Women in trauma and orthopaedics: are we losing them at the first hurdle?

INTRODUCTION: Diversity in the healthcare workforce is associated with improved performance and patient-reported outcomes. Gender disparity in Trauma and Orthopaedics (T&O) is well recognised. The aim of this study was to compare factors that influence career choice in T&O between male and female final-year students. Furthermore, the trend of representation of women in T&O over the last decade was also compared with other surgical specialities. METHODS: An online survey of final-year students who attended nationally advertised T&O courses over a 2-year period was conducted. Data from NHS digital was obtained to assess gender diversity in T&O compared with other surgical specialities. RESULTS: A total of 414 students from 13 UK medical schools completed the questionnaire. Compared with male students (34.2%), a significantly higher proportion of women (65.8%) decided against a career in T&O, p<0.001. Factors that dissuaded a significantly higher percentage of women included gender bias, technical aspects of surgery, unsociable hours, on-call commitments, inadequate undergraduate training and interest in another specialty (p<0.05). Motivating factors for choosing a career in T&O were similar between both sexes. T&O was the surgical specialty with the lowest proportion of women at both consultant and trainee level over the last decade. CONCLUSION: T&O remains an unpopular career choice among women. To enhance recruitment of women in T&O, future strategies should be directed toward medical students. Universities, orthopaedic departments and societies must work collaboratively to embed culture change, improve the delivery of the undergraduate curriculum, and facilitate students' exposure to operating theatres and female role models.

Complications and mortality associated with olecranon fractures in the elderly: a retrospective cohort comparison from a large level one trauma centre.

Background: Olecranon fractures in the elderly have an increasing incidence. This retrospective study aims to identify the complications and survivorship of these patients. Methods: All patients >70 years old treated for an olecranon fracture at our institution were identified between 2007 and 2019. Loss of reduction and/or metalwork loosening was recorded. Also noted were wound healing problems, deep/superficial infections, and any subsequent treatment including return to surgery and/or removal of metalwork. Results: From a total of 177 cases, 28 presented with concomitant fractures (16%), half of which were hip fractures. The largest treatment group underwent tension band wiring (n = 82, 46%, mean age 80.8 yrs). Twenty-one of these suffered failure of fixation (26%), all requiring return to surgery. The second largest treatment group underwent plating (n = 50 28%, mean age 80.1 yrs). Four of these suffered failure of fixation (8%), all requiring return to surgery. Forty-four patients were treated non-operatively (25%, mean age 83.8 yrs). Two patients suffered other complications (4.5%). Overall 1 year survivorship was 0.82. Discussion: Olecranon fractures in the elderly have higher than expected 1 year mortality rates. Operative management results in high complication rates, often requiring return to surgery for metalwork problems. Significant consideration of treatment options is required in this cohort.

Survivorship of fixed vs mobile bearing unicompartmental knee replacement: A systematic review and meta-analysis of sixty-four studies and National Joint Registries.

BACKGROUND: Unicompartmental knee replacement (UKR) prostheses can use fixed (FB) or mobile bearing (MB) constructs. We compared survivorship and failure modes of both designs. METHODS: The inclusion criteria were studies published between 2005 and 2020 with minimum average follow-up of five years reporting the survival and/or number of revisions of specific designs in medial and lateral UKRs. Pooled rate of revision per 100 patient years (PTIR) was estimated using a random effects model. RESULTS: Seventy cohorts of 17,405 UKRs with weighted mean follow-up of 7.3 years (0.1-29.4 years) were included. A total of 170,923 UKRs were identified in registry reports at a weighted mean implant survival time of 15.4 years. PTIR in MB UKR versus FB UKR was similar [1.45 vs 1.40, (p = 0.8)]. In cohort studies, the overall PTIR for MB was also similar to FB [1.03 vs 0.78, (p = 0.1)]. For medial UKR, the PTIR for MB was marginally greater but not significantly different to FB [0.96 vs 0.81, (p = 0.3)], whilst for lateral UKR, the PTIR for MB was significantly worse than for FB [2.20 vs 0.72, (p < 0.01)]. Polyethylene wear is more common in FB implants, whilst MB implants are revised more often for bearing dislocation. CONCLUSIONS: Overall implant survival in mid- to long-term studies is similar for MB versus FB medial UKRs. MB have a four-fold higher risk of revision in comparison to FB when used for lateral UKR.

A novel mechanical inclinometer device to measure acetabular cup inclination in total hip arthroplasty.

It is well recognised that acetabular cup orientation influences patient function and implant survival post-THR. Reliable intra-operative determination of cup orientation remains a challenge. We describe the design and testing of a novel mechanical inclinometer to measure intra-operative acetabular cup inclination. The aim was to design a generic inclinometer to measure acetabular inclination to within + 5° without requiring modification to existing instrumentation while remaining easy to handle, robust/reusable, and sterilizable. The device was drafted using CAD software, prototyped using a 3D printer and constructed using stainless steel. Two experiments were undertaken to test accuracy: (1) the absolute accuracy was tested; (2) placement of an acetabular component using the device was compared to a freehand technique using a sawbone pelvis. 18 surgeons were asked to place an uncemented acetabular cup in a saw bone pelvis to a target of 40°. The average root-mean-square error was 1.1° (SD: 0.9°). Comparison showed that with the freehand component placement 50% of the surgeons were outside the specified range (35°-45°) where all participants achieved placement within range when using the inclinometer. This work demonstrates that the design and initial testing of a mechanical inclinometer which is suitable for use in determining the acetabular cup inclination in THR.

Risk Factors for Revision of Polished Taper-Slip Cemented Stems for Periprosthetic Femoral Fracture After Primary Total Hip Replacement: A Registry-Based Cohort Study from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.

BACKGROUND: Total hip replacement (THR) with a cemented polished taper-slip (PTS) femoral stem has excellent long-term results but is associated with a higher postoperative periprosthetic femoral fracture (PFF) risk compared with composite beam stems. This study aimed to identify risk factors associated with PFF revision following THR with PTS stems. METHODS: In a retrospective cohort study, 299,019 primary THRs using PTS stems from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) were included, with a median follow-up of 5.2 years (interquartile range [IQR], 3.1 to 8.2 years). The adjusted hazard ratio (HR) of PFF revision was estimated for each variable using multivariable Cox survival regression analysis. RESULTS: Of 299,019 THR cases, 1,055 underwent revision for PFF at a median time of 3.1 years (IQR, 1.0 to 6.1 years). The mean age (and standard deviation) was 72 ± 9.7 years, 64.3% (192,365 patients) were female, and 82.6% (247,126 patients) had an American Society of Anesthesiologists (ASA) class of 1 or 2. Variables associated with increased PFF were increasing age (HR, 1.02 per year), intraoperative fracture (HR, 2.57 [95% confidence interval (CI), 1.42 to 4.66]), ovaloid (HR, 1.96 [95% CI, 1.22 to 3.16]) and round cross-sectional shapes (HR, 9.58 [95% CI, 2.29 to 40.12]), increasing stem offset (HR, 1.07 per millimeter), increasing head size (HR, 1.04 per millimeter), THR performed from 2012 to 2016 (HR, 1.45 [95% CI, 1.18 to 1.78]), cobalt-chromium stem material (HR, 6.7 [95% CI, 3.0 to 15.4]), and cobalt-chromium stems with low-viscosity cement (HR, 22.88 [95% CI, 9.90 to 52.85]). Variables associated with a decreased risk of PFF revision were female sex (HR, 0.52 [95% CI, 0.45 to 0.59]), increasing stem length (HR, 0.97 per millimeter), and a ceramic-on-polyethylene bearing (HR, 0.55 [95% CI, 0.36 to 0.85]). CONCLUSIONS: Increased risk of PFF revision was associated with PTS stems that are short, have high offset, are used with large femoral heads, are made of cobalt-chromium, or have ovaloid or round cross-sectional shapes. Large increases in PFF risk were associated with cobalt-chromium stems used with low-viscosity cement. Further study is required to confirm causation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A calcar collar is protective against early periprosthetic femoral fracture around cementless femoral components in primary total hip arthroplasty: a registry study with biomechanical validation.

AIMS: The aim of this study was to estimate the 90-day risk of revision for periprosthetic femoral fracture associated with design features of cementless femoral stems, and to investigate the effect of a collar on this risk using a biomechanical in vitro model. MATERIALS AND METHODS: A total of 337 647 primary total hip arthroplasties (THAs) from the United Kingdom National Joint Registry (NJR) were included in a multivariable survival and regression analysis to identify the adjusted hazard of revision for periprosthetic fracture following primary THA using a cementless stem. The effect of a collar in cementless THA on this risk was evaluated in an in vitro model using paired fresh frozen cadaveric femora. RESULTS: The prevalence of early revision for periprosthetic fracture was 0.34% (1180/337 647) and 44.0% (520/1180) occurred within 90 days of surgery. Implant risk factors included: collarless stem, non-grit-blasted finish, and triple-tapered design. In the in vitro model, a medial calcar collar consistently improved the stability and resistance to fracture. CONCLUSION: Analysis of features of stem design in registry data is a useful method of identifying implant characteristics that affect the risk of early periprosthetic fracture around a cementless femoral stem. A collar on the calcar reduced the risk of an early periprosthetic fracture and this was confirmed by biomechanical testing. This approach may be useful in the analysis of other uncommon modes of failure after THA. Cite this article: Bone Joint J 2019;101-B:779-786.

Preservation vs. resection of the infrapatellar fat pad during total knee arthroplasty Part I: A survey of current practice in the UK.

BACKGROUND: The management of the infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) is the subject of ongoing debate. In part 1 of this two-part series, we present an overview of current practice regarding the management of the IPFP in elective TKA among surgeons in the UK. METHODS: A web-based survey was offered to 269 delegates of the BASK 2017 annual conference. RESULTS: The survey showed a large variation in practice. Of the 173 responders, 86.7% were consultants; 62.4% partially resected the IPFP; 23.1% totally resected the IPFP, and 9.8% preserved it. Forty percent felt that resection made a difference. Only 23% stated that they were aware of guidelines/evidence. CONCLUSION: There is wide variation in practice with regard to the IPFP in TKA. The available literature with regard to resection or preservation of the IPFP is not conclusive. IMPLICATIONS: There are no definitive guidelines available for the management of the IPFP in TKA resulting in a wide variation in practice amongst surgeons.

Preservation vs. resection of the infrapatellar fat pad during total knee arthroplasty part II: A systematic review of published evidence.

BACKGROUND: The management of the infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) is the subject of ongoing debate. In part 2 of this two part series the authors aimed to investigate if resection of the IPFP affects clinical outcomes. METHODS: A systematic search of CENTRAL Cochrane library, Medline, Embase and Web-of-science databases for the past 10 years was performed. Studies of patients undergoing primary TKA comparing outcomes between IPFP resection and preservation were included. The meta-analysis was performed with Review Manager 5.3. RESULTS: Seven studies, involving 2815 patients (3312 knees) were included in the systematic review, of which two were RCTs. Outcome measures included patellar tendon length (PTL), post-operative pain, Knee Society Scores (KSS) and Functional Scores. Meta-analysis identified a trend toward shortening of the patellar tendon with IPFP resection. Resection correlated with a lower incidence of post-operative pain at one to two months, however at three to six months pain scores were higher in this group. No statistical difference was found in KSS and Functional Scores. CONCLUSION: There is wide variation in practice with regard to the IPFP in TKA. The available literature with regard to resection or preservation of the IPFP is not conclusive. IMPLICATIONS: There is no clear consensus in the literature on the resection or preservation of the IPFP indicating a clear need for high quality studies in the future to provide meaningful answers.

Epidemiology of pertrochanteric fractures: our institutional experience.

PURPOSE: Hip fractures, a common manifestation of fragility fractures, represent a major cause of morbidity and mortality in the elderly population and may have devastating consequences to the patient, their family, and society thereafter. We attempted to define the epidemiology of pertrochanteric fractures treated at a large university teaching hospital in the UK and compared our findings with the national and international literature. METHODS: Between April 2008 and March 2013, we conducted a retrospective cohort study at our institution. All adult patients sustaining a proximal femoral fracture were included in our study. The following parameters were collected and evaluated: (1) demographics, (2) fracture pattern, (3) American Society of Anaesthesiologists (ASA) grade, (4) type of pre-injury mobilization, and (5) method of stabilization. Our findings were then compared to the national data as published in the National Hip Fracture Database (NHFD). RESULTS: Over a period of 5 years, 3,036 proximal femoral fractures were managed at our institution, with 916 (30.2 %) being classified as pertrochanteric fractures (250 male; mean age 82.0, SD 11.2). No significant change in the incidence of pertrochanteric fractures was evident during the same period. Between 2012 and 2013, 51,705 proximal femoral fractures were recorded in England, of which 19,569 (37.8 %) were classified as pertrochanteric fractures. Comparison between pertrochanteric and intracapsular fractures with respect to their demographics did not reveal any significant difference. In female patients, the relative incidence of pertrochanteric fractures was shown to increase with age. However, this was not the case in the male population. CONCLUSIONS: The incidence of pertrochanteric fractures remained unchanged over the last 5 years. The relative incidence of pertrochanteric fractures is higher in elderly females; this may be explained by reduced bone mineral density and reduced trochanteric bone strength. Rigorous preventive treatments of osteoporosis should be considered in high-risk patients, along with improved safety measures to reduce falls.

Facilitators and barriers to teamworking and patient centeredness in multidisciplinary cancer teams: findings of a national study.

BACKGROUND: Multidisciplinary teams (MDTs) are the standard means of making clinical decisions in surgical oncology. The aim of this study was to explore the views of MDT members regarding contribution to the MDT, representation of patients' views, and dealing with disagreements in MDT meetings-issues that affect clinical decision making, but have not previously been addressed. METHODS: Responses to open questions from a 2009 national survey of MDT members about effective MDT working in the United Kingdom were analyzed for content. Emergent themes were identified and tabulated, and verbatim quotes were extracted to validate and illustrate themes. RESULTS: Free-text responses from 1,636 MDT members were analyzed. Key themes were: (1) the importance of nontechnical skills, organizational support, and good relationships between team members for effective teamworking; (2) recording of disagreements (potentially sharing them with patients) and the importance of patient-centered information in relation to team decision making; (3) the central role of clinical nurse specialists as the patient's advocates, complementing the role of physicians in relation to patient centeredness. CONCLUSIONS: Developing team members' nontechnical skills and providing organizational support are necessary to help ensure that MDTs are delivering high-quality, patient-centered care. Recording dissent in decision making within the MDT is an important element, which should be defined further. The question of how best to represent the patient in MDT meetings also requires further exploration.