Aims

The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures

In professional football a key factor regarding injury is the time to return to play. Accurate prediction of this would aid planning by the club in the event of injury. It would also aid the club medical staff. Gaussian processes may be used for machine learning tasks such as regression and classification. This study determines whether machine-learning methods may be used for predicting how many days a player is unavailable to play.

A database of injuries at one English Premier League Professional Football Club was reviewed for a number of factors for each injury. Twenty-five variables were recorded for each injury, including time to return to play. This was determined to be the response variable. We used a Gaussian process model with a Laplacian kernel to determine whether the return to play could be predicted from the other variables.

The root mean square error was 13.186 days (S.D.: 8.073), the mean absolute error was 8.192 days (S.D.:13.106) and the mean relative error 171.97% (S.D.:75.56%). A linear trend was observed and the model demonstrated high accuracy with greater errors being observed for cases where the value of the response variable was higher, i.e. in those cases where the time to return to play was lengthy.

This is the first step in attempting to design a computer-based model that will accurately predict the time for a professional footballer to return to play. The model is extremely accurate for most cases, with errors increasing as the severity of the case increases too.

In 1902 Shenton described his “line” which, “is formed by the outlines of the upper margin of the obturator foramen and the inner margin of the neck of the femur” stating, “broken continuity of which infallibly indicates displacement or trouble in the hip region. Some 110 years later with significant advancements in Radiology, we assessed whether there is still a role in modern Orthopaedics.

We reviewed 900 anterior-posterior bilateral hips on pelvis radiographs and noted whether Shenton's line was intact or broken. We recorded the presence or absence of pathology in each hip along with age and sex of the patient. In addition 15 independent observers were asked to blindly independently review 15 pelvic radiographs on two separate occasions. They noted whether Shenton's line was intact or disrupted. From this data we analysed the intra and inter-observer reliability.

1547 hips were analysed. 63% (971/1547) had an intact Shenton's line, 37% (576/1547) had a disrupted line. Of 271 femoral neck fractures, 44 (16%) were seen to have an intact Shenton's line. Regarding other pathologies, 2% of osteoarthritic hips, 0.1% of dysplastic hips and 20% of prosthetic hips had a disrupted Shenton's line. No ‘normal’ hips had a broken line. There was significant inter-observer error yet little intra-observer error found.

Our evidence reaffirms Shenton's original work. With a disrupted line there is a high probability of pathology within the hip. However, there may still be a fracture with an intact line, suggesting that Shenton's line is highly sensitive yet not greatly specific.

Introduction

Fifth metatarsal fractures are a common injury suffered by professional footballers. It is frequently reported in the media that such an injury will result in a 6-week absence from play. The purpose of this study was to assess frequency of media reporting of fifth metatarsal fractures, the time that is predicted by the media before the player will return to soccer and the actual time taken for the player to return to play.

Introduction

Patella tendonitis is common amongst sportsmen. No published evidence of this injury in elite professional footballers exists. The aim of this study was to determine the frequency of this injury in the elite professional footballer, along with the impact of such an injury on the amount of time missed and the outcomes of various treatment options.

Introduction

MRSA colonisation increases the risk of acquiring a surgical site infection (SSI). Screening identifies such patients and provides them with suitable eradication treatment prior to surgery to decrease their risk of infection. Our aim was to determine whether receiving effective eradication therapy decreases the risk of infection in a patient previously screening positive for MRSA to that of someone screening negative.

Introduction

Classification systems are used throughout Trauma and Orthopaedic (T&O) surgery, designed to be used for communication, planning treatment options, predicting outcomes and research purposes. As a result the majority of T&O knowledge is based upon such systems with most of the published literature using classifications. Therefore we wanted to investigate the basis for the classification culture in our specialty by reviewing Orthopaedic classifications and the literature to assess whether the classifications had been independently validated.

Introduction

Knee injuries are common amongst footballers. The aim of this study was to establish frequency and variation of knee injuries within one English Premier League (EPL) professional football club over two seasons, to assess number of days missed due to injury, and analyse current treatment regimen for each injury type.

Introduction

Foot and ankle injuries are a common occurrence amongst all footballers. The aim of this study was to establish the frequency and variation of foot and ankle injuries within one English Premier League (EPL) professional football club over the course of a season and attempt to identify any factors associated with the injuries.

Introduction

There are over 110 special tests described in the literature for clinical examination of the shoulder, but there is no general consensus as to which of these are the most appropriate to use. Individual opinion appears to dictate clinical practice. Rationalising which tests and clinical signs are the most useful would not only be helpful for trainees, but would also improve day to day practice and promote better communication and understanding between clinicians.

Pre-operative templating has become an essential aspect of pre-operative preparation for elective total hip replacement. The techniques involved have evolved from acetates used with analogue radiographs to digital processes. This study audits the accuracy of the TraumaCad software in total hip replacement since its introduction at two centres in the same trust.

The pre and post-operative radiographs of 40 patients undergoing total hip replacement by a single surgeon at a district general hospital were retrospectively reviewed. Patients that had templating of their digital Picture Archiving and Communications Systems (PACS) pelvic images using the TraumaCad software programme (Orthocrat Ltd, Petach-Tikva, Israel) were included. The templated acetabular component and femoral stem was compared to the actual size of acetabular and femoral prostheses inserted at surgery.

The acetabulum was accurately templated in 38.9% of the hips and within ± 1 size in a further 44.4% (total 83.3%). The femoral stem size was accurate in 27.8% of the hips and within ± 1 size in a further 52.8% of the hips (total 80.6%). Such a variation is likely due to the variable positioning of the calibration ball.

TraumaCad is a useful tool in the pre-operative templating of hips successfully predicting the prosthesis components within ± 1 size in the majority of hips studied. However, it should not be relied upon as an absolute measurement of the size of prosthesis to be used, rather be used as a suitable guide to intra-operative stages such as the femoral neck cut position.

Quality assurance for training in trauma and orthopaedics was provided by the JCHST through the SAC for Trauma and Orthopaedics. To date there have been written SAC standards; some are compulsory and others advisory and will generate requirements or recommendations to change if unmet on inspection. There has been a major change in the way postgraduate training is monitored and quality assured, with the formation of the PMETB, which now has the combined responsibility for all postgraduate training.

The aims and objectives of our study were to measure the effectiveness of the current quality assurance system for training in Trauma and Orthopaedics, and to determine the reduction in the number of unmet compulsory standards at the end of the visits process and how effectively these requirements were implemented. We also identified the deficiencies in each component of training and determined the current general profile of the quality of training in Trauma and Orthopaedics. The inspection visits, progress and revisit reports were collected from training regions that were visited after the standards were implemented.

In 109 units, in the 3 years studied, the inspection process reduced the overall unmet standards from a mean of 14.8% (10.3-19.2%) to 8.9% (6.5%-12.7%). The number of unmet requirement per unit fell from 4.6 to 2.8 (p<0.05). 27% of units did not improve. Overall 15% of standards were deficient, least in Scottish units and most in Irish units. Currently registrars do 1.4 trauma lists, 2.8 elective lists, 1.3 fracture clinics and 2.1 elective clinics per week. This is the first multi-regional study of a national accreditation process. Quality assurance requires standards setting and rectification. These findings are important for the imminent restructuring by the Postgraduate Medical Education Board.

The focus of deep vein thrombosis (DVT) prophylaxis following total joint arthroplasty has shifted in recent years to the reduction of symptomatic pulmonary emboli (PE). The relative infrequency and presumed delayed occurrence of these events has led many to suggest that the risks of more frequent early postoperative complications of treatment, especially bleeding, be weighed against the benefits of thromboembolic prophylaxis. The purpose of this study was to determine the timing and risk factors associated with the development of symptomatic PE following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

A retrospective analysis was performed of all patients diagnosed with a symptomatic pulmonary embolism following THA and TKA performed from January, 2004 to March, 2008. The records of 4706 patients were reviewed who were operated upon by 7 surgeons, and a total of 58 PE were identified. All patients were managed and treated by an anti-coagulation dosing service. Helical CT Scans were used to make the diagnosis of PE.

The overall incidence of PE was 1.2%, with 1.8% occurring in TKAs and 0.5% occurring in THAs. 48 of the 58 PE patients (83%) were women. 33 patients (57%) had unilateral TKA, 14 (24%) had bilateral TKA and 11 (19%) had THA. The average patient age was 65 (range: 44–88) and BMI was 33.8 (range: 24.7–51.9). There was no apparent correlation between age and BMI with incidence of PE. The PE were diagnosed an average of 4 days (range: 1–46) following surgery. 56 of the 58 patients (97%) were diagnosed by the sixth postoperative day. The average INR at the time of diagnosis was 1.7 (range: 1.0–3.0). There were two mortalities (3%), both of which occurred within the first two postoperative days.

The PE in this study occurred predominantly in women undergoing TKA. There appears to be an urgent need to develop an effective prophylaxis program aimed at preventing PE in the early post-operative period and to identify patients at risk of these PE.

Aim: Our aim was to find the effect of implementation of European working time directive on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: The audit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. We have analysed the results of the this and have identified a potential area of concern.

Results: An orthopaedic trainee of registrar level(Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. Overall, a trust grade surgeon (non-training grade) was the lead surgeon in 24% of cases. Comparing with the previous audits performed in the same hospitals, the number of hip fracture operations performed by trainees have reduced drastically. In 2003 and 2005 audits, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. There is a definite trend suggesting decrease in number of operations by trainees since the implementation of European working time directive as it has been introduced in a phased manner since 2004. In NHS, Current target is to achieve it fully by next year which may make the situation even worse from training point of view.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. On the other hand, the modernising medical curriculum (MMC) emphasises demonstration and record keeping of core competencies of surgical skills. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in England are mirrored elsewhere in Europe, the implications for orthopaedic training are significant. We are setting very high standards for training on one side but on practical grounds, not able to achieve the requirements set by educational bodies like OCAP and ISCP.

Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England.

Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant.

Classification systems are used for communication, deciding/planning treatment options, predicting outcome and research purposes. The vast majority of subtrochanteric fractures are now treated with intramedullary nails, which questions the need for classification.

Our objective was to assess the intra- and inter-observer reliability of the Seinsheimer, AO and Russell-Taylor (RT) classification systems and assess a new simple system (KMG).

The KMG system was developed to alert the surgeon to potential hazards: Type 1 – subtrochanteric fracture (ST#) with intact trochanters. Type 2 ST# involving greater trochanter (entry point for nailing difficulty). Type 3 –ST# involving lesser trochanter (most unstable).

32 AP and lateral radiographs of subtrochanetric fractures were classified independently by 4 observers twice with a 6-week interval (2 Consultants and 2 Registrars). The observers were asked to rank the systems based on how descriptive they thought they were, whether they felt they influenced treatment plan and whether they would predict outcome.

The intra- and inter-observer variation was poor in all systems. KMG gave the best inter-observer reproducibility (Kappa 0.3 to 0.6) followed by AO and RT, and then Seinsheimer. The observers felt that Seinsheimer and KMG were the most descriptive and would influence the treatment plan, and Russell-Taylor would perform worst at predicting outcomes. All of the fractures in this series united

The classification systems analysed in this study have poor reproducibility and seem to be of little value in predicting outcome of intramedullary nailing. The KMG system may be of some use in alerting the surgeon to potential problems.

Introduction: The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element.

Study Design: Prospective cohort.

Methods: All subtrochanteric fractures(AO31A3) admitted to the department were treated with the PFNA and specified data was recorded.

Results: From April 2006 to June 2007, 62 patients were included in the study.4 month follow up has been completed in 30 patients(77% of those available).11 are awaiting follow up and 12 died.The mean age was 79.9 years.

1 patient with a short PFNA nail sustained a fracture of the femur through the site of the distal locking bolt during the follow up period and required revision.

The mobility and social function scores were significantly reduced at follow up compared to pre-operative status(p=0.001).All domains of SF36 were low compared to normative data.

All 30 fractures united and there was no migration, lysis around or cut out of the helical blade.In total, 46 distal locking bolts were utilised.4 of these had migrated or become loose.

Conclusions: Subtrochanteric fractures in the elderly are a devastating injury. Patients do not return to pre-fracture function at 4 months post injury. Early results suggest that the PFNA appears to work well.

The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element. The PFNA makes use of a helical blade that compresses rather than destroys osteopaenic cancellous bone.

All subtrochanteric fractures admitted to the department were treated with the PFNA (AO 31A3). Demographic and clinical data during admission was recorded and formal post-operative X-Rays performed.

Outcome assessment consisted of a 4 month follow-up appointment with clinical and radiological assessments, VAS, SF36, Jensen Social Function Score and Parker Mobility Score.

From April to December 2006, 46 patients were included in the study. 4 month follow up has been completed in 17 of 23 patients. The average age was 78. 11 short and 7 long nails were inserted. Four patients required open reduction and internal fixation. There were no significant intra-operative or immediate postoperative complications. 1 short nail fractured through the site of the distal locking bolt during the follow up period and required revision.

At follow up, 5 patients had tenderness over the greater trochanter and 2 had leg length discrepancy. None had malrotation. Only 2 patients regained their pre-operative mobility status. The mobility and social function scores were significantly reduced at follow up compared to pre-operative status (p=0.003 and p=0.001 respectively). All domains of SF36 were low compared to normative data. The mean VAS was 3/10.

All fractures united and there was no migration, lysis around or cut out of the helical blade. In total, 25 distal locking bolts were utilised. Four of these had migrated or become loose.

Patients with subtrochanteric fractures do not return to pre-fracture function at 4 months post injury. The PFNA appears to work well although there may be concern about bone hold of the distal locking bolts.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

With the imminent introduction of the Modernising Medical Careers (MMC) post-graduate training programme, we undertook a study to assess how informed the orthopaedic Multi Disciplinary Team (MDT) and patients were with regard to the details, implementation and future implications of MMC.

Methods: A questionnaire was designed to record the level of awareness of MMC using a visual analogue scale and to document individual preferences for surgical training, either traditional or MMC. 143 questionnaires were completed – consultant orthopaedic surgeons (n=12); orthopaedic nursing staff (n=54); musculoskeletal physiotherapists (n=27); and trauma and orthopaedic patients (n=50).

Results: Consultants felt most informed about MMC compared to patients and other members of the multidisciplinary team (p < 0.01). Consultants preferred old style training in terms of their juniors as well as future consultant colleagues. Nurses showed no preference for either system. Patients and physiotherapists expressed a preference for their surgeon to have been trained under the traditional, rather than the new system.

Conclusions: Our study showed that there is a wide variation in the degree to which patients and healthcare professionals are informed about MMC.

In order to assess the efficacy of inspection and accreditation by the Specialist Advisory Committee for higher surgical training in orthopaedic surgery and trauma, seven training regions with 109 hospitals and 433 Specialist Registrars were studied over a period of two years.

There were initial deficiencies in a mean of 14.8% of required standards (10.3% to 19.2%). This improved following completion of the inspection, with a mean residual deficiency in 8.9% (6.5% to 12.7%.) Overall, 84% of standards were checked, 68% of the units improved and training was withdrawn in 4%.

Most units (97%) were deficient on initial assessment. Moderately good rectification was achieved but the process of follow-up and collection of data require improvement. There is an imbalance between the setting of standards and their implementation. Any major revision of the process of accreditation by the new Post-graduate Medical Education and Training Board should recognise the importance of assessment of training by direct inspection on site, of the relationship between service and training, and the advantage of defining mandatory and developmental standards.