Aims. The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O). Methods. Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines. Results. Compared to the overall cohort of CSTs, females were significantly less likely to apply to T&O (OR 0.37, 95% CI 0.30 to 0.46; n = 155/720 female vs n = 535/1,240 male; p < 0.001). CSTs who were not UK-domiciled prior to university were nearly twice as likely to apply to T&O (OR 1.99, 95% CI 1.39 to 2.85; n = 50/205 vs not UK-domiciled vs n = 585/1,580 UK-domiciled; p < 0.001). Age, ethnicity, SES, and medical school category were not associated with applying to T&O. Applicants who identified as ‘black and minority ethnic’ (BME) were significantly less likely to be offered a T&O ST3 post (OR 0.70, 95% CI 0.51 to 0.97; n = 165/265 BME vs n = 265/385 white; p = 0.034). Differences in age, sex, SES, medical school category, and SJT scores were not significantly associated with being offered a T&O ST3 post. Conclusion. There is an evident disparity in sex between T&O applicants and an ethnic disparity between those who receive offers on their first attempt. Further high-quality, prospective research in the post-COVID-19 pandemic period is needed to improve equality, diversity, and inclusion in T&O training. Cite this article: Bone Jt Open 2024;5(8):697–707

Aims. This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures. Methods. Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results. Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events. Conclusion. COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic. Cite this article: Bone Jt Open 2023;4(9):704–712

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Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Aims. There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019. Methods. A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019. Results. A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery. Conclusion. Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery. Level of evidence: III. Cite this article: Bone Jt Open 2022;3(1):42–53

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The aim of this study was to surveil whether the standard operating procedure created for the NHS Golden Jubilee sufficiently managed COVID-19 risk to allow safe resumption of elective orthopaedic surgery.

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Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems.

Aims. As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. Methods. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. Results. In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). Conclusion. Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886–892

Aims. The COVID-19 pandemic drastically affected elective orthopaedic services globally as routine orthopaedic activity was largely halted to combat this global threat. Our institution (University College London Hospital, UK) previously showed that during the first peak, a large proportion of patients were hesitant to be listed for their elective lower limb procedure. The aim of this study is to assess if there is a patient perception change towards having elective surgery now that we have passed the peak of the second wave of the pandemic. Methods. This is a prospective study of 100 patients who were on the waiting list of a single surgeon for an elective hip or knee procedure. Baseline characteristics including age, American Society of Anesthesiologists (ASA) grade, COVID-19 risk, procedure type, and admission type were recorded. The primary outcome was patient consent to continue with their scheduled surgical procedure. Subgroup analysis was also conducted to define if any specific patient factors influenced decision to continue with surgery. Results. Overall, 88 patients (88%) were happy to continue with their scheduled procedure at the earliest opportunity. Patients with an ASA grade I were most likely to agree to surgery, followed by patients with ASA grades II, then those with grade III (93.3%, 88.7%, and 78.6% willingness, respectively). Patients waitlisted for an injection were least likely to consent to surgery, with just 73.7% agreeing. In all, there was a large increase in the proportion of patient willingness to continue with surgery compared to our initial study during the first wave of the pandemic. Conclusion. As COVID-19 lockdown restrictions are lifted after the second peak of the pandemic, we are seeing greater willingness to continue with scheduled orthopaedic surgery, reinforcing a change in patient perception towards having elective surgery. However, we must continue with strict COVID-19 precautions in order to minimize viral transmission as we increase our elective orthopaedic services going forward. Cite this article: Bone Jt Open 2021;2(10):865–870

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The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection.

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COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms.

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Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre.

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COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic.

Aims. Due to widespread cancellations in elective orthopaedic procedures, the number of patients on waiting list for surgery is rising. We aim to determine and quantify if disparities exist between inpatient and day-case orthopaedic waiting list numbers; we also aim to determine if there is a ‘hidden burden’ that already exists due to reductions in elective secondary care referrals. Methods. Retrospective data were collected between 1 April 2020 and 31 December 2020 and compared with the same nine-month period the previous year. Data collected included surgeries performed (day-case vs inpatient), number of patients currently on the orthopaedic waiting list (day-case vs inpatient), and number of new patient referrals from primary care and therapy services. Results. There was a 52.8% reduction in our elective surgical workload in 2020. The majority of surgeries performed in 2020 were day case surgeries (739; 86.6%) with 47.2% of these performed in the independent sector on a ‘lift and shift’ service. The total number of patients on our waiting lists has risen by 30.1% in just 12 months. As we have been restricted in performing inpatient surgery, the inpatient waiting lists have risen by 73.2%, compared to a 1.6% rise in our day-case waiting list. New patient referral from primary care and therapy services have reduced from 3,357 in 2019 to 1,722 in 2020 (49.7% reduction). Conclusion. This study further exposes the increasing number of patients on orthopaedic waiting lists. We observed disparities between inpatient and day-case waiting lists, with dramatic increases in the number of inpatients on the waiting lists. The number of new patient referrals has decreased, and we predict an influx of referrals as the pandemic eases, further adding to the pressure on inpatient waiting lists. Robust planning and allocation of adequate resources is essential to deal with this backlog. Cite this article: Bone Jt Open 2021;2(7):530–534

Aims. The purpose of our study was to determine which groups of orthopaedic providers favour virtual care, and analyze overall orthopaedic provider perceptions of virtual care. We hypothesize that providers with less clinical experience will favour virtual care, and that orthopaedic providers overall will show increased preference for virtual care during the COVID-19 pandemic and decreased preference during non-pandemic circumstances. Methods. An orthopaedic research consortium at an academic medical system developed a survey examining provider perspectives regarding orthopaedic virtual care. Survey items were scored on a 1 to 5 Likert scale (1 = “strongly disagree”, 5 = “strongly agree”) and compared using nonparametric Mann-Whitney U test. Results. Providers with less experience were more likely to recommend virtual care for follow-up visits (3.61 on the Likert scale (SD 0.95) vs 2.90 (SD 1.23); p = 0.006) and feel that virtual care was essential to patient wellbeing (3.98 (SD 0.95) vs 3.00 (SD 1.16); p < 0.001) during the pandemic. Less experienced providers also viewed virtual visits as providing a similar level of care as in-person visits (2.41 (SD 1.02) vs 1.76 (SD 0.87); p = 0.006) and more time-efficient than in-person visits (3.07 (SD 1.19) vs 2.34 (SD 1.14); p = 0.012) in non-pandemic circumstances. During the pandemic, most providers viewed virtual care as effective in providing essential care (83.6%, n = 51) and wanted to schedule patients for virtual care follow-up (82.2%, n = 50); only 10.9% (n = 8) of providers preferred virtual visits in non-pandemic circumstances. Conclusion. Orthopaedic providers with less clinical experience seem to favourably view virtual care both during the pandemic and under non-pandemic circumstances. Providers in general appear to view virtual care positively during the pandemic but are less accommodating towards it in non-pandemic circumstances. Cite this article: Bone Jt Open 2021;2(6):405–410

The response to the COVID-19 pandemic has raised the profile and level of interest in the use, acceptability, safety, and effectiveness of virtual outpatient consultations and telemedicine. These models of care are not new but a number of challenges have so far hindered widespread take-up and endorsement of these ways of working. With the response to the COVID-19 pandemic, remote and virtual working and consultation have become the default. This paper explores our experience of and learning from virtual and remote consultation and questions how this experience can be retained and developed for the future.

Cite this article: Bone Jt Open 2021;2(5):301–304.

Aims. Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined. Methods. This multicentre observational study included 1,633 patients who sustained a hip fracture across nine hospital trusts in North West England. Data were collected for three months from March 2020 and for the same period in 2019. Patients were matched by Nottingham Hip Fracture Score (NHFS), hospital, and fracture type. We looked at the mortality outcomes of COVID-19 positive and COVID-19 negative patients sustaining a hip fracture. We also looked to see if vitamin D levels had an impact on mortality. Results. The demographics of the 2019 and 2020 groups were similar, with a slight increase in proportion of male patients in the 2020 group. The 30-day mortality was 35.6% in COVID-19 positive patients and 7.8% in the COVID-19 negative patients. There was a potential association of decreasing vitamin D levels and increasing mortality rates for COVID-19 positive patients although our findings did not reach statistical significance. Conclusion. In 2020 there was a significant increase in 30-day mortality rates of patients who were COVID-19 positive but not of patients who were COVID-19 negative. Low levels of vitamin D may be associated with high mortality rates in COVID-19 positive patients. Cite this article: Bone Joint J 2021;103-B(4):782–787

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

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The ongoing COVID-19 pandemic has disrupted and delayed medical and surgical examinations where attendance is required in person. Our article aims to outline the validity of online assessment, the range of benefits to both candidate and assessor, and the challenges to its implementation. In addition, we propose pragmatic suggestions for its introduction into medical assessment.

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The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers.

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The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period.