Can guided wave ultrasound predict bone mechanical properties at the femoral neck in patients undergoing hip arthroplasty?

The bone quality of patients undergoing hip replacement surgery is poorly predicted by radiographs alone. With better bone quality information available to a surgeon, the operation can be performed more safely. The aim of this study was to investigate whether ultrasound signals of cortical bone at peripheral sites such as the tibia and radius can be used to predict the compressive mechanical properties of cortical bone at the femoral neck. We recruited 19 patients undergoing elective hip arthroplasty and assessed the radius and tibia of these patients with the Azalée guided wave ultrasound to estimate the porosity and thickness of the cortex. Excess bone tissues were collected from the femoral neck and the compressive mechanical properties of the cortex were characterised under a mechanical loading rig to determine stiffness, ultimate strength, and density. The correlations between the ultrasound measurements and mechanical properties were analysed using linear regression, Pearson correlation statistics, and multiple regression analysis. Cortical mechanical properties were weakly to moderately correlated with the ultrasound measurements at various sites (R2 = 0.00-0.36). The significant correlations found were not consistent across all 4 peripheral measurement sites. Additionally, weak to moderate ability of the ultrasound to predict mechanical properties at the neck of femur with multiple regression analysis was found (R2 = 0.00-0.48). Again, this was inconsistent across the different anatomical sites. Overall, the results demonstrate the need for ultrasound scans to be collected directly from clinically relevant sites such as the femoral neck due to the inconsistency of mechanical properties across various sites.

Impact of COVID-19 pandemic on hip fractures: the central London experience COVID-related urgent geriatric hip trauma (COUGH) study COVERT ( COVid Emergency-Related Trauma and orthopaedics) collaborative.

INTRODUCTION: COVID-19 has been recognized as the unprecedented global health crisis in modern times. The purpose of this study was to assess the impact of COVID-19 on treatment of neck of femur fractures (NOFF) against the current guidelines and meeting best practice key performance indicators (KPIs) according to the National Hip Fracture Database (NHFD) in two large central London hospitals. MATERIALS AND METHODS: A multi-center, longitudinal, retrospective, observational study of NOFF patients was performed for the first 'golden' month following the lockdown measures introduced in mid-March 2020. This was compared to the same time period in 2019. RESULTS: A total of 78 cases were observed. NOFFs accounted for 11% more of all acute referrals during the COVID era. There were fewer overall breaches in KPIs in time to theatre in 2020 and also for those awaiting an orthogeriatric review. Time to discharge from the trust during the pandemic was improved by 54% (p < 0.00001) but patients were 51% less likely to return to their usual residence (p = 0.007). The odds ratio was significantly higher for consultant surgeon-led operations and consultant orthogeriatric-led review in the post-COVID era. There was no significant difference in using aerosol-generating anaesthetic procedures or immortality rates between both years. CONCLUSION: The impact of COVID-19 pandemic has not adversely affected the KPIs for the treatment of NOFF patients with significant improvement in numerous care domains. These findings may represent the efforts to ensure that these vulnerable patients are treated promptly to minimize their risks from the coronavirus.

Filarial thioredoxin reductase exerts anti-inflammatory effects upon lipopolysaccharide induced inflammation in macrophages.

Lymphatic filariasis and its associated health hazards have taken enormous tolls especially in the tropical and sub-tropical countries round the globe. Our present work contemplates the immunomodulatory role of filarial Thioredoxin reductase (TrxR) for the survival of the parasite inside the human host. For this, the protein TrxR was purified from the filarial parasite Setaria cervi and further substantiated through specific anti-TrxR antibody raised in mice. Both commercially available anti-TrxR antibody and laboratory raised antibody produced a single band with a molecular mass of ~80 kDa on western blot. The protein is optimally active at pH 7.0 and at temperature 37 °C. This protein contains both alpha helix and beta pleated sheet with selenocysteine at its active site. The Km was found to be 2.75 ± 0.49 mM. TrxR was found to downregulate lipopolysaccharide (LPS)-induced inflammation in macrophages due to inhibition of TLR4-NF-κB pathway. The result was further supported by the downregulation of inflammasome pathway and activation of alternatively activated macrophages upon TrxR treatment. Hence this study projects insights into the importance of filarial TrxR in host-parasite interface as well as it illustrates novel therapeutic strategy towards anti-filarial drug development.

Theatre efficiency in COVID-19 pandemic conditions: The collaborative experience of four level 1 major trauma centres in the UK.

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.

Training Surgeons to Perform Arthroscopic All-Inside Meniscal Repair: A Randomized Controlled Trial Evaluating the Effectiveness of a Novel Cognitive Task Analysis Teaching Tool, Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA).

BACKGROUND: All-inside meniscal repair is an increasingly common technique for the surgical treatment of meniscal tears. There are currently no standardized techniques for training residents in this procedure. Cognitive task analysis (CTA) is a method of analyzing and standardizing key steps in a procedure that allows training to be conducted in a validated and reproducible manner. PURPOSE: (1) To design a digital CTA teaching tool for a standardized all-inside meniscal repair. (2) To evaluate whether CTA-trained residents would perform better in a meniscal repair task compared with a control group who underwent traditional apprenticeship methods of training. STUDY DESIGN: Controlled laboratory study. METHODS: Three expert knee surgeons were interviewed using a modified Delphi method to generate a consensus among the ideal technical steps, cognitive decision points, and common errors and solutions for an all-inside meniscal repair. This written information was then combined with visual and audio components and integrated onto a digital platform to create the Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA) tool. Eighteen novice residents were randomized into an intervention group (digital CTA tool) and control group (equipment instruction manual). Both groups performed an all-inside meniscal repair on high-fidelity, phantom knee models and were assessed by expert surgeons, blinded to the interventions, using a validated global rating scale (GRS). After a power calculation, median GRS scores were compared between groups using the Mann-Whitney U test; significance was set at P < .05. RESULTS: For the IUMeRCTA tool design, the procedure was divided into 55 steps across 9 phases: (1) preoperative planning, (2) theater and patient setup, (3) portal placement, (4) meniscal examination, (5) tear reduction, (6) suture planning, (7) suture insertion, (8) repair completion, and (9) postoperative care and rehabilitation. For the trial, the intervention group (mean ± SD GRS, 32 ± 2.9) performed significantly better than did the control group (GRS, 24 ± 3.3; P < .001). CONCLUSION: This is the first CTA tool to demonstrate objective benefits in training novices to perform an arthroscopic all-inside meniscal repair. CLINICAL RELEVANCE: The IUMeRCTA tool is an easily accessible and effective adjunct to traditional teaching that enhances learning the all-inside meniscal repair for novice surgeons.

Reflections from London's Level-1 Major Trauma Centres during the COVID crisis.

Emergence of the Covid-19 pandemic resulted in dramatic changes in global healthcare provision. Resources were redirected across all healthcare sectors to support the treatment of viral pneumonia with resultant effects on other essential services. We describe the impact of this on the provision of major trauma care in a major capital city.

Fibular nails for open and closed ankle fractures: Results from a non-designer level I major trauma centre.

AIM: To evaluate the outcome of a fibular nail in the treatment of open and closed unstable ankle fractures in a non-designer centre. METHODS: In a retrospective cohort study, a total of 39 ankle fractures (14 open and 25 closed) treated with a locking fibular nail were evaluated between 2012 and 2015 in a non-designer level I major trauma centre. Post-operative radiographs were analysed to assess the quality of reduction (McLennan and Ungersma marking system), fracture union and complications. Three patient reported outcome scores (Olerud and Molander score (OMAS), American Association of Orthopaedic Surgeons (AAOS) foot and ankle score and 12-Item Short Form Survey (SF-12)) were collected to obtain an overall measure of the patient's physical and mental outcome. RESULTS: The adequacy of reduction data was available for 38 of 39 cases; 33 (87%) achieved good, 3 (8%) fair and 2 (5%) poor ratings, based on the McLennan and Ungersma marking system. Thirty-five (12 open and 23 closed) patients were available for initial follow-up. Five (14.3%) of 35 had documented complications (2 of 12 in the open cohort and 3 of 23 in the closed cohort). All fibular fractures treated with the fibular nail went on to unite. Twenty-three (66%) of 35 patients were available at 1-year follow-up for measurement of objective outcome. The combined mean OMAS for both groups was 53.7 (0-85) with statistically better results (59.5 (25-85) vs. 37.3 (0-75)) in favour of the closed versus open injuries, respectively. The mean AAOS score was also statistically better for the closed group than the open, 70.3 (30-95) versus 46.6 (20-77), respectively. The mean SF-12 score (physical component) was 40 (21.6-52.4) in the closed group versus 36.1 (19.4-51.5) in the open group; the mean mental component was 42.5 (26.6-54.3) in the closed group versus 38.8 (28.4-60.5) in the open group, these however were not statistically different. CONCLUSION: Fibular nails are an effective alternative for the treatment for both closed and open unstable ankle fractures with soft tissue compromise.

Trauma simulation training: a randomized controlled trial -evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool.

Background and purpose - Cognitive task analysis (CTA) has been used extensively to train pilots and in other surgical specialties. However, the use of CTA within orthopedics is in its infancy. We evaluated the effectiveness of a novel CTA tool to improve understanding of the procedural steps in antegrade femoral intramedullary nailing. Material and methods - Design: A modified Delphi technique was used to generate a CTA from 3 expert orthopedic trauma surgeons for antegrade femoral intramedullary nailing. The written and audiovisual information was combined to describe the technical steps, decision points, and errors for each phase of this procedure Validation: A randomized double-blind controlled trial was undertaken with 22 medical students (novices) randomized into 2 equal groups. The intervention group were given the CTA tool and the control group were given a standard operative technique manual. They were assessed using the validated "Touch Surgery™" application assessment tool on femoral intramedullary nailing. Results - The pre-test scores between the two groups were similar. However, the post-test scores were statistically significantly better in the intervention group compared with the control group. The improvement (post-test median scores) in the intervention group compared with the control group was 20% for patient positioning and preparation, 21% for femoral preparation, 10% for proximal locking, and 19% for distal locking respectively (p < 0.001 for all comparisons). Interpretation - This is the first multimedia CTA tool in femoral intramedullary nailing that is easily accessible, user-friendly, and has demonstrated significant benefits in training novices over the traditional use of operative technique manuals.

Knee Arthroscopy: A Simulation Demonstrating the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool.

BACKGROUND: Virtual reality and cadaveric simulations are expensive and not readily accessible1. Innovative and accessible training adjuncts are required to help meet training needs. Cognitive task analysis (CTA) has been used extensively to train pilots and surgeons in other surgical specialties2-6. However, the use of CTA tools within orthopaedics is in its infancy. Arthroscopic procedures are minimally invasive and require a different skill set compared with open surgery. Residents often feel poorly prepared to perform this in the operating room because of the steep learning curve associated with acquiring basic arthroscopic skills. We designed the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) tool, which is, to our knowledge, the first CTA tool described in the orthopaedic literature, demonstrating significant objective benefits in training novices to perform diagnostic knee arthroscopy. DESCRIPTION: The IKACTA tool, which is the combination of the written description of the phases below and the videos (with superimposed audio recordings) of each phase, utilizes simultaneous written and audiovisual modalities to teach diagnostic knee arthroscopy. The procedure was divided into 7 phases: (1) operating room and patient setup, (2) preparation and draping, (3) anterolateral portal placement, (4) examination of the patellofemoral joint and the lateral gutter, (5) examination of the medial compartment and anteromedial portal placement, (6) examination of the intercondylar notch and the lateral compartment, and (7) postoperative care and rehabilitation.For each phase, there are sections on the technical steps, cognitive decision-making behind each technical step, and potential errors and solutions. Video clips recorded by an expert surgeon in the operating room specific to each phase and audio voice recordings explaining each phase superimposed on the video clips were combined with the written information to design the IKACTA tool. ALTERNATIVES: Not applicable. RATIONALE: This learning tool allows a trainee to learn each technical step, the cognitive decision-making underpinning each step, and potential errors and solutions relevant to each phase of the procedure. Furthermore, the learner can use written and audiovisual modalities simultaneously to learn this technique by reading the written component of the tool first and then watching the relevant video clips with the audio recordings for each phase of the procedure. Alternative training techniques currently include the traditional apprenticeship model, which is becoming increasingly insufficient in the current environment of reduced training hours7,8. Adjuncts to this model are essential to help meet training needs. The IKACTA tool has demonstrated significant objective benefits for novice trainees to learn diagnostic knee arthroscopy9. The idea behind this learning tool is for the trainee surgeon to use this tool independent of the trainer, prior to attending the operating room. The tool provides trainees with knowledge and cognitive understanding of the procedural steps before they perform this procedure on patients. They are aware of potential errors and methods to avoid or overcome these errors. We believe that this tool will reduce the initial difficult phase of the learning curve for junior residents and, therefore, will improve training efficiency in the operating room.

Knee Arthroscopy Simulation: A Randomized Controlled Trial Evaluating the Effectiveness of the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool.

BACKGROUND: Virtual-reality and cadaveric simulations are expensive and not readily accessible. Innovative and accessible training adjuncts are required to help to meet training needs. Cognitive task analysis has been used extensively to train pilots and in other surgical specialties. However, the use of cognitive task analyses within orthopaedics is in its infancy. The purpose of this study was to evaluate the effectiveness of a novel cognitive task analysis tool to train novice surgeons in diagnostic knee arthroscopy in high-fidelity, phantom-limb simulation. METHODS: Three expert knee surgeons were interviewed independently to generate a list of technical steps, decision points, and errors for diagnostic knee arthroscopy. A modified Delphi technique was used to generate the final cognitive task analysis. A video and a voiceover were recorded for each phase of this procedure. These were combined to produce the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) tool that utilizes written and audiovisual stimuli to describe each phase of a diagnostic knee arthroscopy. In this double-blinded, randomized controlled trial, a power calculation was performed prior to recruitment. Sixteen novice orthopaedic trainees who performed ≤10 diagnostic knee arthroscopies were randomized into 2 equal groups. The intervention group (IKACTA group) was given the IKACTA tool and the control group had no additional learning material. They were assessed objectively (validated Arthroscopic Surgical Skill Evaluation Tool [ASSET] global rating scale) on a high-fidelity, phantom-knee simulator. All participants, using the Likert rating scale, subjectively rated the tool. RESULTS: The mean ASSET score (and standard deviation) was 19.5 ± 3.7 points in the IKACTA group and 10.6 ± 2.3 points in the control group, resulting in an improvement of 8.9 points (95% confidence interval, 7.6 to 10.1 points; p = 0.002); the score was determined as 51.3% (19.5 of 38) for the IKACTA group, 27.9% (10.6 of 38) for the control group, and 23.4% (8.9 of 38) for the improvement. All participants agreed that the cognitive task analysis learning tool was a useful training adjunct to learning in the operating room. CONCLUSIONS: To our knowledge, this is the first cognitive task analysis in diagnostic knee arthroscopy that is user-friendly and inexpensive and has demonstrated significant benefits in training. CLINICAL RELEVANCE: The IKACTA will provide trainees with a demonstrably strong foundation in diagnostic knee arthroscopy that will flatten learning curves in both technical skills and decision-making.

Comparison of cement pressurisation in flanged and unflanged acetabular cups.

BACKGROUND: This biomechanical study examined difference in cement pressures generated by flanged and unflanged acetabular cups in hip arthroplasty. METHOD: Using a model acetabulum, cement was inserted and pressurised followed by cup insertion and pressurisation. Pressures were recorded using transducers in the acetabulum. We compared Charnley Ogee (flanged), Exeter contemporary (flanged) and Exeter low profile (unflanged) cups using Simplex and CMW1 cements in turn. RESULTS: Using Simplex, Charnley Ogee cup generated highest initial peak pressure and overall mean pressure. Exeter unflanged cup generated higher initial and mean pressures compared to Exeter flanged cup. With CMW, there was no significant difference between the pressures generated by the cups. CONCLUSIONS: Our experiment suggests that flanged cups do not consistently generate significantly higher cement pressures compared to unflanged cups.