This indicates that the tools may be useful for clinicians and researchers. Future research is required to develop risk tools that incorporate clinical variables such as functional demands.

Distracted driving is now the number one cause of death among teenagers in the United States of America according to the National Highway Traffic Safety Administration. However, the risks and consequences of driving while distracted spans all ages, gender, and ethnicity. The Distractions on the Road: Injury eValuation in Surgery And FracturE Clinics (DRIVSAFE) Study aimed to examine the prevalence of distracted driving among patients attending hospital-based orthopaedic surgery fracture clinics. We further aimed to explore factors associated with distracted driving.

In a large, multi-center prospective observational study, we recruited 1378 adult patients with injuries treated across four clinics (Hamilton, Ontario, Toronto, Ontario, Calgary, Alberta, Halifax, Nova Scotia) across Canada. Eligible patients included those who held a valid driver's license and were able to communicate and understand written english. Patients were administered questions about distracted driving. Data were analyzed with descriptive statistics.

Patients average age was 45.8 years old (range 16 – 87), 54.3% male, and 44.6% female (1.1% not disclosed). Of 1361 patients, 1358 self-reported distracted driving (99.8%). Common sources of distractions included talking to passengers (98.7%), outer-vehicle distractions (95.5%), eating/drinking (90.4%), music listening/adjusting the radio (97.6%/93.8%), singing (83.2%), accepting phone calls (65.6%) and daydreaming (61.2%). Seventy-nine patients (6.3%), reported having been stopped by police for using a handheld device in the past. Among 113 drivers who disclosed the cause of their injury as a motor vehicle crash (MVC), 20 of them (17%) acknowledged being distracted at the time of the crash. Of the participants surveyed, 729 reported that during their lifetime they had been the driver in a MVC, with 226 (31.1%) acknowledging they were distracted at the time of the crash.

Approximately, 1 in 6 participants in this study had a MVC where they reported to be distracted. Despite the overwhelming knowledge that distracted driving is dangerous and the recognition by participants that it can be dangerous, a staggering amount of drivers engage in distracted driving on a fairly routine basis. This study demonstrates an ongoing need for research and driver education to reduce distracted driving and its devastating consequences.

Background and Purpose

The STarT Back approach comprises subgrouping of LBP patients according to risk of persistent LBP-related disability, and matches patients to appropriate treatments. In a clinical trial and implementation study, this stratified care approach was clinically and cost-effective compared to usual non-stratified care. However, the long-term cost- effectiveness is unknown, and could be established with decision modelling. A systematic review of model-based economic evaluations in LBP found shortcomings with existing models, including inadequate characterisation of the condition in health states and absence of long-term modelling. This study conceptualises the first decision model of this stratified care approach for LBP management, and assesses long-term cost-effectiveness.

Aims

To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF).

As residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees’ performance in managing orthopaedic trauma patients.

This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States.

In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma.

Cite this article: Bone Joint J 2016;98-B:1320–5.

Several recent studies have shown an increased incidence of symptomatic non-unions and malunions after non-operative treatment of displaced clavicle fractures. Our multicenter randomized control trial comparing sling treatment and plate fixation shows statistically significant improvement in patient oriented outcome measures at all time points measured over one year of follow-up. Non-operative group complications included six non-unions, one symptomatic malunion and one patient with reflex sympathetic dystrophy in thirty-four patients. Complications in the operative group included one wound dehiscence and two patients requiring plate removal in thirty-seven patients. This study supports plate fixation of acute clavicle fractures in selected cases.

To compare patient oriented outcomes of non-operative and operative treatment of displaced clavicle shaft fractures.

Operative fixation of displaced clavicle shaft fractures provides statistically significant improvement in functional outcome over sling treatment at one year of follow-up.

This study supports operative fixation of displaced clavicle shaft fractures in selected cases.

Seventy-one of one hundred and twenty patients have at least one year of follow-up. Non-operative group (N=34) consisted of twenty-four males with an average age thirty-two injuring fourteen dominant clavicles. The operative group (N= 37) consisted of thirty-three males with an average age of 34.5 years injuring twenty-one dominant clavicles. CSS and DASH scores were statistically different at all time points measured (p=0.001, p=0.021 respectively). Complications in the non-operative group included one patient with RSD, one symptomatic malunion and six patients with non-unions requiring ORIF. In the operative group, two patients experienced local plate irritation and one late wound dehiscence.

Randomization was by sealed envelope. Non-operative treatment was symptomatic in a sling, while operative patients underwent ORIF. CSS, DASH and SF-36 scores were collected at six weeks, three months, six months and twelve months. Statistical analysis was completed by repeated measures multivariate analysis using SPSS.

Recent studies have shown a higher incidence of symptomatic malunions and non-unions after sling treatment. Currently, sling treatment is standard of care for these fractures. Our study shows statistically signifi-cant improvement in functional outcome with operative treatment with few complications. This study supports operative treatment of displaced clavicle shaft fractures in selected cases.

Funding: OTA, Zimmer Inc

Please contact author for graphs and diagrams.

This study was designed to prospectively evaluate the efficacy of indomethacin as prophylaxis for heterotopic ossification (HO) after operatively treated acetabular fractures.

An IRB approved, prospective double blind placebo controlled clinical trial was performed at two level I trauma centres to evaluate the efficacy of indomethacin as prophylaxis for heterotopic ossification after the operative treatment of acetabular fractures. Between January 1, 1999 and May 31, 2003, two hundred and thirty-two patients with acetabular fractures were treated operatively through a posterior approach. Patients with the following conditions were excluded from study participation: age < 18, spinal cord injury, ankylosing spondylitis, burns, gastrointestinal bleed, Glasgow coma scale < 12, cerebrovascular accident, pregnancy and use of other non-steroidal anti-inflammatory drugs. One hundred and fifty-seven eligible patients were identified and one hundred and twenty-five patients were enrolled in the clinical trial. One hundred and seven patients have sufficient follow up to be included in data analysis. All patients underwent operative stabilization of their ace-tabular fractures by either a combined anterior and posterior approach or an isolated posterior Kocher-Lan-genbock approach. After fixation and prior to wound closure, any necrotic gluteus minimus muscle was debrided to viable muscle. Sixty-one patients were randomized to the placebo group and forty-six patients to the indomethacin treatment group. Indomethacin 75 mg SR and the placebo were administered to the patients by the investigational drug pharmacy in a blinded fashion. The medication was taken once daily for six weeks. Patient compliance was measured by obtaining indomethacin serum levels at the first postoperative visit (2 weeks). The extent of HO was evaluated on plain radiographs (AP and Judet) at three months postoperatively. The radiographs were scored for the presence of HO using the Brooker classification as modified by Moed. The data were analyzed two ways: 1) by excluding patients with protocol deviations and 2) by using an intent-to-treat model, where all enrolled subjects with 3 month Brooker scores were included in the analysis, regardless of whether they withdrew or were dropped from the study for clinical reasons. The sample size was estimated to produce a statistical power of 80% to detect a difference of 15% between the two treatment groups with alpha = .05.

There were no significant differences with regards to age, sex, body mass index (BMI), ISS (injury severity score) and complications between the two treatment groups. The overall incidence of HO (Brooker I-IV) was 52.8% and the overall incidence of significant HO (Brooker III/IV) was 19.6%. There were four patients with Brooker IV HO. There was no significant difference between the treatment groups in the incidence of HO according to Brooker class (p=0.23). Significant HO (Brooker grades III-IV) occurred in 8 cases (17%) in the indomethacin group and 13 cases (21%) in the placebo group. There was no significant difference in the presence of moderate to severe HO (Brooker III/IV) between the two treatment groups (Fisher’s exact test p=0.81). Eighty-two of one hundred and seven patients enrolled completed the protocol. Twenty-five patients did not complete the treatment protocol for the following reasons: stopped medication due to side effects, did not receive medication at discharge, lost medication, or medication stopped by another physician who did not understand the purpose of the study. Nine patients (8.4%) did not receive the full medication course, sixteen patients (15%) were dropped or withdrew from the study for adverse events or gastrointestinal symptoms. Twelve patients dropped or withdrew from the indomethacin group and three from the placebo group. Forty percent of patients in the indomethacin group had non-detectable serum levels at two weeks. Complications identified in the indomethacin treatment group included deep venous thrombosis (5), wound infection (2), nonunion (1), gastrointestinal bleed (1) and perforated ulcer (1). Complications identified in the placebo group included deep venous thrombosis (6) and wound infection (2).

In this prospective randomized study, a placebo provided as effective prophylaxis against the development of heterotopic ossification as indomethacin. More patients withdrew from the indomethacin group for gastrointestinal side effects or adverse events than in the placebo group. Patient compliance with indomethacin was poor with 40% of patients having no detectable indomethacin serum level. Serious gastrointestinal complications (gastrointestinal bleed and perforated ulcer) occurred in two patients treated with indomethacin.

Forty cases of congenital pseudarthrosis of the tibia were reviewed. The results were assessed so as to emphasise function rather than simply the presence or absence of union. At the time of review, 14 patients had undergone amputation; eight others had non-union or tenuous union. No surgical procedure except the Farmer operation (a composite skin and bone pedicle graft from the other leg) showed any clear superiority. Among the factors associated with a poor result were considerable shortening, older children, and rapid resorption of the bone graft. It is felt that congenital pseudarthrosis of the tibia is a biological problem and not merely a mechanical one; consequently biological approaches to its treatment are needed.