Virtual Trauma Meeting as a Component of Undergraduate Orthopaedic Education.

INTRODUCTION: Virtual teaching has proven effective for medical students during the COVID-19 pandemic. This study is the first to describe an undergraduate orthopaedic teaching strategy in the format of virtual trauma meetings (VTM). METHODS: Clinical medical students from the Universities of Bristol and Cardiff were invited to attend five VTM between October and November 2020. These were delivered by consultants and speciality doctors via Zoom software. An 11-item feedback form was distributed after each session to assess the relevance of teaching material, student confidence in asking and answering questions, and if students would benefit from further sessions. Several open-ended questions were designed to evaluate aspects of the session that were most useful, which orthopaedic topics were of high priority and if they had any suggestions for improvement. Our initial aim was to assess student acceptance of the virtual format. Several months later pre-recorded material was uploaded onto YouTube and post hoc questionnaires were analysed. RESULTS: A total of 50 students attended, with a median of 11±6 attending per session, producing a total of 26 feedback responses. Among the responders, there were 10 males and nine females and 63% of the students were in their third year. 100% of students felt comfortable asking questions and 96% felt comfortable answering questions. X-ray interpretation and management of fractures were the highest priority subjects. The majority of students considered the interaction between senior and junior doctors most valuable, and the most common improvement suggested was the inclusion of polls or OSCE-styled questions. CONCLUSIONS: VTM could be a useful resource to enhance undergraduate trauma and orthopaedic (T&O) education by providing student-focused material in an open learning environment.

The EQ-5D-3L administered by text message compared to the paper version for hard-to-reach populations in a rural South African trauma setting: a measurement equivalence study.

INTRODUCTION: Administering patient-reported outcome measures (PROMs) by text message may improve response rate in hard-to-reach populations. This study explored cultural acceptability of PROMs and compared measurement equivalence of the EQ-5D-3L administered on paper and by text message in a rural South African setting. MATERIALS AND METHODS: Participants with upper or lower limb orthopaedic pathology were recruited. The EQ-5D was administered first on paper and then by text message after 24 h and 7 days. Differences in mean scores for paper and text message versions of the EQ-5D were evaluated. Test-retest reliability between text message versions was evaluated using Intraclass Correlation Coefficients (ICCs). RESULTS: 147 participants completed a paper EQ-5D. Response rates were 67% at 24 h and 58% at 7 days. There were no differences in means between paper and text message responses for the EQ-5D Index (p = 0.95) or EQ-5D VAS (p = 0.26). There was acceptable agreement between the paper and 24-h text message EQ-5D Index (0.84; 95% Confidence Interval (CI) 0.78-0.89) and EQ-5D VAS (0.73; 95% CI 0.64-0.82) and acceptable agreement between the 24-h and 7-day text message EQ-Index (0.72; CI 0.62-0.82) and EQ-VAS (0.72; CI 0.62-0.82). Non-responder traits were increasing age, Xhosa as first language and lower educational levels. CONCLUSIONS: Text messaging is equivalent to paper-based measurement of EQ-5D in this setting and is thus a viable tool for responders. Non-responders had similar socioeconomic characteristics and attrition rates to traditional modes of administration. The EQ-5D by text message offers potential clinical and research uses in hard-to-reach populations.

Classification of Bone Defects: An Extension of the Orthopaedic Trauma Association Open Fracture Classification.

OBJECTIVES: To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability. DESIGN: Retrospective classification. SETTING: Tertiary referral trauma center. PATIENTS/PARTICIPANTS: Twenty open fractures with bone loss. INTERVENTION: Assignment of a bone defect classification grade. MAIN OUTCOME MEASUREMENTS: Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1-incomplete defects, D2-minor/subcritical (complete) defects (<2 cm), and D3-segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A-<25% cortical loss, D1B-25%-75% cortical loss, and D1C->75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A-2 oblique ends allowing for possible overlap, D2B-one end oblique/one end transverse, and D2C-2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A-moderate defects, 2 to <4 cm; D3B-major defects, 4 to <8 cm; and D3C-massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests. RESULTS: Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478-0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421-0.1679), P < 0.00001. CONCLUSIONS: This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.

The effect of antibiotic-loaded bone cement on risk of revision following hip and knee arthroplasty.

AIMS: This study aimed to compare the effect of antibiotic-loaded bone cement (ALBC) versus plain bone cement (PBC) on revision rates for periprosthetic joint infection (PJI) and all-cause revisions following primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: MEDLINE, Embase, Web of Science, and Cochrane databases were systematically searched for studies comparing ALBC versus PBC, reporting on revision rates for PJI or all-cause revision following primary elective THA or TKA. A random-effects meta-analysis was performed. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42018107691). RESULTS: Nine studies and one registry report were identified, enabling the inclusion of 371,977 THA and 671,246 TKA. Pooled analysis for THA demonstrated ALBC was protective against revision for PJI compared with PBC (relative risk (RR) 0.66, 95% confidence interval (CI) 0.56 to 0.77; p < 0.001), however, no differences were seen for all-cause revision rate (RR 0.62, 95% CI 0.35 to 1.09; p = 0.100). For TKA, there were no significant differences in revision rates for PJI or all causes between ALBC and PBC (RR 0.92, 95% CI 0.59 to 1.45; p = 0.730, and RR 0.73, 95% CI 0.53 to 1.02; p = 0.060, respectively). CONCLUSION: ALBC demonstrated a protective effect against revision for PJI compared with PBC in THA with no difference in all-cause revisions. No differences in revision rates for PJI and all-cause revision between ALBC and PBC for TKA were observed. Cite this article: Bone Joint J 2021;103-B(1):7-15.

Human-factors training for surgical trainees.

BACKGROUND: Shortcomings in non-technical skills have frequently been shown to play a role in adverse events during surgery. Human-factors training has an increasing role to play in enhancing patient safety and reducing medical errors. Programmes in non-technical skills are promoted by the surgical Royal Colleges in the UK and Ireland, and are currently aimed at consultants, senior trainees and theatre teams. Since 2009, the Severn Postgraduate Deanery School of Surgery in the UK has developed a 1-day human-factors training course specifically designed for junior surgical trainees. METHODS: Analysis of post-course feedback on self-assessed confidence in the use of non-technical skills was undertaken for all junior surgical trainees undertaking the course in 2012/13. RESULTS: Thirty-three junior surgical trainees attended the 1-day human-factors training course. In all, 91 per cent of trainees reported that the course would change their practice. There was a statistically significant difference between the self-assessed confidence of trainees in the use of all four categories of non-technical skills (p ≤ 0.001) before and after the course. DISCUSSION: The Severn Deanery offers a compulsory human-factors training course for surgeons at the start of their career. Given the importance of reducing human error, maintaining patient safety and the introduction of competency-based training with an emphasis on simulation, human-factors training has a vital place in surgical training, and is highly recommended to others involved in training junior surgical trainees.

Early and ultra-early surgery in hip fracture patients improves survival.

BACKGROUND: Hip fracture is a common injury with associated high mortality. Recent drives by the Department of Health have sought to prioritise these patients' care. In April 2010, the Best Practice Tariff was introduced in England and Wales. This offers financial incentives to institutions that provide holistic care and surgery within 36h for hip fracture patients. The England and Wales National Institute for Health and Clinical Excellence (NICE) published its first guidance on hip fracture management in June 2011, and emphasised the need for surgery on the day or day after admission. In spite of the emphasis placed on this injury, the predictors of in-hospital mortality remain ill-defined. In particular the effect of the timing of surgery remains contentious. OBJECTIVE: To address the issues raised by NICE around surgical timing and examine whether surgery before a 36h watershed improves survival. In addition, to examine survival outcomes for each 12h watershed following admission. MATERIALS AND METHODS: Prospectively collected data on 2056 patients presenting to our unit with hip fractures between February 2008 and May 2011 were retrospectively reviewed. Multivariate regression analysis was used to correct for confounders, and so determine the effect of various parameters on in-patient mortality. RESULTS: Age (p<0.0001), male-gender (p<0.0001), source of admission (p<0.05), ASA-grade (p<0.0001) and delay of surgery (p<0.01) were associated with an increased risk of in-hospital mortality. The adjusted odds of in-hospital mortality were 1.58 (p<0.05) times higher in those undergoing surgery after 36h compared to surgery before this time. Early surgery (within 24h) resulted in reduced in-hospital mortality when compared to the 36h watershed. Similarly ultra-early surgery (within 12h) was even better still (adjusted odds ratio 3.9 p<0.05). CONCLUSIONS: Expeditious surgery is associated with improved patient survival. Other predictors of in-hospital mortality include age, gender, in-hospital fracture and ASA-grade. Ultra-early surgery (within 12h) reduces risk of in-hospital mortality.

Serum lactate is a prognostic indicator in patients with hip fracture.

BACKGROUND AND PURPOSE: Serum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures. METHOD AND RESULTS: Over a 38-month period the admission venous lactate of 807 patients with hip fractures was collated. Mean age was 82 years. The overall in-hospital mortality for this cohort was 9.4%. Mortality was not influenced by the fracture pattern or the type of surgery - be it internal fixation or arthroplasty (p = 0.7). A critical threshold of 3 mmol/L with respect to the influence of venous lactate level on mortality was identified. Mortality rate in those with a lactate level of less than 3 mmol/L was 8.6% and 14.2% for those whose level was 3 mmol/L or greater. A 1 mmol/L increase in venous lactate was associated with a 1.2 (1.02-1.41) increased risk of in-hospital mortality. Patients with a venous lactate of 3 mmol/L or higher had twice the odds of death in hospital compared to matched individuals. There was no statistically significant difference in ASA distribution between those with a lactate of less than or greater than 3 mmol/L. CONCLUSIONS: Patients with an elevated venous lactate following hip trauma should be identified as being at increased risk of death and may benefit from targeted medical therapy.

Surgical training in your hands: organising a skills course.

BACKGROUND: The advent of simulated surgical skills courses has brought dynamic changes to the traditional approach to acquiring practical skills in surgery. CONTEXT: Teaching is a core part of the surgical profession, and any trainee can be involved in the organisation of skills training courses. This paper outlines the importance of organising surgical skills courses for trainees, and provides a practical guide on how to do so within busy clinical environments. INNOVATION: The paper examines how to plan a course, how to design the programme, and provides tips on faculty staff requirements, venue, finance and participants, with additional suggestions for assessment and evaluation. IMPLICATIONS: We recommend the organisation of skills courses to any trainee. By following key ground rules, the surgical trainee can enable the acquisition of advanced learning opportunities and the ability to demonstrate valuable organisational skills.

Bilateral subtrochanteric fractures in tumour-induced osteomalacia caused by a nasal haemangiopericytoma.

Bilateral insufficiency fractures of the proximal femur often have a pathological basis. Diagnosis of rare causes of insufficiency fractures can be challenging. Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome of mesenchymal tumours which leads to hypophosphataemia and osteomalacia. Suspected pathological fractures should be investigated thoroughly including a fasting serum phosphate level. Further investigations should include serum levels of fibroblast growth factor 23 (FGF23) which is a peptide hormone secreted by mesenchymal tumours. Available imaging modalities include Octreotide scanning which detects somatostatin receptors commonly expressed on mesenchymal tumours. After localisation and resection of the tumour, a full recovery from TIO is achievable.