Do Hypoalbuminaemia Increase the Risk of Surgical Site Infection in Neck of Femur Fracture Patients: A Systematic Review and Meta-Analysis.

Serum albumin plays an important role in physiological and inflammatory haemostasis, and low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in the spine and elective arthroplasty settings, there is a paucity of evidence with regard to the effect of low serum albumin on rates of SSI following surgery for adult patients suffering from traumatic and acute hip fractures. A systematic review was conducted using the PRISMA guidelines. Four databases were searched for randomised controlled trials (RCTs), cohort studies, and case-controlled studies. The risk of bias was assessed using the Newcastle-Ottawa Score (NOS). Data was collected and pooled using RevMan Web software. Results were reported as odds ratios (OR) with 95% confidence intervals (CI) and statistical significance of p <0.05. An inverse variance model was used in the meta-analysis. Six retrospective studies (five cohorts and one case-control) with a total of 43,059 patients were included. 45.3% (n=19 496) had low serum albumin (<3.5 g/dL). Hypoalbuminemia was associated with a significantly higher risk of any form of SSI (OR 1.25, p=0.008) and deep SSI (OR 1.76, p=0.05). There was no statistical significance between hypoalbuminemia and the incidence of superficial SSI (OR 1.06, p=0.77). Organ-space SSI was associated with hypoalbuminemia, although one study reported this with poor statistical significance (OR 8.74, p<0.054). Hypoalbuminemia increases the risk of most forms of surgical site infections, both superficial and deep. There is a weak conclusion to draw between the incidence of deep-space organ infections and low serum albumin.

The characteristics and predictors of mortality in periprosthetic fractures around the knee.

Aims: Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods: Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results: Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion: The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

The effect of tranexamic acid and epinephrine on visual clarity during arthroscopic shoulder surgery: A meta-analysis of RCTs.

INTRODUCTION: Visual clarity in arthroscopic rotator cuff repair is essential to reduce the operative time and for efficiency of repair. Tranexamic acid (TXA) in open shoulder surgery has been shown to reduce blood loss but its use in shoulder arthroscopy for rotator cuff repair for improved clarity is not understood. The purpose of this SR is to determine the effect of TXA and epinephrine on visual clarity in shoulder arthroscopy for rotator cuff repair. HYPOTHESIS: We hypothesise that visual clarity should improve in those that have TXA compared to those who do not receive TXA. METHODS: A review of the online databases MEDLINE and Embase was conducted on 8th October 2022 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Randomised clinical trials reporting visual clarity and/or, operative time, volume of irrigation fluid used and mean arterial pressure were included. The studies were appraised using the CONSORT tool. RESULTS: Seven studies met eligible criteria, all of which were double-blinded RCTs. Five studies reported no difference in visual clarity between TXA vs. saline, while two reported a significant improvement with TXA. Pooling of data showed that visual clarity was significantly better in the TXA group vs. saline, on a standardised 10-point Likert scale (mean difference 0.73 points, p=0.03). However, the use of epinephrine was reported in two studies and its administration offered significantly better visual clarity than TXA (mean difference 0.9 points, p=0.02). There was no significant difference with TXA use in MAP (mean difference 1.2mmHg, p=0.14), operative time (mean difference 6.8minutes, p=0.11), irrigation volume used (mean difference 0.2L, p=0.88), or postoperative pain (mean difference 3.89 on a 0-100 VAS, p=0.34). CONCLUSION: The use of TXA in shoulder arthroscopy has shown to have significantly improved visual clarity in comparison to saline irrigation alone. This may not necessarily result in a significant clinical difference and may not translate to significantly less operative time or postoperative pain score. Furthermore, epinephrine use alone offers significantly better clarity than TXA. There may not be an added benefit to give both, but this area requires further research. LEVEL OF EVIDENCE: II; systematic review.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study.

INTRODUCTION: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip. METHODS: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality. RESULTS: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. CONCLUSION: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

Suture Button Fixation in Latarjet Has Similar Load to Failure and Clinical Outcomes but Lower Bone Resorption Compared With Screw Fixation: A Systematic Review.

PURPOSE: To compare the 2 Latarjet fixation techniques-screw fixation (SF) versus suture button (SB) -for clinical, biomechanical, and radiologic outcomes. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic and Meta-Analyses guidelines using MEDLINE and Embase databases and was prospectively registered on PROSPERO. Only comparative clinical and biomechanical studies of Latarjet with SF and SB were included. Studies were appraised using the Methodical Index for Non-Randomised Studies (MINORS) tool. RESULTS: Eleven studies met eligible criteria: 7 clinical studies (SB, n = 279; SF, n = 845) and 4 biomechanical. In total, 80.9% (SB) and 84.2% (SF) of patients were male. Follow-up ranged from 6 to 63.6 months. The overall recurrent instability rate for SB ranged from 0 to 8.3% and for SF ranged from 0 to 2.75%. Only one study demonstrated a greater recurrent instability rate with SB (P = .02). Overall SB complication rates ranged from 0 to 12.5% and SF ranged from 0 to 27%. Two studies reported greater complications and reoperations with SF related to hardware. Summary forest plots from 4 studies showed no significant difference in Walch Duplay score (mean difference, range -5.00 to 1.20 [95% confidence interval {CI} -12.13 to 8.56], I2 inconsistency = 0%), Rowe score (mean difference, range -2.00 to 4.00 [95% CI -7.37 to 7.66], I2 inconsistency = 45%), and VAS for pain (mean difference, range -0.10 to 0.60 [95% CI -0.72 to 1.33], I2 inconsistency = 0%). There was no statistically significant difference between SB and SF in the postoperative range of motion. Radiologically, there was no significant difference in graft positioning and union at final follow-up, but graft resorption was greater in SF (range 25.2%-47.6%) compared with SB (range 10.1%-18.5%). Biomechanical studies showed no significant difference in maximum load to failure (SB, range 184-266 N vs SF, range 148-288 N). CONCLUSIONS: Clinically, SB fixation demonstrated similar functional outcome and range of motion when compared with SF, with the potential benefit of lower rates of graft resorption and hardware-related complications. Biomechanically there was no difference in maximum load to failure. LEVEL OF EVIDENCE: Level III, cohort studies (all clinical studies were Level III cohort studies).

A systematic review and meta-analysis comparing the use of hook plates and superior plates in the treatment of displaced distal clavicle fractures.

INTRODUCTION: Non-operative treatment of displaced distal clavicle fractures results in high non-union and yet there is no consensus on superior treatment modality. While there are a number of different techniques available for fixation, hook plate (HP) has been used most commonly. A number of modern techniques, including superior plate (SP), have shown less complications but equivocal union rate and shoulder function. The aim of this systematic review and meta-analysis is to compare the outcome of HP fixation with superior plate in surgical fixation of displaced distal clavicle fractures. PATIENTS AND METHODS: A review of the online databases MEDLINE and Embase was conducted on 15 January 2021 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting union rate, complications and shoulder function were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 42 studies eligible for inclusion with a total of 1,261 patients. These included 17 hook-plate case series (n = 573), 18 superior plate case series, of which 6 used SP alone (n = 223) and 12 SP and simultaneous CCLR case series (n = 189), and 7 studies comparing HP and SP (n = 276). The overall complication rate was significantly higher with HP when compared to SP [(32.7% vs 12.7%; OR 6.31 (95% CI: 2.67-14.91)]. The overall union rates in the case series appeared comparable in the current SR; HP 96.4%, SP 96.9% and SP with simultaneous CCLR 97.9%. Shoulder function was most commonly assessed using CM score and the mean ranged from 83.8 to 97.2 in HP, 89 to 98 in SP group and 90.6 to 97.6 in SP with CCLR. Meta-analysis of CM score failed to show a significant difference for HP versus SP (pooled weighted mean difference was 2.67 (95% CI: - 0.09 to 5.43) with a trend to favour SP fixation. CONCLUSION: The current review has demonstrated that HP, SP alone or with CCLR all offer excellent union rate and appear to provide comparative functional outcomes. However, HP is associated with significantly higher complication rates.

Open coraco-clavicular ligament reconstruction (CCLR) in treatment of displaced distal clavicle fractures has low complication rate and excellent union rate: a systematic review.

BACKGROUND: It is well established that non-operative treatment of displaced distal clavicle fractures (DDCF) leads to a high non-union rate. A number of open surgical treatments in the past have shown good to excellent outcomes including shoulder function and union rate. Despite this there is no consensus on the outcome of open coraco-clavicular ligament reconstruction (CCLR). The aim of this systematic review was to assess the union rate, complications and shoulder function of open CCLR techniques in the treatment of DDCF. PATIENTS AND METHODS: A review of the online databases MEDLINE and Embase was conducted on 1 January 2021 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting union rate, complications and shoulder function were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 18 studies eligible for inclusion with a total of 330 patients. These included 12 retrospective case series and 5 nonrandomized retrospective comparative studies and one RCT. All but one study reported on shoulder function, while all the studies reported on union rate and complications. The overall shoulder function was good to excellent using Constant-Murley score. The overall union rate was 97.6% and complication rate was 7.6%. CONCLUSION: Open CCLR for displaced distal clavicle fractures that have a disruption of CC ligament, is a reliable treatment with excellent union rate and good to excellent shoulder functional scores. LEVEL OF EVIDENCE: IV; Systematic review.

A comparison of the post-fusion outcome of patients with early-onset scoliosis treated with traditional and magnetically controlled growing rods.

AIMS: The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs). METHODS: We undertook a retrospective review of skeletally mature patients who had undergone fusion for an EOS, which had been previously treated using either TGRs or MCGRs. Measured outcomes included sequential coronal T1 to S1 height and major curve (Cobb) angle on plain radiographs and any complications requiring unplanned surgery before final fusion. RESULTS: We reviewed 43 patients (63% female) with a mean age of 6.4 years (SD 2.6) at the index procedure, and 12.2 years (SD 2.2) at final fusion. Their mean follow-up was 8.1 years (SD 3.4). A total of 16 patients were treated with MCGRs and 27 with TGRs. The mean number of distractions was 7.5 in the MCGR group and ten in the TGR group (p = 0.471). The mean interval between distractions was 3.4 months in the MCGR group and 8.6 months in the TGR group (p < 0.001). The mean Cobb angle had improved by 25.1° in the MCGR group and 23.2° in TGR group (p = 0.664) at final follow-up. The mean coronal T1 to S1 height had increased by 16% in the MCGR group and 32.9% in TGR group (p = 0.001), although the mean T1 to S1 height achieved at final follow-up was similar in both. Unplanned operations were needed in 43.8% of the MCGR group and 51.2% of TGR group (p = 0.422). CONCLUSION: In this retrospective, single-centre review, there were no significant differences in major curve correction or gain in spinal height at fusion. Although the number of planned procedures were fewer in patients with MCGRs, the rates of implant-related complications needing unplanned revision surgery were similar in the two groups. Cite this article: Bone Joint J 2022;104-B(2):257-264.

Arthroscopically Assisted Coraco-Clavicular Ligament Reconstruction in Treatment of Acute Displaced Distal Clavicle Fractures Provides Good to Excellent Shoulder Function Despite Low Union Rates and High Complication Rates: A Systematic Review.

PURPOSE: The aim of this systematic review was to assess the clinical outcome of arthroscopically assisted coraco-clavicular ligament (AACCL) reconstruction for treatment of displaced distal clavicle fractures in terms of union rate, complications, and shoulder function. METHODS: A review of the online databases Medline and Embase was conducted on January 1, 2021, according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting union rate, complications, and shoulder function were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 14 studies eligible for inclusion, 12 retrospective case series and 2 nonrandomized retrospective comparative studies. All studies reported on shoulder function, union rate, and complications. The overall shoulder function was good to excellent according to Constant-Murley score, with mean scores ranging from 81.8 to 96.2 [I2 (inconsistency) = 0% (95% confidence interval [CI] = 0% to 61%)]. The mean union rate ranged from 70% to 100% [I2 = 32.6% (95% CI = 0% to 63.4%)], and the mean complication rate ranged from 0 to 28.6% [I2 = 43.4% (95% CI = 0% to 68.4%)]. The most common complications were hardware related (3.1%), wound related (2.7%), and postoperative shoulder stiffness (2.2%). CONCLUSION: This systematic review analyzed clinical studies that evaluated the outcome of AACCL reconstruction in displaced distal clavicle fractures. The overall findings of this systematic review are that the union rate can be as low as 70% with this technique and the complication rate as high as 28.6%. Overall shoulder function was good to excellent according to Constant-Murley score. As the literature surrounding this topic is heterogeneous, further comparative clinical studies are required to assess superiority compared with other traditional techniques. LEVEL OF EVIDENCE: V: systematic review of level III and IV studies.

An international comparison of competency-based orthopaedic curricula and minimum operative experience - Review article.

INTRODUCTION: Orthopaedic training has undergone considerable changes in the last few decades. Although structured training pathways exist in most countries, the requirements for completion of training are remarkably different. This review aims to assess key differences among orthopaedic curricula in selected high-income countries with well-established orthopaedic training programmes, focusing on their criteria for assessing technical competence prior to completion of training. METHODS: Current orthopaedic training curricula published by the relevant accrediting bodies in the UK, USA, Canada, Australia, Germany and the European Union were reviewed. Data extracted included specified training duration, minimum or desirable operative experience requirements, methods and timing of in-training assessments. RESULTS: The overall training duration ranged between 9 and 10 years in the UK and Australia, compared to 5-6 years in all other countries. While operative logbook was an essential component of formative and end-of-training reviews in all countries, minimum indicative numbers in index operations were a requirement only in the UK (minimum total required; 1800, index operations; 365) and USA (minimum total required; 1000, index operations; 455). On average, USA residents performed 1700 procedures compared to German residents performing 730 procedures before completion of training. CONCLUSION: There is a lack of robust data describing the operative experiences of orthopaedic trainees outside of the UK and USA. UK training is the longest among countries compared in this review and also sets the highest standards in minimum operative experience requirements. Based on the evidence available, surgeons exiting training and entering independent practice in the above countries are not trained to the same minimum standard.

Arthroscopic bone block stabilisation procedures for glenoid bone loss in anterior glenohumeral instability: A systematic review of clinical and radiological outcomes.

INTRODUCTION: Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation. METHODS: This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20th July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5-37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0-18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92-100% in 8 out of 10 studies at mean follow up range 6-78.7 months but two reported lower rates ranging from 58.3-84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10-16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation. CONCLUSION: Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods. LEVEL OF EVIDENCE: IV; systematic review.

A quality improvement project to assess and refine the handover process at morning trauma meetings.

BACKGROUND: Poor handover and inadequate transmission of clinical information between shifts can result in patient harm. This study was designed to evaluate the impact of implementing a handover protocol on the quality of information exchanged in the trauma handover meetings in a UK district general hospital. METHODS: A prospective single centre observational study was performed at an acute NHS trust, using the define, measure, analyse, improve and control (DMAIC) methodology. Ten consecutive weekday trauma meetings, involving 43 patients, were observed to identify poor practices in handover. This data was used in conjunction with the Royal College of Surgeon's recommendations for effective handover (2007) to create a standard operating protocol (SOP). Following the implementation of the SOP, a further eight consecutive weekday trauma meetings, involving a further 47 patients, were observed. The data collection was performed by five trained independent observers. The data was analysed using t-test for quantitative variables and chi-square or Fisher's exact tests for categorical variables. RESULTS: An improvement in the trauma handover was demonstrated in multiple aspects of trauma handover including patient's past medical history, date of injury, results, diagnosis, consent, mark and starvation status (all p < 0.001). Subgroup analyses showed that handover of neck of femur patients including information on baseline mobility (p = 0.04), Nottingham Hip Fracture Score (p = 0.01), next of kin discussion (p = 0.075) and resuscitation status (p = 0.001) all improved following our interventions. CONCLUSION: These results demonstrate that the implementation of a well-structured handover protocol can improve the transmission of critical information in trauma meetings.

Does the posterior glenoid osteotomy reduce the rate of recurrence in patients with posterior shoulder instability - A systematic review.

BACKGROUND: Posterior shoulder instability (PSI) is becoming an increasingly recognised condition. A number of different treatment modalities exist to treat PSI including arthroscopic or open surgeries when non-operative treatment has failed. The primary aim of this systematic review was to analyse the rate of recurrent instability after posterior glenoid osteotomy (PGO) for recurrent PSI, while secondary aim was to identify complication rate and the amount of retroversion correction. PATIENTS AND METHODS: A review of the online databases MEDLINE and Embase was conducted on 1 November 2019 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database (Registration No. CRD42020161984). Clinical studies reporting either the recurrence rate, complications or amount of retroversion correction after PGO for PSI were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 9 studies eligible for inclusion. Of the 9 studies, 4 showed an improvement in retroversion with a mean change in retroversion of 10o. All 9 studies reported on recurrence rate with an overall rate of 22%. Complications were discussed in only 7 of the studies with overall rate of 18.3%. The most common complication reported in the studies were degenerative changes of the glenohumeral joint (7.3%) and iatrogenic fractures (5.5%). CONCLUSION: PGO is a viable option in patients with recurrent PSI that have increased retroversion and have failed non-operative or arthroscopic treatment. It does however carry a significant risk of complications. LEVEL OF EVIDENCE: IV; Systematic review.

Outcome of Ewing's sarcoma of the scapula-a long-term follow-up study.

OBJECTIVE: The aim of this study was to review our experience of managing Ewing's sarcoma of scapula and to identify features predictive of a good outcome. HYPOTHESIS: Surgery and neo-adjuvant chemotherapy would have a better survival than surgery alone. PATIENTS AND METHODS: Between 1988 and 2018, 29patients, (14females and 15males) were treated at a single hospital: The median age at diagnosis was 17.6years (range: 2 to 51years). Of the 29cases, 3 were primary soft tissue Ewing's invading bone and remainder were bony sarcoma. Twenty three patients underwent surgery and 6 patients were managed non-operatively. All surgical resection specimens were classified according to Musculoskeletal Tumour Society based on surgical margins assessed by specialist musculoskeletal pathologists. The function was assessed using the Musculoskeletal Tumour Society Score. RESULTS: The median follow-up for all patients was 10 years (range: 2 months to 30 years) and for survivors, median follow-up was 13.7 years (range: 18months to 30 years). The estimated disease-specific survival for all patients was 71.4% (95% CI 84.6-50.7%) at five years and 63% (95% CI 78.3-41.9%) at ten years. The estimated disease-specific survival for patients that underwent surgery was 86.5% (95% CI 95.5-63.7%) at five years and 81% (95% CI 92.5-56.9%) at ten years. The median MSTS score was 67.4%. CONCLUSION: In this, the largest single series of patients with an Ewing's sarcoma of the scapula treated in a single hospital, those treated with surgery and neo-adjuvant chemotherapy had the best chance for survival compared to chemotherapy and/or radiotherapy alone. Local recurrence did not have an affect on survival. LEVEL OF EVIDENCE: IV, retrospective study.

Is shortening of displaced midshaft clavicle fractures associated with inferior clinical outcomes following nonoperative management? A systematic review.

BACKGROUND: Management of displaced midshaft clavicle fractures is controversial. Nonoperative treatment can lead to shortening, a risk factor for nonunion and poor functional outcomes. These inferior results have resulted in authors recommending surgical fixation for fractures with significant shortening. The aim of this systematic review was to analyze the effect of fracture shortening on shoulder function and nonunion rates in nonoperatively managed displaced midshaft clavicle fractures. METHODS: A review of the online databases MEDLINE and Embase was conducted on February 16, 2018, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies with midshaft clavicle fractures treated nonoperatively reporting an evaluation of the degree of clavicle shortening and either shoulder function or nonunion were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 16 studies eligible for inclusion, comprising 4 randomized controlled trials and 12 nonrandomized retrospective comparative studies. Of the 12 case series, 11 failed to demonstrate any correlation between shortening and shoulder outcome scores. Of the 4 randomized controlled trials, 3 reported no significant association between fracture shortening and shoulder outcome scores. The studies also failed to demonstrate a significant association between nonunion and the presence of clavicle shortening. CONCLUSION: There is no significant association between fracture shortening and nonunion rates or shoulder outcome scores in displaced midshaft clavicle fractures managed nonoperatively.

Risk factors for onset of delirium after neck of femur fracture surgery: a prospective observational study.

BACKGROUND: Delirium is a common complication after surgery in the elderly that leads to increased length of stay and other adverse outcomes. The aim of this study was to better understand the exact causes of post-operative delirium in patients undergoing surgery for neck of femur (NOF) fractures. METHODS: We performed a prospective cohort study of 381 consecutive patients undergoing surgery for NOF fractures at a single institution. Baseline cognitive status and risk factors were recorded on admission. Post-operative cognitive status was assessed at regular intervals until discharge. Binary logistic regression was performed to identify independent predictors of delirium. RESULTS: Patients who developed post-operative delirium (n = 70) were significantly older (average age 83 vs. 78, p = 0.019) and more likely to be female (79% vs. 67%, p = 0.062) than non-affected patients. The presence of delirium was associated with increased length of stay (13 vs. 10 days, p = 0.001) and 1-year mortality (25.7% vs. 15% p = 0.03). Independent predictors of delirium included age ≥65 years (Odds Ratio = 5.8), presence of anaemia (OR = 2.9), hypoxia (OR = 2.86), cardiac disease (OR = 2.8), Chronic Obstructive Pulmonary Disease (OR = 2.5), new onset electrolyte imbalance (OR = 2.2) and renal failure (OR = 1.9). CONCLUSION: Overall analysis demonstrated an increased incidence of delirium in older females with greater comorbid conditions. It was also found to be associated with increased morbidity and mortality. We recommend clinicians put greater effort into recognising risk factors of delirium and diagnosing it in a timely manner to mitigate its effects.

Acquisition of basic microsurgery skills using home-based simulation training: A randomised control study.

INTRODUCTION: Acquisition of fine motor skills required in microsurgery can be challenging in the current training system. Therefore, there is an increased demand for novel training and assessment methods to optimise learning outside the clinical setting. Here, we present a randomised control trial of three microsurgical training models, namely laboratory tabletop training microscope (Laboratory Microscope, LM), low-cost jewellers microscope (Home Microscope, HM) and iPad trainer (Home Tablet, HT). METHODS: Thirty-nine participants were allocated to four groups, control n = 9, LM n = 10, HM n = 10 and HT n = 10. The participants performed a chicken femoral artery anastomosis at baseline and at the completion of training. The performance was assessed as follows: structured assessment of microsurgery skills (SAMS) score, time taken to complete anastomosis and time for suture placement. RESULT: No statistically significant difference was noted between the groups at baseline. There was a statistically significant improvement in all training arms between the baseline and post-training for SAMS score, time taken to complete the anastomosis and time per suture placement. In addition, a reduction was observed in the leak rate. No statistical difference was observed among the training arms. CONCLUSION: Our study demonstrated that at the early stages of microsurgical skill acquisition, home training using either the jewellers microscope or iPad produces comparable results to laboratory-based training using a tabletop microscope. Therefore, home microsurgical training is a viable, easily accessible cost-effective modality that allows trainees to practice and take ownership of their technical skill development in this area.

Identifying quality markers and improvement measures for ward-based surgical care: a semistructured interview study.

BACKGROUND: The surgical ward round (WR) represents the primary interface between the clinical team and the patient and is integral to the quality of postoperative care and subsequent patient outcomes. This study aims to explore key issues pertaining to the surgical WR, defining challenges in current practice, and identifying potential means of quality assessment and improvement. METHODS: A qualitative, semistructured interview-based approach was adopted, including patients, nurses, interns, residents, and attendings. RESULTS: Twenty-five interview subjects were recruited across 8 hospitals. Twenty-three of the 25 (92%) subjects believed that there was significant variation in the quality of WRs and that this affected patient care. Lack of thoroughness (18/25, 72%) and poor communication (12/25, 48%) were the most commonly identified causes. Nontechnical skills such as communication (25/25, 100%) were seen as crucial to WR quality. Quality markers for surgical WRs were identified. Simulation-based training was recommended (13/25, 52%) to improve performance. CONCLUSIONS: Clinical staff and patients alike perceive there to be significant variability in current surgical WR practice. Further development of interventions to assess and improve surgeons' performance is necessary to standardize and improve WRs and patient care.

A randomized controlled study to evaluate the role of video-based coaching in training laparoscopic skills.

OBJECTIVE: This study evaluates whether video-based coaching can enhance laparoscopic surgical skills performance. BACKGROUND: Many professions utilize coaching to improve performance. The sports industry employs video analysis to maximize improvement from every performance. METHODS: Laparoscopic novices were baseline tested and then trained on a validated virtual reality (VR) laparoscopic cholecystectomy (LC) curriculum. After competence, subjects were randomized on a 1:1 ratio and each performed 5 VRLCs. After each LC, intervention group subjects received video-based coaching by a surgeon, utilizing an adaptation of the GROW (Goals, Reality, Options, Wrap-up) coaching model. Control subjects viewed online surgical lectures. All subjects then performed 2 porcine LCs. Performance was assessed by blinded video review using validated global rating scales. RESULTS: Twenty subjects were recruited. No significant differences were observed between groups in baseline performance and in VRLC1. For each subsequent repetition, intervention subjects significantly outperformed controls on all global rating scales. Interventions outperformed controls in porcine LC1 [Global Operative Assessment of Laparoscopic Skills: (20.5 vs 15.5; P = 0.011), Objective Structured Assessment of Technical Skills: (21.5vs 14.5; P = 0.001), and Operative Performance Rating System: (26 vs 19.5; P = 0.001)] and porcine LC2 [Global Operative Assessment of Laparoscopic Skills: (28 vs 17.5; P = 0.005), Objective Structured Assessment of Technical Skills: (30 vs 16.5; P < 0.001), and Operative Performance Rating System: (36 vs 21; P = 0.004)]. Intervention subjects took significantly longer than controls in porcine LC1 (2920 vs 2004 seconds; P = 0.009) and LC2 (2297 vs 1683; P = 0.003). CONCLUSIONS: Despite equivalent exposure to practical laparoscopic skills training, video-based coaching enhanced the quality of laparoscopic surgical performance on both VR and porcine LCs, although at the expense of increased time. Video-based coaching is a feasible method of maximizing performance enhancement from every clinical exposure.