Taking time out of training: a Malawi experience.

There has been increased focus on global surgery in low-income and middle-income countries (LMICs) since the Lancet commission on global surgery was published in 2015. Interest from surgical trainees in overseas placements during their training is high with a number of motivating factors to engage in overseas work. In this article, we outline the overseas experience of a UK-based orthopaedic trainee during their time out of training in Malawi from both the trainee and training program director perspectives. Overseas LMIC placements during orthopaedic training are encouragingly becoming more established and are supported by a growing body of literature showing widespread benefits to the individual volunteer, donor and host institutions.

Modern management of paediatric tibial shaft fractures: an evidence-based update.

AIMS: This review provides a summary of recent evidence surrounding the treatment of paediatric tibial shaft fractures and presents an algorithm to aid management of these injuries. This article reviews the relevant anatomy, epidemiology and aetiology of tibial shaft fractures and summarises contemporary treatment principles. Management recommendations and supporting evidence are given for fractures according to age (< 18 months, 18 months-5 years, 6-12 years, and 13-18 years). The relative merits of casting, plate fixation, elastic and rigid intramedullary nailing, and external fixation are discussed. Special attention is paid to the management of open tibial shaft fractures and to complications including infection and acute compartment syndrome. CONCLUSIONS: There has been a shift away from non-operative management of paediatric tibial shaft fractures over the last 30 years. However, recent evidence highlights that a non-operative approach produces acceptable outcomes when used in simple closed fractures at any age. Operative management may be indicated for unstable fractures where satisfactory alignment cannot be maintained or in specific circumstances including open injuries and polytrauma. Open injuries require urgent assessment by a combined orthopaedic and plastic surgery team at a specialist tertiary centre.

The use of ionising radiation in orthopaedic surgery: principles, regulations and managing risk to surgeons and patients.

The use of ionising radiation for plain film radiography and computerised tomography is fundamental in both diagnostics and treatment for orthopaedics. However, radiation is not without risk as high exposure can increase the risk of cancer. Little time is spent educating doctors about the relative risks of radiation, both to patients and themselves. In addition, there are common misunderstandings about the best ways to mitigate such risk. We aim to provide an overview of the fundamental principles of the use of ionising radiation and its risks within the context of orthopaedic surgery. While providing a narrative review of the current literature, we discuss the basic physics, standards of good practice and relevant UK and European regulations. We discuss the risks to patients and surgeons and suggest ways that these can be mitigated in the operating theatre. A thorough understanding of the risks, and appropriate procedural rules, with respect to the use of ionising radiation is essential for those in orthopaedic practice.

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy.

Introduction: Tomita En-bloc spondylectomy of L5 is one of the most challenging techniques in radical oncological spine surgery. A 42-year-old female was referred with lower back pain and L5 radiculopathy with a background of right shoulder liposarcoma excision. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation hence wasn't suitable for Stereotactic Ablative Radiotherapy (SABR) alone. The seeding nature of sarcoma prevents the indication of separation surgery hence excisional surgery is considered for radical curative treatment. This case report demonstrates dual-staged modified TES including the utilisation of novel techniques to allow for maximum radical oncological control in the era of SABR and lesser invasive surgery. Methods: First-stage: Carbonfibre pedicle screws planned from L2 to S2AI-Pelvis, aligned, to her patient-specific rods. Radiofrequency ablation of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone-cutter assisted inferior L4 and superior S1 endplate osteotomies. Second-stage: Vascular-assisted retroperitoneal approach at L4-S1 was undertaken protecting the great vessels. Completion of osteotomies at L4 and S1 to En-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Results: Patient rehabilitated well and was discharged after 42 days. Cyberknife of 30Gy in 5 fractions was delivered two months post-op. Despite left foot drop, she's walking independently 9 months post-op. Conclusion: These are challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR to achieve maximum local control in spinal oligometastatic disease. This case promotes our modified TES technique in the era of SABR and separation surgery in carefully selected cases.

Pakistan's kidney trade: an overview of the 2007 'Transplantation of Human Organs and Human Tissue Ordinance.' To what extent will it curb the trade?

Pakistan has the unenviable reputation for being one of the world's leading 'transplant tourism' destinations, largely the buying and selling of kidneys from its impoverished population to rich international patients. After nearly two decades of pressure to formally prohibit the trade, the Government of Pakistan promulgated the 'Transplantation of Human Organs and Human Tissue Ordinance' (THOTO) in 2007. This was then passed by Senate and enshrined in law in March 2010. This paper gives a brief overview of the organ trade within Pakistan and analyses the criteria of THOTO in banning the widespread practise. It then goes on to answer: 'To what extent will THOTO succeed in curbing Pakistan's kidney trade?' This is aided by the use of a comparative case study looking at India's failed organ trade legislation. This paper concludes THOTO has set a strong basis for curbing Pakistan's kidney trade. However, for this to be successfully achieved, it needs to be implemented with strong and sustained political will, strict and efficient enforcement as well as effective monitoring and evaluation. Efforts are needed to tackle both 'supply' and 'demand' factors of Pakistan's kidney trade, with developed countries also having a responsibility to reduce the flow of citizens travelling to Pakistan to purchase a kidney.

The Fragility Fracture Postoperative Mobilisation multicentre audit : the reality of weightbearing practices following operations for lower limb fragility fractures.

AIMS: The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. METHODS: The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, "all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living". RESULTS: A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). CONCLUSION: Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J 2022;104-B(8):972-979.

The effect of three-dimensional (3D) printing on quantitative and qualitative outcomes in paediatric orthopaedic osteotomies: a systematic review.

Three-dimensional (3D) printing technology is increasingly being utilized in various surgical specialities. In paediatric orthopaedics it has been applied in the pre-operative and intra-operative stages, allowing complex deformities to be replicated and patient-specific instrumentation to be used. This systematic review analyses the literature on the effect of 3D printing on paediatric orthopaedic osteotomy outcomes.A systematic review of several databases was conducted according to PRISMA guidelines. Studies evaluating the use of 3D printing technology in orthopaedic osteotomy procedures in children (aged ≤ 16 years) were included. Spinal and bone tumour surgery were excluded. Data extracted included demographics, disease pathology, target bone, type of technology, imaging modality used, qualitative/quantitative outcomes and follow-up. Articles were further categorized as either 'pre-operative' or 'intra-operative' applications of the technology.Twenty-two articles fitting the inclusion criteria were included. The reported studies included 212 patients. There were five articles of level of evidence 3 and 17 level 4.A large variety of outcomes were reported with the most commonly used being operating time, fluoroscopic exposure and intra-operative blood loss.A significant difference in operative time, fluoroscopic exposure, blood loss and angular correction was found in the 'intra-operative' application group. No significant difference was found in the 'pre-operative' category.Despite a relatively low evidence base pool of studies, our aggregate data demonstrate a benefit of 3D printing technology in various deformity correction applications, especially when used in the 'intra-operative' setting. Further research including paediatric-specific core outcomes is required to determine the potential benefit of this novel addition. Cite this article: EFORT Open Rev 2021;6:130-138. DOI: 10.1302/2058-5241.6.200092.

Radiation in orthopaedics (RIO) study: a national survey of UK orthopaedic surgeons.

OBJECTIVES: Orthopaedic surgeons have a responsibility to minimise risks of ionising radiation to patients, themselves and staff. This study aims to establish the understanding of radiation practice, legislation and risk by orthopaedic surgeons. METHODS: A nationwide online survey of UK-based orthopaedic surgeons was conducted. Participants answered 18 multiple-choice questions assessing level of radiation safety training, basic principles/knowledge of ionising radiation, relevant legislation and operating practice. RESULTS: A total of 406 surgeons completed the survey. 92% reported using intraoperative ionising radiation at least once per week. 38% received no formal training on radiation safety. Knowledge of basic principles of radiation and legislation was limited. There was variable knowledge when labelling an image intensifier machine and choosing its safest orientation. Poor uptake of radiation protection equipment was noted. Only 19% agreed they had adequate training in ionising radiation safety and 27% reported receiving adequate training in equipment emitting ionising radiation in the operating theatre. CONCLUSION: Many orthopaedic surgeons in the UK do not believe they are adequately trained in radiation safety. There is a deficiency amongst practicing surgeons in basic knowledge, relevant legislation and practicalities of the use of ionising radiation in the operating room. This could potentially put patients and health-care professionals at additional risk. We recommend that a standardised national training programme on the basic principles and safety of ionising radiation is implemented for all practicing orthopaedic surgeons. ADVANCES IN KNOWLEDGE: This paper is the first UK national survey amongst orthopaedic surgeons and is one of the largest reported internationally.

What is the optimal treatment for equinus deformity in walking-age children with clubfoot? A systematic review.

Equinus contracture is the most common deformity at clubfoot relapse and causes pain and functional limitation. It presents a challenge to the orthopaedic surgeon throughout childhood.A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were: (i) original articles, (ii) investigating management of relapsed idiopathic clubfoot, (iii) with at least a partial study population of primarily equinus deformity, and (iv) a paediatric study population of independent walking age.Nine studies were included with a total of 163 patients (207 feet). Studies presented five management paradigms: gastrocnemius-soleus complex release, extensive posterior soft tissue and joint release, anterior distal tibial hemi-epiphysiodesis, distal tibial osteotomy, and circular frame distraction.All approaches reported success in at least one of our selected outcome domains: plantigrade status, range of motion, clinical outcome scores, functional status, radiographic outcomes, patient-reported outcomes, and complications. Younger children tend to be managed with soft tissue release while older children tend to require more extensive bone/joint procedures. Relapse in surgically treated feet is harder to treat.Comparison across treatment approaches is limited by the small size and low evidence level of the literature, as well as a lack of consistent outcome reporting. It is therefore not possible to recommend any one treatment option in any age group.This review highlights the need for a validated core outcome set to enable high-quality research into the management of equinus deformity. Cite this article: EFORT Open Rev 2021;6:354-363. DOI: 10.1302/2058-5241.6.200110.

Response of the Pre-Oriented Goal-Directed Attention to Usual and Unusual Distractors: A Preliminary Study.

INTRODUCTION: In this study, we investigated the distraction power of the unusual and usual images on the attention of 20 healthy primary school children. METHODS: Our study was different from previous ones in that the participants were asked to fix the initial position of their attention on a predefined location after being presented with unusual images as distractors. The goals were presented in locations, which were far from the attraction basin of distractors. We expected that the pre-orienting of the attention to the position of targets would reduce the attractive effect of unusual images compared to the usual ones. The percentage of correct responses and the reaction time were measured as behavioral indicators of attention performance. RESULTS: Results showed that using the goal-directed attention, subjects ignored both kinds of distractors nearly the same way. CONCLUSION: With regard to previous reports about more attraction towards the unusual images, it is suggested that the dynamics of the visual attention system be sensitive to the initial condition. That is, changing the initial position of the attention can lead to the decrement of the unusual images effects. However, several other possibilities such as a probable delay in processing unusual features could explain this observation, too.