Ankle fracture internal fixation performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary, multicentre randomized controlled trial.

Aims: Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. Methods: We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs. Results: Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym2, 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time. Conclusion: Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required.

Hip fracture surgery performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary multicentre randomized controlled trial.

Aims: To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods: This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results: Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion: Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required.

Assessing technical skill in ankle fracture surgery from the postoperative radiograph : pilot development and validation of a final product analysis core outcome set.

AIMS: To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten's criteria for effective assessment. METHODS: An e-Delphi exercise was undertaken at a major trauma centre (n = 39) to identify relevant parameters. Feasibility was tested by two authors. Reliability and validity was tested using postoperative radiographs of ankle fracture operations performed by trainees enrolled in an educational trial (IRCTN 20431944). To determine construct validity, trainees were divided into novice (performed < ten cases at baseline) and intermediate groups (performed ≥ ten cases at baseline). To assess concurrent validity, the procedure-based assessment (PBA) was considered the gold standard. The inter-rater and intrarater reliability was tested using a randomly selected subset of 25 cases. RESULTS: Overall, 235 ankle ORIFs were performed by 24 postgraduate year three to five trainees during ten months at nine NHS hospitals in England, UK. Overall, 42 PBAs were completed. The e-Delphi panel identified five 'final product analysis' parameters and defined acceptability thresholds: medial clear space (MCS); medial malleolar displacement (MMD); lateral malleolar displacement (LMD); tibiofibular clear space (TFCS) (all in mm); and talocrural angle (TCA) in degrees. Face validity, content validity, and feasibility were excellent. PBA global rating scale scores in this population showed excellent construct validity as continuous (p < 0.001) and categorical (p = 0.001) variables. Concurrent validity of all metrics was poor against PBA score. Intrarater reliability was substantial for all parameters (intraclass correlation coefficient (ICC) > 0.8), and inter-rater reliability was substantial for LMD, MMD, TCA, and moderate (ICC 0.61 to 0.80) for MCS and TFCS. Assessment was time efficient compared to PBA. CONCLUSION: Assessment of technical skill in ankle fracture surgery using the first postoperative radiograph satisfies the tested Van der Vleuten's utility criteria for effective assessment. 'Final product analysis' assessment may be useful to assess skill transfer in the simulation-based research setting. Cite this article: Bone Jt Open 2022;3(6):502-509.

Disruption to Surgical Training during Covid-19 in the United States, United Kingdom, Canada, and Australasia: A Rapid Review of Impact and Mitigation Efforts.

OBJECTIVE: To synthesise the current evidence of pandemic-related impact on surgical training internationally and describe strategies that have been put in place to mitigate disruption. DESIGN: Rapid scoping review of publically available published web-literature. SETTING: Five large English speaking countries; United States (US), United Kingdom (UK), Canada, Australia and New Zealand (NZ). RESULTS: Recruitment and selection to residency programmes in the US, Australia and NZ has been largely unaffected. Canada has implemented video-conferencing in lieu of face-to-face interviews. The UK has relied upon trainee self-assessment for selection. Widespread postponement and cancellation of surgical board examinations was seen across the studied countries. Resident assessment-in-training and certification procedures have been heavily modified. Most didactics have moved online, with some courses and conferences cancelled where this has not been possible. None of the studied countries had a central mandate on resident operating privileges during Covid-19. CONCLUSIONS: The collective response by international surgical training bodies to the dual challenges of safeguarding residents whilst minimising disruption to training has been agile and resident centred. The pandemic has exposed weaknesses in existing training systems and has highlighted opportunity for future improvement.

Current provision of simulation in the UK and Republic of Ireland trauma and orthopaedic specialist training: a national survey.

AIMS: The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation. METHODS: The development of the survey was a collaborative effort between the authors and the British Orthopaedic Association Simulation Group. The survey items were embedded in the Performance and Opportunity Dashboard, which annually audits quality in training across several domains on behalf of the Speciality Advisory Committee (SAC). The survey was sent via email to the 30 training programme directors in March 2019. Data were retrieved and analyzed at the Warwick Clinical Trials Unit, UK. RESULTS: Overall, 28 of 30 programme directors completed the survey (93%). 82% of programmes had access to high-fidelity simulation facilities such as cadaveric laboratories. More than half (54%) had access to a non-technical skills simulation training. Less than half (43%) received centralized funding for simulation, a third relied on local funding such as the departmental budget, and there was a heavy reliance on industry sponsorship to partly or wholly fund simulation training (64%). Provision was higher in the mid-stages (ST3-5) compared to late-stages (ST6-8) of training, and was formally timetabled in 68% of prostgrammes. There was no assessment of the impact of simulation training using objective behavioural measures or real-world clinical outcomes. CONCLUSION: There is currently widespread, but variable, provision of simulation in T&O training in the UK and RoI, which is likely to expand further with the new curriculum. It is important that research activity into the impact of simulation training continues, to develop an evidence base to support investment in facilities and provision.

Assessment of technical skill in hip fracture surgery using the postoperative radiograph: pilot development and validation of a final product analysis core outcome set.

AIMS: To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten's criteria for effective assessment. METHODS: A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases. RESULTS: In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four 'final product analysis' (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA. CONCLUSION: Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre.Cite this article: Bone Joint Open 2020;1-9:594-604.

Analysis of Tools Used in Assessing Technical Skills and Operative Competence in Trauma and Orthopaedic Surgical Training: A Systematic Review.

BACKGROUND: Robust assessment of skills acquisition and surgical performance during training is vital to ensuring operative competence among orthopaedic surgeons. A move to competency-based surgical training requires the use of tools that can assess surgical skills objectively and systematically. The aim of this systematic review was to describe the evidence for the utility of assessment tools used in evaluating operative performance in trauma and orthopaedic surgical training. METHODS: We performed a comprehensive literature search of MEDLINE, Embase, and Google Scholar databases to June 2019. From eligible studies we abstracted data on study aim, assessment format (live theater or simulated setting), skills assessed, and tools or metrics used to assess surgical performance. The strengths, limitations, and psychometric properties of the assessment tools are reported on the basis of previously defined utility criteria. RESULTS: One hundred and five studies published between 1990 and 2019 were included. Forty-two studies involved open orthopaedic surgical procedures, and 63 involved arthroscopy. The majority (85%) were used in the simulated environment. There was wide variation in the type of assessment tools in used, the strengths and weaknesses of which are assessor and setting-dependent. CONCLUSIONS: Current technical skills-assessment tools in trauma and orthopaedic surgery are largely procedure-specific and limited to research use in the simulated environment. An objective technical skills-assessment tool that is suitable for use in the live operative theater requires development and validation, to ensure proper competency-based assessment of surgical performance and readiness for unsupervised clinical practice. CLINICAL RELEVANCE: Trainers and trainees can gain further insight into the technical skills assessment tools that they use in practice through the utility evidence provided.

Cadaveric simulation versus standard training for postgraduate trauma and orthopaedic surgical trainees: protocol for the CAD:TRAUMA study multicentre randomised controlled educational trial.

INTRODUCTION: The quantity and quality of surgical training in the UK has been negatively affected by reduced working hours and National Health Service (NHS) financial pressures. Traditionally surgical training has occurred by the master-apprentice model involving a process of graduated responsibility, but a modern alternative is to use simulation for the early stages of training. It is not known if simulation training for junior trainees can safeguard patients and improve clinical outcomes. This paper details the protocol for a multicentre randomised controlled educational trial of a cadaveric simulation training intervention versus standard training for junior postgraduate orthopaedic surgeons-in-training. This is the first study to assess the effect of cadaveric simulation training for open surgery on patient outcome. The feasibility of delivering cadaveric training, use of radiographic and clinical outcome measures to assess impact and the challenges of upscaling provision will be explored. METHODS AND ANALYSIS: We will recruit postgraduate orthopaedic surgeons-in-training in the first 3 years (of 8) of the specialist training programme. Participants will be block randomised and allocated to either cadaveric simulation or standard 'on-the-job' training, learning three common orthopaedic procedures, each of which is a substudy within the trial. The procedures are (1) dynamic hip screw, (2) hemiarthroplasty and (3) ankle fracture fixation. These procedures have been selected as they are very common procedures which are routinely performed by junior surgeons-in-training. A pragmatic approach to sample size is taken in lieu of a formal power calculation as this is novel exploratory work with no a priori estimate of effect size to reference. The primary outcome measure is the technical success of the surgery performed on patients by the participating surgeons-in-training during the follow-up period for the three substudy procedures, as measured by the implant position on the postoperative radiograph. The secondary outcome measures are procedure time, postoperative complication rate and patient health state at 4 months postoperation (EQ-5D-substudies 1 and 2 only). ETHICS, REGISTRATION AND DISSEMINATION: National research ethics approval was granted for this study by the NHS Research Authority South Birmingham Research Ethics Committee (15/WM/0464). Confidentiality Advisory Group approval was granted for accessing radiographic and outcome data without patient consent on 27 February 2017 (16/CAG/0125). The results of this trial will be submitted to a peer-reviewed journal and will inform educational and clinical practice. TRIAL REGISTRATION NUMBER: ISRCTN20431944.

How Does Cadaveric Simulation Influence Learning in Orthopedic Residents?

OBJECTIVE: The objectives of this study were to understand how cadaveric simulation impacts learning in orthopedic residents, why it is a useful training tool, and how skills learnt in the simulated environment translate into the workplace. DESIGN: This is a qualitative research study using in-depth, semistructured interviews with orthopedic residents who underwent an intensive cadaveric simulation training course. SETTING: The study was conducted at the University Hospital Coventry & Warwickshire, a tertiary care center with integrated cadaveric training laboratory in England, United Kingdom. PARTICIPANTS: Orthopedic surgery residents in the intervention group of a randomized controlled trial comparing intensive cadaveric simulation training with standard "on the job" training were invited to participate. Eleven of 14 eligible residents were interviewed (PGY 3-6, 8 male and 3 female). RESULTS: Learning from cadaveric simulation can be broadly categorized into intrinsic, surgeon-driven factors, and extrinsic environmental factors. Intrinsic factors include participant ability to "buy-in" to the simulation exercise, willingness to push one's own learning boundaries in a "safe space" and take out on resident experience and self-reported confidence, with the greatest learning gains seen at around the PGY4 stage in individuals who reported low preintervention operative confidence. Extrinsic factors included; the opportunity to perform operations in their entirety without external pressures or attending "take-over," leading to subjective improvement in participant operative fluency and confidence. The intensive supervision of subspecialist attending surgeons giving real-time performance feedback, tips and tricks, and the opportunity to practice unusual approaches was highly valued by participants, as was paired learning with alternating roles as primary surgeon/assistant and multidisciplinary involvement of scrub-staff and radiographers. Cadaveric simulation added educational value beyond that obtained in low-fidelity simulation training by "stirring into practice" and "becoming through doing." In providing ultrarealistic representation of the space, ritualism, and costuming of the operating theater, cadaveric simulation training also enabled the development of a range of nontechnical skills and sociocultural "nontechnical" lessons of surgery. CONCLUSIONS: Cadaveric simulation enhances learning in both technical and nontechnical skills in junior orthopedic residents within a single training package. Direct transfer of skills learnt in the simulation training to the real-world operating theater, with consequent patient benefit, was reported. Cadaveric simulation in the UK training system of orthopedics may be of greatest utility at around the PGY 4 stage, at which point operative fluency, independence, and confidence can be rapidly improved in the cadaveric laboratory, to enable the attainment of competence in index trauma operations.

The effect of regional trauma networks on paediatric trauma care in an integrated adult service.

OBJECTIVE: Our study analyzes the impact of becoming a major trauma centre (MTC) on paediatric trauma workload in a centre outside a major city without specialist paediatric surgical services. METHODS: Paediatric 'trauma calls' presenting between 1 April 2010 and 31 March 2013 were retrospectively reviewed. As our centre became an MTC on 1 April 2012, our study population was split into 'pre-MTC' and 'post-MTC' groups. Patient demographics, mechanism of injury, patient outcome, Injury Severity Score and results of radiological investigations were recorded. RESULTS: There were 132 paediatric trauma calls, with a 72% annual increase post-MTC. More children with minor injuries, according to the Injury Severity Score, were seen post-MTC (47.5 vs. 29.6%). Although the proportion of patients undergoing a CT scanning remained static, the actual number increased and a higher proportion were normal in the post-MTC group (72.9 vs. 52.4%). This contributed to a higher proportion of patients being discharged home directly from the emergency department post-MTC (47.5 vs. 36.6%). Practice moved away from targeted CT scanning, in favour of trauma scanning post-MTC. CONCLUSION: The implementation of a regional trauma network has led to a rise in paediatric trauma cases. Paediatric trauma patients tend to be less severely injured, but the proportion undergoing CT scanning has remained the same, and these scans are more likely to be normal. A more rational approach for imaging of paediatric trauma patients is required to reduce the potentially harmful effects of exposure to ionizing radiation, and criteria for implementing trauma calls in children should be reconsidered.

Developmental dysplasia of the hip.

The close interaction between community practitioners and young families provides an invaluable opportunity for prevention, education, support and even diagnosis in cases of developmental hip dysplasia. This article provides a brief overview of the condition, including clinical findings, screening protocols, 'hip safe' practices, and common treatments that may be encountered in the community.

Improving parental satisfaction in pediatric orthopaedics.

BACKGROUND: No previous studies have attempted to measure parental satisfaction and service quality with regards to pediatric orthopaedic inpatient care. We performed a prospective observational study to identify areas of inpatient care which might be improved to increase overall parental satisfaction. METHODS: We used the validated Swedish parent satisfaction questionnaire to generate data from 104 pediatric orthopaedic hospital inpatients between August 2009 and May 2010 (49 elective and 55 trauma pediatric orthopaedic admissions; median age range, 2 to 6 y). Questions focused on 8 domains of quality: information on illness, information on routines, accessibility, medical treatment, care processes, staff attitudes, parent participation, and staff work environment. Scores generated a percentage of the maximum achievable for that quality index. Data were analyzed using recognized statistical methods. RESULTS: Overall mean combined scores for the care indices were highest for parents' perception of "medical treatment" (95%) and "staff attitudes" (95%). The medical treatment index includes questions regarding staff member's skill and competence. Lowest scores corresponded to the index "information on routines" (86%). DISCUSSION: Information on routines applies to parental awareness of ward rounds, to whom questions should be directed and which doctors and nursing staff are responsible for their child's care. Lower scores in relation to this index were substantiated by comments from relatives requesting greater information provision. The information parents required was routinely provided suggesting that retention rather than lack of information is the main issue. Provision of information pamphlets tailored to common injuries or elective procedures might prove an effective method for improving parental satisfaction and overall care. Improving information provision and parental retention of this information is the strategy most likely to improve quality of service and parental satisfaction for pediatric orthopaedic inpatient care. LEVEL OF EVIDENCE: Level 2 evidence, prospective comparative study investigating results of treatment.

Modelling the effects of the weather on admissions to UK trauma units: a cross-sectional study.

OBJECTIVE: To assess the relationship between daily trauma admissions and observed weather variables, using data from the Trauma Audit and Research Network of England and Wales and the UK Meteorological Office. DESIGN: A cross-sectional study. SETTING: Twenty-one accident and emergency departments (ED) located across England. PARTICIPANTS: All patients arriving at one of the selected ED, with a subsequent death, inpatient stay of greater than 3 days, interhospital transfer or requiring critical care between 1 January 1996 and 31 December 2006. MAIN OUTCOME MEASURES: Daily counts of adult and paediatric trauma admissions. RESULTS: Multivariate regression analysis indicated that there were strong seasonal trends in paediatric (χ(2) likelihood ratio test p<0.001), and adult (p=0.016) trauma admissions. For adults, each rise of 5°C in the maximum daily temperature and each additional 2 h of sunshine caused increases in trauma admissions of 1.8% and 1.9%. Effects in the paediatric group were considerably larger, with similar increases in temperature and hours of sunshine causing increases in trauma admissions of 10% and 6%. Each drop of 5°C in the minimum daily temperature, eg, due to a severe night time frost, caused adult trauma admissions to increase by 3.2%. Also the presence of snow increased adult trauma admissions by 7.9%. CONCLUSION: This is the largest study of its kind to investigate and quantify the relationship between trauma admissions and the weather. The results show clear associations that have direct application for planning and resource management in UK ED.

Optimal sequencing of bedside teaching and computer-based learning: a randomised trial.

OBJECTIVES: We aimed to establish the most effective order in which to deliver teaching to medical students when using both bedside teaching (BT) and computer-based learning (CBL) and to ascertain the students' preferred method and order of delivery. METHODS: A sample of 28 medical students were randomly divided into two equal groups during their orthopaedic knee examination teaching session. Group 1 received standard BT and group 2 undertook a CBL package. Each group then undertook an objective structured clinical examination (OSCE). The groups then received the other method of teaching followed by another OSCE. A questionnaire was administered to all students to assess their views on, and preferences for, the various teaching methods. RESULTS: Mean scores on the first OSCE were 12.19 for group 1 (BT then CBL) and 11.96 for group 2 (CBL then BT) (P = 0.692). Mean scores on the second OSCE were 11.81 for group 1 compared with 12.79 for group 2 (P = 0.038). Statistical analysis showed a significantly better score improvement for group 2 (CBL then BT) over group 1 (BT then CBL). Of the 26 students who returned questionnaires, 24 (92%) expressed their preference for traditional BT over CBL only, and 23 (88%) were in favour of undertaking CBL prior to traditional BT. CONCLUSIONS: The CBL package is a useful tool and is most effective if used before BT. Students prefer BT alone over CBL alone, but, if offered both, prefer to undertake CBL first.

Patient-reported outcomes after total hip and knee arthroplasty: comparison of midterm results.

The aim of this study was to compare the midterm functional outcomes of total knee arthroplasty (TKA) and total hip arthroplasty (THA). A cross-sectional postal audit survey of all consecutive patients who had a primary joint replacement at one orthopedic center 5 to 8 years ago was conducted. Participants completed an Oxford hip score or Oxford knee score, which are self-report measures of functional ability. Completed questionnaires were returned from 1112 THA patients and 613 TKA patients, giving a response rate of 72%. The median Oxford knee score of 26 was significantly worse than the median Oxford hip score of 19 (P < .001). In conclusion, TKA patients experience a significantly poorer functional outcome than THA patients 5 to 8 years postoperatively.

Dislocation following total hip replacement: the Avon Orthopaedic Centre experience.

INTRODUCTION: The aim of this study was to determine the incidence and outcome of dislocation after total hip arthroplasty at our unit. PATIENTS AND METHODS: In total, 1727 primary total joint arthroplasties and 305 revision total hip arthroplasties were performed between 1993 and 1996 at our unit. We followed up 1567 (91%) of the primary hip arthroplasties and 284 (93%) of the revision hip arthroplasties at 8-11 years after surgery. Patients were traced by postal questionnaire, telephone interview or examination of case notes of the deceased. RESULTS: The dislocation rates by approach were 23 out of 555 (4.1%) for the posterior approach, 0 out of 120 (0%) for the Omega approach and 30 out of 892 (3.4%) for the modified Hardinge approach. Of dislocations after primary total hip arthroplasty, 58.5% were recurrent. The mean number of dislocations per patient was 2.81. Overall, 8.1% of revision total hip arthroplasties dislocated. 70% of these became recurrent. The mean number of dislocations per patient was 2.87. The vast majority of dislocations occurred within 2 months of surgery. DISCUSSION: To our knowledge, this is the largest multisurgeon audit of dislocation after total hip arthroplasty published in the UK. The follow-up of 8-11 years is longer than most comparable studies. The results of this study can be used to inform patients as to the risk and outcome of dislocation, as well as to the risk of further dislocation.

Early death following primary total hip arthroplasty: 1,727 procedures with mechanical thrombo-prophylaxis.

BACKGROUND: The aims of this study were to quantify the risk and identify the causes of early postoperative mortality after total hip arthroplasty. This would help clinicians address preventable causes of death and help in accurate counseling and consenting of patients. METHODS: We determined the death rate at 90 days in an unselected consecutive series of 1,727 primary total hip arthroplasties where patients had not routinely received chemothromboprophylaxis. RESULTS: The mortality at 90 days was 17/1,727 (1%). The 90-day mortality was 0.2% in patients under 70 years of age, 1.3% in patients between 70 and 80, and 2.5% in those over 80. 7 patients died from ischemic heart disease, 4 died following cerebrovascular events, and 2 from pulmonary embolism. 4 patients died from non-vascular causes. Of the vascular deaths, ischemic heart disease outnumbered cerebrovascular events which, in turn, outnumbered pulmonary embolism (7 vs. 4 vs. 2). INTERPRETATION: Strategies aimed at reducing deaths should address all vascular causes, not just pulmonary embolism. Our findings can be used to inform patients as to the risk of early death after total hip arthroplasty.

The Oxford Knee Score; problems and pitfalls.

The Oxford Knee Score is a self-completed patient based outcome score. We audited the outcome of total knee arthroplasty at our unit using the Oxford Knee Score. The hypothesis of this study is that the OKS can be easily and accurately completed by unassisted patients. Of 856 patients who had undergone total knee arthroplasty and were given questionnaires, 769 (90%) responded. 624 (81%) of the respondents managed to complete the questionnaire. A number of the 12 items composing the questionnaire posed problems for the patients and a number of items were left blank. Item 4 (concerning walking time) was omitted in 82 (13%) of the 624 completed questionnaires. Calculation of Cronbach's alpha for internal consistency suggests that there are redundancies within the Score. Limitations in some of the items of the scale suggest the need for reconsideration and reformulation of questions and response categories. This study suggests that where detailed assessment of outcome is required, such as for outcome studies or controlled trials, the Oxford Knee Score, in its present form, is not ideal for use as a postal questionnaire.