Role of patient specific 3D printed models in patient confidence, understanding and satisfaction of care in Singapore.

Introduction: Patient specific 3D models have been widely used for pre-op planning and intra-op guidance in orthopaedic surgery. These models however are not often used in pre-operative doctor-patient communication. This study evaluates the roles of customized 3D models in improving patient understanding, confidence, and satisfaction of patient care when they were used during preoperative counselling. Materials and methods: A prospective survey was conducted on 33 orthopaedic trauma patients who were required to rate on a scale of 1-5, the effectiveness of patient specific 3D models in: 1) improving patient's understanding and, 2) helping patients cope with the condition, 3) boosting patients' confidence in the treatment and 4) in the surgeon; and on a scale of 0-10, their overall satisfaction. Subgroup analysis was done to compare ratings of patients by age and by education levels. Results: Over 90% patients rated agree or strongly agree on customised 3D models' effectiveness in improving understanding of injury and boosting confidence in treatments and surgeons. 87% patients agreed or strongly agreed that the models enhanced patient self-efficacy. No significant correlation was identified between age and patients' perceived effectiveness of customised 3D models in improving patient care. Ratings on four areas evaluated by pre-secondary and post-secondary groups were comparable. Post-secondary group had significantly higher satisfaction level than the pre-secondary group. Conclusion: Customized 3D models help patients visualise complex pathology to facilitate patients' understanding of their condition and treatment, resulting in improved self-efficacy, confidence, and overall satisfaction. The use of patient specific 3D models in pre-operative counselling allows greater patient involvement therefore prompting patient-centred healthcare. Age does not influence patients' perceived effectiveness of customised 3D models in improving patient care. Patients with higher education level are likely to experience higher satisfaction level due to their willingness to take responsibility for their care.

Femoral neck system as a safe alternative to cannulated compression screw and dynamic hip screw in femoral neck fractures: an early comparative study.

INTRODUCTION: The femoral neck system (FNS) is a safe alternative to cannulated compression screw (CCS) and dynamic hip screw (DHS) in femoral neck fractures. METHODS: A dual-centre retrospective cohort study was performed on femoral neck fractures (AO type 31-B) treated with closed reduction and internal fixation using FNS, DHS or CCS between April 2016 and April 2020. Exclusion criteria were as follows: patients aged below 16 years; chronic fractures beyond 7 days; pathological fractures; fracture extension to the intertrochanteric region or ipsilateral neck and shaft fractures; and open fractures. A total of 85 patients were identified: FNS (n = 28), DHS (n = 29) and CCS (n = 28). RESULTS: The FNS and CCS groups had a lower Garden and Pauwels classification compared to the DHS group (both P < 0.001). Both FNS and CCS groups were comparable in postoperative orthopaedic complications (10.7% [n = 3] vs. 3.6% [n = 1], adjusted P = 0.321). The DHS group had more postoperative orthopaedic complications than the FNS group, but this was not statistically significant (27.6% [n = 8] vs. 10.7% [n = 3], adjusted P = 0.321). There were no significant differences in median time to radiological union or median femoral neck shortening at union (both P > 0.05) among the three groups. CONCLUSION: The new DePuy Synthes FNS is a safe alternative to CCS with comparable complication rates for femoral neck fractures that are less displaced and more stable. The FNS also appears to be a safe alternative to DHS in the fixation of femoral neck fractures for the few cases of high-energy femoral neck fractures.

3D-printed patient specific surgical guides: Balancing accuracy with practicality.

Introduction: Three-dimensional (3D) printing technology has been used in orthopaedic surgery in recent years to manufacture customized surgical cutting jigs. However, there is scarcity of literature and information regarding the optimal parameters of an ideal jig. Our study aims to determine the optimum parameters to design surgical jigs that can produce accurate cuts, and remain practical for use, to serve as a guide for jig creation in future. Methods and materials: A biomechanical lab study was designed to investigate whether the thickness of a jig and the height of its cutting slot can significantly affect cutting accuracy. Surgical jigs were 3D printed in medical grade, and an oscillating sawblade was used to mimic intraoperative surgical cuts through the cutting slots onto wooden blocks, which were then analysed to determine the accuracy of cuts. Results: Statistical analysis was performed on a total of 72 cuts. The cutting accuracy increased when the thickness of the jig increased, at all slot heights. The cutting accuracy also increased as the slot height decreased, at all jig thicknesses. Overall, the parameters for jig construction that yielded the most accurate cuts were a jig thickness of 15 mm, in combination with a slot height of 100 % of the width of the sawblade. Additionally, at a jig thickness of 15 mm, there was no statistically significant difference in cutting accuracy when increasing the slot height to 120 %. Conclusion: This study is the first to propose tangible parameters that can be applied to surgical jig construction to obtain reproducible accurate cuts. Provided that a jig of 15 mm thickness can be accommodated by the size of the wound, the ideal surgical jig with a superior balance of accuracy and useability is 15 mm thick, with a cutting slot height of 120 % of the sawblade thickness.

Bundled Payments for Hip Fracture Surgery Are Associated With Improved Access, Quality, and Health Care Utilization, but Higher Costs for Complex Cases: An Interrupted Time Series Analysis.

OBJECTIVES: To study the impact of bundled payments for surgically managed hip fractures on care access, care quality, health care resource utilization, clinical impact, and acute care cost. DESIGN: An observational retrospective cohort study using a quasi-experimental design comparing prebundled and postbundled payments through an interrupted time series analysis. SETTING: A public acute care general hospital. PATIENTS: Patients 60 years and older, with surgery for an isolated, unilateral, nonpathological hip fracture during 2014-first quarter of 2019 [diagnosis-related group codes: I03A, I03B, I08A, and I08B] and transferred to specific rehabilitation institutions were studied. INTERVENTION: Bundled payments for funder-to-provider reimbursement. MAIN OUTCOMES MEASUREMENTS: Care access, care quality, health care resource utilization, clinical impact, and cost. RESULTS: Of 1477 patients, 811 were assigned to prebundled and 666 to postbundled payments. Although there was an improving trend of ward admission waiting times during postbundled payments [odds ratio (OR) = 1.14; 95% confidence interval (CI): 1.02-1.28], ward admission waiting times were longer when compared with prebundled payments (OR = 0.45; 95% CI: 0.23-0.85). Rates of 30-day all-cause readmissions were lower (OR = 0.08; 95% CI: 0.01-0.67), and trends of reducing inpatient rehabilitation and overall episode length of stay (OR = 1.26; 95% CI: 1.16-1.37 and OR = 1.17; 95% CI: 1.07-1.28, respectively) were demonstrated during postbundled payments. Acute care cost for complex cases were higher (OR = 0.49; 95% CI: 0.26-0.92) during bundled payments, compared with prebundled payments. CONCLUSIONS: Bundled payments for surgically managed hip fractures were associated with benefits for several outcomes pertinent to clinical improvement initiatives. More work, especially concerning cost-effective surgical implants and better care cost computations, are critically needed to contain the growth of acute medical care cost for these patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Application of a Stereotactic Frame-Specific 3D-Printed Attachment for Deep Brain Stimulation Surgery.

BACKGROUND: Mispositioning of microelectrodes during deep brain stimulation surgery can incur serious complications for patients. Current practice of creating a burr hole for introduction of the microelectrode is done freehand and can cause trajectory misalignment. We aimed to create a sterilizable surgical adjunct to minimize error from burr hole placement. METHODS: We designed and demonstrated clinical use of a 3D-printed surgical jig that can be mounted to the current Cosman-Roberts-Wells stereotactic frame. The jig allowed accurate placement of the perforating burr for creation of the burr hole. RESULTS: Intraoperative usage of the jig in 11 patients who underwent bilateral deep brain stimulation microelectrode placement for Parkinson disease demonstrated high accuracy of microelectrode placement, with an average 1.18 mm deviation (range, 0-2.7 mm) from intended trajectories. No intraoperative complications were encountered. CONCLUSIONS: This proof-of-concept study highlights the utility of 3D-printed surgical adjuncts that are fully customizable and rapidly produced to improve current surgical practice. The jig reduced surgery duration, need for multiple trajectories, and risk of potentially devastating neurological complications. As demonstrated, 3D-printed devices are useful as surgical adjuncts to optimize safety and efficacy in deep brain stimulation surgeries.

Effectiveness of anabolic steroids in improving outcomes for post-operative hip fracture patients: A randomized controlled trial.

Background: Post-operative elderly hip fracture patients require significant rehabilitation. Nandrolone is an anabolic steroid used to promote muscle growth. This study aims to examine the effect of nandrolone in improving rehabilitation and quality of life in elderly female patients with hip fractures undergoing hemiarthroplasty. Methods: This is a double-blinded prospective randomized-controlled-trial consisting of female patients above the age of 65 with an isolated neck of femur fracture planned for a hip hemiarthroplasty. Participants were randomized into two arms of the study - 50 mg intramuscular nandrolone vs normal saline placebo administered on post-operative day 0, and weeks 2, 6 and 12. The participants were followed up across a 1-year period following the surgery. Clinical outcomes such as time taken to achieve rehabilitation milestones, distance of ambulation and thigh muscle girth, and functional scoring with SF-36 questionnaire were recorded at intervals of 2, 6 and 12 weeks, 6 months and 1 year following the surgery. Results: There were a total of 23 subjects with 11 in the steroid group and 12 in the placebo group. There was no significant difference in demographics and injury patterns between both groups. There was no significant difference for time taken to achieve various rehabilitation milestones and distance of ambulation. SF-36 scores on discharge and at 1-year follow-up mark were comparable. There was no difference in the complication rate between both groups. Conclusion: Intra-muscular Nandrolone after hip surgery in elderly female patients does not result in short to mid-term improved rehabilitation or functional outcomes. Nandrolone did not result in increased short-term complications after hip surgery. Level of evidence: I.

3D printed patient specific customised surgical jig for reverse shoulder arthroplasty, a cost effective and accurate solution.

INTRODUCTION: The reverse shoulder arthroplasty is a common orthopaedic procedure, where placement of the initial guiding wire is paramount to the implant instrumentation and position. To improve the position of the guiding wire, navigation and patient specific instrumentation have been used. These are however expensive and lengthy with many logistical issues. MATERIAL AND METHODS: We utilised in house 3D printing to create a surgical guide to help with positioning of the central guiding wire. Pre and post op CT scans were utilised to determine positioning of the central screw. RESULTS: Position of the screw tip was a mean of 3.3 mm away from the central point of the thickest portion of bone in the scapula with good bony purchase. There were no complications reported. DISCUSSION: We report our experience in creation of the 3D printed surgical jig and the pearls of its creation, detailing from CT scan image acquisition to creation of surgical guide to intraoperative usage. 3D printing is a cost effective and accurate solution for the positioning of orthopaedic instrumentation. This can be easily applied to other operations in our institution, even with a low start up cost.

Functional Outcomes of Patients with Schizophrenia After Hip Fracture Surgery: A 1-Year Follow-up from an Institutional Hip Fracture Registry.

BACKGROUND: Schizophrenia impairs a patient's self-care abilities, which are crucial after a hip fracture. Studies on the outcomes of patients with schizophrenia after a hip fracture are dated. This study aims to investigate the complication rates, 1-year mortality, and functional outcomes of surgically managed hip fractures in elderly patients with schizophrenia. METHODS: This is a retrospective, single-institution cohort study based on a prospectively maintained registry of patients with hip fracture. In this study, 3,056 patients who were ≥60 years of age were treated under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Baseline demographic characteristics and the Modified Barthel Index (MBI) scores were obtained at admission and at 6 months and 1 year after the fracture. Complications from the fracture and the surgical procedure were recorded during a minimum follow-up period of 2 years. A matching process (based on age, sex, and the MBI at admission) of up to 6 patients without schizophrenia per 1 patient with schizophrenia was utilized to increase power. Differences in perioperative, 6-month, and 1-year outcomes were compared for significance among surgically managed patients with schizophrenia and patients without schizophrenia. RESULTS: Thirty-eight patients with schizophrenia were compared with 170 geriatric patients without schizophrenia who underwent a surgical procedure for a hip fracture. Patients with schizophrenia were more likely to be institutionalized postoperatively (26.3% compared with 4.7%; p < 0.001). Patients with schizophrenia had poorer MBI scores at 12 months (76 compared with 90 points; p = 0.006). The 1-year mortality rate was comparable (p = 0.29) between patients with schizophrenia (5.7%) and those without schizophrenia (2.4%). Similar trends in MBI were observed in the conservatively managed group of patients. CONCLUSIONS: There was no increase in postoperative complications after a surgical procedure for a hip fracture in elderly patients with schizophrenia. The 1-year mortality after a surgical procedure for hip fracture is similar in both patients with schizophrenia and those without schizophrenia. Patients with schizophrenia and hip fracture who were surgically managed had poorer 1-year functional outcomes compared with patients without schizophrenia matched for age, sex, and MBI at admission. This information will be useful in shared decision-making discussions with patients and families. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cephalomedullary blade cut-ins: a poorly understood phenomenon.

OBJECTIVES: Proximal femoral nail antirotation (PFNA) cut-in is a unique phenomenon seen in pertrochanteric hip fractures treated with the PFNA. Cut-in refers to the superomedial migration of the proximal femoral blade into the femoral head and hip joint. We recognize that cut-in is a completely separate entity from the well-described cut-out failure. This study assesses relevant radiological and patient risks factors for cut-in. DESIGN: Retrospective multicenter study looking at patients with pertrochanteric hip fractures managed with the Synthes PFNA SETTING: Four tertiary hospitals over 7 years. PATIENTS: Patients with cut-ins were identified. OUTCOME MEASUREMENT: The radiological appearance of this mode of failure was assessed and compared to cut-outs. Patient demographics, fracture configuration, time to implant failure (cut-in), bone mineral density, tip-apex distance, neck-shaft angle and position of the tip of the helical blade in the femoral head were collected. RESULTS: There was a total of 1027 patients across 4 institutions with 23 patients with cut-in. Average neck-shaft angle was 133 degrees. 16 out of 19 patients had severe osteoporosis with BMD < - 2.5. 14 of 23 patients had poor placement of the blade. 13 of 23 had a tip-apex distance of more than 20 mm. CONCLUSION: We propose a standardized nomenclature of "cut-in" for the phenomenon of superomedial migration of the proximal femoral blade. An anatomical neck-shaft reduction, accurate blade placement and increased surveillance for patients with severe osteoporosis are required to reduce the incidence and morbidity of cut-in.

Reduction of Physiological Strain Under a Hot and Humid Environment by a Hybrid Cooling Vest.

Chan, APC, Yang, Y, Wong, FKW, Yam, MCH, Wong, DP, and Song, W-F. Reduction of physiological strain under a hot and humid environment by a hybrid cooling vest. J Strength Cond Res 33(5): 1429-1436, 2019-Cooling treatment is regarded as one of good practices to provide safe training conditions to athletic trainers in the hot environment. The present study aimed to investigate whether wearing a commercial lightweight and portable hybrid cooling vest that combines air ventilation fans with frozen gel packs was an effective means to reduce participants' body heat strain. In this within-subject repeated measures study, 10 male volunteers participated in 2 heat-stress trials (one with the cooling vest-COOL condition, and another without-CON condition, in a randomized order) inside a climatic chamber with a controlled ambient temperature 33° C and relative humidity (RH) 75% on an experimental day. Each trial included a progressively incremental running test, followed by a 40-minute postexercise recovery. Core temperature (Tc), heart rate (HR), sweat rate (SR), rating of perceived exertion (RPE), exercise duration, running distance, and power output were measured. When comparing the 2 conditions, a nonstatistically significant moderate cooling effect in rate of increase in Tc (0.03 ± 0.02° C·min for COOL vs. 0.04 ± 0.02° C·min for CON, p = 0.054, d = 0.57), HR (3 ± 1 b·min·min for COOL vs. 4 ± 1 b·min·min for CON, p = 0.229, d = 0.40), and physiological strain index (PSI) (0.20 ± 0.06 unit·min for COOL vs. 0.23 ± 0.06 unit·min for CON, p = 0.072, d = 0.50) was found in the COOL condition during exercise. A nonstatistically significant (p > 0.05) trivial cooling effect (d < 0.2) was observed between the COOL and CON conditions for measures of exercise duration, running distance, power output, SR, and RPE. It is concluded that the use of the hybrid cooling vest achieved a moderate cooling effect in lowering the rate of increase in physiological strain without impeding the performance of progressively incremental exercise in the heat.

Return to car driving is safe 6 weeks after operative treatment of right ankle fractures.

BACKGROUND: There is no clear consensus on when patients with surgically treated right ankle fractures can return to car driving, or how best to assess their fitness to drive. Through a rigorous driving assessment program consisting of both off-road and on-road tests, we aim to determine if these patients are able to pass a standard driving test, even before weight bearing has been initiated. METHODS: A prospective grant-funded (Supported by AOTrauma Asia Pacific Ref: AOTAP12-17) clinical study was conducted. Patients aged 25-65 years who underwent surgery for right ankle fractures and held a valid motorcar driving license were recruited in a single institution from 2013 to 2015. The surgeon and a specialist occupational therapist assessed the patients at 2, 6 and 12 weeks post-surgery. A Short Musculoskeletal Functional Assessment (SMFA) Questionnaire was administered and the brake reaction time was measured using a driving simulator. Patients who met the minimal criteria were then subjected to a full on-road driving test in a real-world environment with a driving instructor. A follow-up telephone questionnaire was administered at least 6 months after return to driving to determine if patients had returned to driving safely. RESULTS: A total of 23 patients (8 females, 15 males) were recruited. The mean age was 42.8 (± 12.9) years. There was a significant improvement in the SMFA (p < 0.05) and braking time (p < 0.05) at 6 and 12 weeks post-surgery. Nearly all (91%) patients passed the on-road driving test at 6 weeks, before their fractures had healed or weight bearing was initiated. The questionnaire administered at least 6 months after return to driving revealed that all patients had returned to regular driving safely. CONCLUSION: We conclude that patients with isolated, surgically treated right ankle fractures can successfully pass a standard driving test at 6 weeks post-surgery, even before weight bearing has been initiated. We also showed that the ability to drive correlates with improvements in the SMFA scores and braking times. LEVEL OF EVIDENCE: II.

Evaluating the Physiological and Perceptual Responses of Wearing a Newly Designed Cooling Vest for Construction Workers.

Construction workers are subjected to heat stress because of the hot environment, physically demanding tasks, and/or personal protective equipment. A tailor-made cooling vest that protects construction workers from heat-related injuries was developed. The purpose of the study is to examine a newly designed cooling vest's effectiveness in alleviating physiological and perceptual strain in a hot and humid environment. Twelve male participants performed two trials, i.e., cooling vest (VEST) and control (CON) in a climatic chamber controlled at 37°C temperature, 60% relative humidity, 0.3 m/s air velocity, and 450 W/m2 solar radiation to simulate the summer working environment of construction sites. Two bouts of treadmill exercise intermitted with 30-minute passive recovery were designed to simulate the practical work-rest schedule of the construction industry. The cooling vest was used during the passive recovery period in the VEST condition, and the results were compared with that of no cooling vest in the CON condition. The results revealed that the newly designed cooling vest can significantly alleviate heat strain and improve thermal comfort, based on the decrease in body temperature, heart rate, and subjective perceptions (including perceived exertion, thermal, wetness, and comfort sensation) of the participants. It can also prolong work duration in the subsequent exercise. The cooling countermeasures proposed in this study will be able to provide an effective solution in situations that involve repeated bouts of outdoor construction work.

Rewriting the tip apex distance for the proximal femoral nail anti-rotation.

INTRODUCTION: The proximal femur nail anti-rotation (PFNA-II) (Synthes GmbH, Oberdorf, Switzerland) is the most commonly used implant for intramedullary nailing of unstable intertrochanteric fractures in our centre. However, mechanical failure of the bone with respect to the implant is a cause of concern due to its significant morbidity especially in the elderly. To date, factors for fixation failures are not well defined in the literature. This study aims to evaluate the factors that predispose to cut out of the PFNA implant and to provide a guide for surgical fixation. PATIENTS AND METHODS: This study was a retrospective analysis of 340 patients who underwent PFNA-II insertion from 2011 to 2013 in our centre. Intraoperative image intensifier images were used for calculation of tip apex distance, neck shaft angles, determination of Cleveland zones. Demographic data was collected on patients age and gender. The fractures were classified based on AO-OTA classification (Marsh et al., 2007) [1]. Patients were followed up for a minimum of 4 months and union of the fracture or until a complication occurred. Risk ratio for cut out was also compared with each statistically significant variable to determine the cut-off point. RESULTS: The incidence of cut out was 6.7% Tip apex distance, neck shaft angles and female gender were statistically significant for cut out. The study found that tip apex distance beyond 27mm increased the risk of cut out. Neck shaft angles less than 128° also increased the risk of cut out. Posterior and superior blade position in the femoral head and AO 31A3 fractures trended towards significance for cut out but were not statistically significant. CONCLUSION: To avoid cut out, one should aim for a tip apex distance of not more than 27mm and preserve a neck shaft angle of more than 128°. Risk stratification of the patient allows the surgeon to take greater caution in the post-operative period to detect early cut out.

Translation and validation of the chinese diabetic foot ulcer scale - short form.

BACKGROUND: The need to assess quality of life (QOL) in patients with a diabetic foot ulcer (DFU) has been well documented. However, no appropriate instrument was available for the Chinese population. OBJECTIVE: The Diabetic Foot Ulcer Scale - Short Form (DFS-SF) is a reliable and valid 29-item instrument comprising six scales, which is used for assessing QOL in patients with DFU. This study aimed to translate the DFS-SF into Chinese and evaluate its psychometric performance. METHODS: The Chinese DFS-SF went through the full linguistic validation process and was evaluated in 60 Hong Kong Chinese patients with current or healed DFU. RESULTS: The internal consistency of all scales of the Chinese DFS-SF was consistently high (Cronbach's alpha ranged from 0.8 to 0.92). Item convergent and discriminant validity was satisfactory (median corrected item-scale correlation ranged from 0.63 to 0.84). Moreover, the instrument also demonstrated good construct validity when correlated with the SF-36. Sensitivity was shown between patients with healed DFU and those whose DFU was not healed, those with different types of foot ulcer, those with different Wagner grade, and those with differing episodes of DFU. CONCLUSIONS: The newly translated Chinese DFS-SF may be used to assess the impact of DFU in Chinese patients.