Delivering surgical education: a specialist surgical society and undergraduate student collaboration.

Currently, the delivery of the undergraduate medical curriculum includes various teaching, learning and assessment strategies. Self-directed learning is an important aspect of this mix and includes the use of resources, sometimes not provided by the parent University, in the student's own time to enhance the student's knowledge, skills and professional practice. Societies aimed at a particular specialty contain a pool of professionals that can provide undergraduate students with opportunities for further self-directed learning, development of specialty-specific core skills and exploration of research interests. This may then enhance and enlighten the students' approach to a particular orthopaedic problem and reinforce the curriculum they are studying while providing an understanding of current areas of debate that are not part of the curriculum at present. The collaboration of postgraduate societies with undergraduate students in developing and implementing undergraduate engagement strategies is of benefit to undergraduate education, the specialty society and the collaborating students. We explore the planning and implementation of an interactive webinar series run by the British Indian Orthopaedic Society in collaboration with undergraduate students. We provide a case study of a surgical specialty society engaging with undergraduate students with synergistic effect. We pay particular attention to the benefits accrued by the specialty society and the student collaborators by this joint effort.

Early failure of coracoclavicular ligament reconstruction using TightRope system.

This prospective study reports the results of early failure of coracoclavicular (CC) ligament reconstruction using TightRope. Nine consecutive patients who had CC ligament reconstruction using TightRope or GraftRope were assessed for radiological and functional outcomes using DASH and Oxford Shoulder scores. With an average age of 38.4 (21-70) years, four patients had type III injuries, two type IV and two type V injuries. The mean follow-up was 22.8 (12-42) months. In 7 out of 9 patients, secondary progressive loss of reduction was observed at an average of 3.1 (1-7) months. Three patients underwent revision. The mean DASH score at latest follow-up was 27.45 (19.6-35) & Oxford shoulder score was 30.5 (20-43). Coraco-clavicular reconstruction with TightRope or GraftRope appears to result in failure with progressive AC joint subluxation perhaps due to 'windscreen wiper' micromotion. Surgeons should be wary of this potential problem whilst choosing this method of -reconstruction for CC ligament reconstructions.

Acromioclavicular joint Stabilization: Our experience with the lockdown technique.

Background: Acromioclavicular joint (AC joint) disruption is a common injury with considerable variation with regards to surgical management. The Lockdown™ procedure (previously known as Surgilig™), Modified Weaver-Dunn procedure, Arthroscopic AC joint stabilization and Ligament Augmentation and Reconstruction system (LARS) procedure have all been described for treatment of this injury with varying outcomes. Purpose: To measure the functional and radiological outcomes following all cases of AC joint reconstruction using the Lockdown™ technique over the last 10 years at Medway Maritime Hospital. Methods: Data on a total of 53 patients who underwent AC joint reconstruction between 2012 and 2021 were collected. Electronic records were used to extract data regarding patient characteristics, surgery details, and duration of follow-up. Telephonic interviews of patients were conducted to collect data on hand dominance, surgical complications, and responses to Oxford shoulder score (OSS) and QuickDASH score questionnaires. Hospital PACS data were reviewed to record preoperative injury severity and postoperative acromioclavicular joint reduction. Results: Results for 42 patients were available and analysed as 10 could not be contacted and 1 patient sadly passed away. Of the patients reviewed, 92.9% were males with a mean age of 42.2 years (Range 16-67 years) and mean follow up of 68 months (12-119.1 months). The injury involved the dominant arm in 59.5%cases. Majority of the cases were Rockwood type V injuries (71.43%) while the rest were either type III(19.05%) or type IV(9.52%).The mean preoperative OSS was 21.3/48 which improved to 44.3/48 in the postoperative period. Similarly, the mean QuickDASH score was 50.6 preoperatively, that improved to 9.1 postoperatively.The most common patient reported complication was prominent metalwork seen in 5 cases (11.6%) followed by stiffness seen in 3 cases (7%) and superficial infection seen in 1 case (2.3%). The AC joint remained reduced radiologically in 81% of cases, while a resubluxation between 50 and 100% was seen in the rest of the cases. Patients with radiological resubluxation did not report this as a complication in 87.5% of the cases. Overall, 38 patients reported their outcome as excellent, 2 patients rated it good while 1 patient reported it as fair and 1 as poor. Conclusion: The Lockdown™ technique for stabilization of AC joint has excellent or good patient satisfaction in 95.2% of cases in long term follow up of more than 5.7 years. Prominent metalwork and stiffness are the commonest clinical complications. Radiological resubluxation can be seen in a fifth of the cases but does not directly lead to patient dissatisfaction. Level of evidence: Level IV Retrospective case series.

Prosthetic joint infections of the shoulder: A review of the recent literature.

Introduction: Shoulder arthroplasty is a common treatment for shoulder arthritis. Prosthetic joint infection of the shoulder (PJIS) is a debilitating complication to the patient and the healthcare system. Incidence of infection is 0.98-5% for primary arthroplasty. The mean hospital cost for two-stage revision was approximately $35,824. The aim of this paper is to review the recent literature and collate the latest evidence to aid diagnosis and treatment of this serious complication. Methods: A literature review was performed using PubMed and Google Scholar databases. A search strategy was adopted using the keywords: 'infection' AND 'shoulder arthroplasty' OR 'total shoulder arthroplasty'OR 'TSA' OR 'reverse shoulder arthroplasty' OR 'RSA' OR 'rTSA'. This initial search resulted in 349 articles. A PRISMA flowchart process was followed. Duplicates were removed, screening was performed and the resulting full texts were analysed and further excluded, leaving 46 articles suitable for inclusion. A PICO search strategy was also used. Results and interpretation: Risk factors for PJIS include procedure type, trauma indications and patient factors.The organism commonly isolated is Cutebacterium acnes, which makes diagnosis challenging due to its indolent nature. Investigations include biochemical tests, synovial aspirate, tissue cultures and radiological examinations.Treatment depends on the depth of the infection and the patient requirements. Medical treatment with antibiotics to local debridement, cement spacer and revision arthroplasty have all been described in the literature. A multidisciplinary decision is made on the microbiological evidence and patient factors. Conclusion: PJIS is a rare but potentially devastating complication of shoulder arthroplasty and diagnosis is often challenging. There has been much research performed recently, providing more evidence on how to optimise management.

Efficacy of Platelet-Rich Plasma Injection in the Management of Rotator Cuff Tendinopathy: A Review of the Current Literature.

Platelet-rich plasma (PRP) is being projected as a newer and superior treatment option for rotator cuff tendinopathy. With the first use of PRP in trauma and orthopedics dating back only to 1998, its advent into the field is relatively recent. Thus, data on long-term efficacy, large cohort studies, or large randomized controlled trials are fairly limited. Moreover, owing to the absence of standardized methods of platelet extraction and lack of consensus on the ideal concentration of platelets in PRP, data comparison from different studies is difficult. Things are complicated by the fact that it is also not clear whether a single injection of PRP is therapeutic or if multiple serial injections are needed to produce the desired effects. The literature on efficacy and pain relief is also obtained from studies with low sample sizes and short follow-ups. The dropout rate and noncompliance rate were also found to be high in some studies. Thus, the data is often not clinically significant and may also be biased due to the non-standardized inclusion and exclusion criteria of the studies. Though multiple studies have suggested good pain control with PRP injection, many studies have found that PRP injection therapy may not be any better than the physical therapy regimen prescribed to patients with rotator cuff tendinopathy. Also, the data on the efficacy of PRP on shoulder function and shoulder range of motion is at variance. This submission aims to evaluate the efficacy and use of PRP in the management of rotator cuff tendinopathy.

Outcomes following non-operatively managed periprosthetic fractures surrounding uncemented femoral stems.

BACKGROUND: The primary aim of this study was to explore the outcomes of Vancouver B periprosthetic hip fractures that were managed non-operatively with a particular focus on 1-year mortality. Understanding this mortality data will allow surgeons to better understand the risk associated with non-operative management. The secondary aim was to evaluate our case series and current literature with regards to identifying suitable patients for non-operative treatment. METHODS: Our electronic fracture database was interrogated for all Vancouver B periprosthetic fractures treated at our institution between April 2009 to April 2019; 18 patients were identified. All available data was then collected from radiographic, electronic and paper notes. A comprehensive literature search of PUBMED and EMBASE databases was then conducted with all relevant literature reviewed. RESULTS: 1-year mortality of these patients was noted at 22.2%; highlighting the severity of these injuries. No patients required conversion to surgical management, sustained a dislocation or went into non-union. With regards to literature no case series focussing on non-operative management outcomes were reported. There was a marked paucity of literature relating to conservative management of these injuries. CONCLUSION: To our knowledge this is the first published case series focussing solely on nonoperatively managed Vancouver B periprosthetic hip fractures. This paper provides evidence from the first reported case series with which surgeons can counsel patients on the significant mortality risk associated with these fractures. Non-operative management of periprosthetic hip fractures is possible after careful analysis of the fracture configuration, implant and patient characteristics. Whilst we have outlined several findings from our first reported case series, further research is required from a larger prospective case series in order to make evidence based recommendations.

Global impact of COVID-19 on surgeons and team members (GlobalCOST): a cross-sectional study.

OBJECTIVES: To investigate the impact of COVID-19 on the well-being of surgeons and allied health professionals as well as the support provided by their institutions. DESIGN: This cross-sectional study involved distributing an online survey through medical organisations, social media platforms and collaborators. SETTING: It included all staff based in an operating theatre environment around the world. PARTICIPANTS: 1590 complete responses were received from 54 countries between 15 July and 15 December 2020. The average age of participants was 30-40 years old, 64.9% were men and 32.5% of a white ethnic background. 79.5% were surgeons with the remainder being nurses, assistants, anaesthetists, operating department practitioners or classified other. MAIN OUTCOME MEASURES: Participants that had experienced any physical illness, changes in mental health, salary or time with family since the start of the pandemic as well as support available based on published recommendations. RESULTS: 32.0% reported becoming physically ill. This was more likely in those with reduced access to personal protective equipment (OR 4.62; CI 2.82 to 7.56; p<0.001) and regular breaks (OR 1.56; CI 1.18 to 2.06; p=0.002). Those with a decrease in salary (29.0%) were more likely to have an increase in anxiety (OR 1.50; CI 1.19 to 1.89; p=0.001) and depression (OR 1.84; CI 1.40 to 2.43; p<0.001) and those who spent less time with family (35.2%) were more likely to have an increase in depression (OR 1.74; CI 1.34 to 2.26; p<0.001). Only 36.0% had easy access to occupational health, 44.0% to mental health services, 16.5% to 24/7 rest facilities and 14.2% to 24/7 food and drink facilities. Fewer measures were available in countries with a low Human Development Index. CONCLUSIONS: This work has highlighted a need and strategies to improve conditions for the healthcare workforce, ultimately benefiting patient care.

Experience of an isolated use of low-intensity pulsed ultrasound therapy on fracture healing in established non-unions: a prospective case series.

Fracture non-unions are responsible for approximately 5% of cases, with low expectation of spontaneous healing thereafter. The fractures that heal without complications can take months to heal completely. An ultrasound, typically at low intensities (0.5-50 mW/cm2), serves a diagnostic purpose, whereas at higher intensities (0.2-100 W/cm2), its role becomes more therapeutic by generating heat energy. Low-intensity pulsed ultrasound (LIPUS) is frequently used to stimulate or to accelerate fracture healing. We present a prospective review of fracture non-unions treated with low-intensity pulsed ultrasound (LIPUS). We enrolled 66 patients during August 2016 and December 2018, 38 males and 28 females; age range 19-85 years (average 49.2 years). All these patients were followed up to minimum 6 months. The average time of referral post-treatment for fractures was 8.2 months (range 6-18 months). Four patients were excluded due to various reasons. 39 out of 62 fractures showed successful healing with symptom improvement and callus formation with 67% success rate. In this case series, we noted LIPUS therapy failure in the post-ORIF scaphoid fracture and post-ankle joint fusion non-union. We did not observe any influence of a medical condition such as diabetes mellitus, osteoporosis or personal habits like smoking. The LIPUS therapy appears to have influence on bone healing, depending on the onset of therapy, fracture type and the approach to fracture care. In this case series, the compliant group showed 67% successful outcome.

Proximal ulna fractures in adults: A review of diagnosis and management.

Proximal ulna fractures are relatively common upper limb injuries, which may represent fragility fractures or result from high-energy trauma. These include fractures of the olecranon, coronoid and associated radial head dislocations. A wide variety of treatment options are available for the management of these injuries that makes the selection of most appropriate treatment difficult. We aim to provide a brief overview of the treatment options for such injuries.

Traumatic rotator cuff tears - Current concepts in diagnosis and management.

Rotator cuff tears represent one of common shoulder pathologies presenting over a wide spectrum of age groups and varying presentation. Typically, rotator cuff tears occur more frequently in elderly than in younger patients, following a chronic or acute-on-chronic course and usually secondary to due to tendon degeneration. Though there has been a considerable debate in the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears, there appears to be consensus about the need for early diagnosis to facilitate prompt surgical treatment and the improve patient outcome. Significant differences in rotator cuff tears between those occurring in younger and older patients could be due to mechanism of injury, presentation, severity of the tear, biological healing potential and rehabilitation. Acute traumatic rotator cuff tears especially in younger age group represent a distinct entity from other patterns of rotator cuff tears. Consequently, a high index of suspicion, focused clinical examination, complementary imaging is a pre-requisite for an early diagnosis and effective management. We analyze the biomechanical consequences of acute rotator cuff tears along with characteristic mechanism of injury and spectrum of tendon involvement. The evolving concepts in the diagnosis and management of these distinct injuries are discussed with review of current literature.

Current concepts in the management of clavicle fractures.

Clavicle fractures comprise approximately 3% of all adult fractures and there is evidence that the incidence is increasing. Fractures of the lateral and middle third of the clavicle present distinct challenges in both surgical fixation techniques and clinical outcome, as such they should be recognised as separate clinical entities. Despite conflicting evidence, most studies indicate that superior clinical results are found in patients with united clavicle fractures rather than those that go onto non-union. Furthermore there is level-1 evidence that operative treatment of clavicle fractures leads to significantly increased rates of union. Despite these findings, significant controversy still exists on which patients would benefit from primary fixation and those who could successfully be managed non-operatively. We present an evidence-based review of clavicle fracture management including surgical indications, techniques, and results.

Outcomes following arthroplasty for proximal humeral fractures.

Fractures of the proximal humerus are very common and increasing in incidence within an ageing population. The majority of undisplaced fractures can be treated conservatively. Displaced fractures in good quality bone or in the young are considered for surgical fixation. However, displaced and comminuted fractures with or without dislocation, especially in the elderly, cannot be reliably treated with fixation. These patients are generally considered for joint arthroplasty. This review article focuses on the outcome following arthroplasty for proximal humeral fractures.

Management of chronic scapholunate ligament injury.

Scapholunate ligament is the most commonly injured ligament in the wrist and requires accurate diagnosis and treatment. It presents with pain, stiffness and can lead to carpal instability as well as degenerative arthritis if left untreated, with subsequent loss of function and disability. There are several management options currently available but there is no consensus on how best to manage a wrist with chronic sequelae of scapholunate ligament injury. This review explores available evidence in the literature on optimal treatment options including non-operative and operative procedures, relevant surgical techniques and their associated outcomes. A summary of the current concepts in the management of Chronic Scapholunate ligament injury is presented.

Dupuytren's Contracture - Current Concepts.

Dupuytren's contracture is a common condition that has the potential to be debilitating. It presents in a variety of manners and can be mild or more aggressive in its progression. There are a large number of management options currently available. In this review of the evidence, non-operative and operative management options are examined, with a consideration of post-operative rehabilitation and complications. A summary of the current concepts in the management of Dupuytren's contracture is presented.

Bone block procedures for glenohumeral joint instability.

Glenoid bone loss is a well established cause of instability and long term morbidity if not adequadely addressed. Anterior glenohumeral instability due an anterior glenoid defect is significantly more common, and for many years has been well treated with open anterior bone block augmentation procedures, most commonly the latarjet procedure. However, with refinement of this technique and some interest in reducing morbidity associated with iliac crest bone harvest, arthroscopic bone block procedures with allograft has become more popular. In this article we will review some of the key available evidence. We will also review management of the less common and more challenging posterior glenoid defects associated with posterior instability.

Early versus delayed mobilization following rotator cuff repair.

Rotator cuff tears are a common cause for pain and reduced function. Tears of the tendons of the cuff can be a result of a degenerative process or as a consequence of trauma. Management of cuff tears are surrounded by controversy from indications for surgical management to rehabilitation protocol post-surgical repair. The aim of post surgical rehabilitation is to improve functional outcome, reduce pain and promote tendon healing. In the case of rotator cuff repair, rehabilitation can be broadly divided into early passive range of motion (EPM) and delayed range of motion (DRM). The EPM regime is defined by minimal immobilisation of the shoulder and passive mobilisation of the joint within the first post-operative period. In contrast, DRM immobilises the shoulder joint up to six weeks post-operatively. Proponents of EPM state various advantages of their rehabilitation protocol including improved range of motion and earlier return to normal activities of daily living. However, there has also been concern that this rehabilitation regime may result in an increased rate of re-rupture. Since this is a highly controversial issue, various high quality literature have been published looking to clarify which regime is best following rotator cuff surgery. Reviewing these articles, it appears that there is an increase rate of re-tear of the repaired rotator cuff tendon when the EPM regime is employed. Statistical significance however was limited by small sample sizes. Range of motion post-repair also appears to be associated with post-operative rehabilitation regime. As expected, the EPM regime has been shown to improve range of motion post-repair. Despite this, literature reports patients managed with the DPM showed a statistically better patient reported outcome measure. We conclude that based on the evidence we currently have, early range of motion post rotator cuff repair is related with an increase risk of re-tear. The DPM regime reduces this risk with the possible complication of reduced range of shoulder movement. This problem is thought to be an easier clinical issue to deal with compared to re-rupture of the repaired rotator cuff tendon. There is however lack of data to achieve statistical significance in most of these analysis. There is a definite need for a large, multi-centre single blinded randomised controlled trial to further shed light on this controversial topic.

Outcomes following fixation for proximal humeral fractures.

Fractures of the proximal humerus are a very common presentation in modern Trauma and Orthopaedic practice. In an ever-aging population, the incidence has dramatically increased resulting in a large socioeconomical burden. The surgical management of these injuries has evolved over the years. Patient outcomes are variable and there is no consensus on treatment approach. This review article focuses on the outcomes following fracture fixation using common surgical techniques.

Current concepts in management of ACJ injuries.

Acromioclavicular joint injury is common in young individuals who suffer direct trauma to the shoulder. Treatment of acromioclavicular dislocation is controversial with regards to the indication of operative management, timing of surgery, whether to perform open or arthroscopic surgery, method of stabilisation (rigid or non-rigid) and type of graft used for repair or reconstruction. Current evidence supports conservative management for Rockwood types I and II, while types IV, V and VI benefit from surgery. The optimal management of type III injuries in high demand patients remains contentious. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Few studies with a low level of evidence suggest arthroscopic techniques and anatomical ligament reconstruction have better outcomes when compared to older techniques of rigid coracoclavicular fixation. The aim of this article is to look at the current evidence and address these controversial issues.