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Background: Strong research capacity and culture (RCC) within professional groups predict engagement in high-quality research and the integration of evidence into practice. However, factors affecting RCC participation and development are currently unknown in Australian Orthopaedic Surgeons. Study design: Cross-sectional survey. Methods: All Australian Orthopaedic Association members were invited to complete the individual domain of the validated Research Capacity and Culture tool. Results: One hundred and sixty-three Australian Orthopaedic Association members (9%) provided survey answers. Survey findings indicated that AOA members scored moderate or high for most RCC domains (14 out of 15). Barriers to the completion of research included a lack of time, other work roles taking priority, and a lack of funds for research. Conclusion: The Australian Orthopaedic Association members surveyed in this study demonstrated adequate research skills and experience, although reported they could benefit from additional support securing funding and navigating specific research tasks. Increasing future collaboration with academic institutions and clinician-researcher roles may enhance the output of high-quality orthopaedic research in Australia. [ABSTRACT FROM AUTHOR]

Background: The use of subtalar arthroereisis as an adjunct to the surgical treatment of stage 1 flexible progressive collapsing foot deformity (PCFD) is controversial. The aim was to investigate the clinical outcomes and report the implant removal rate of subtalar arthroereisis as an adjunct for stage 1 PCFD. Methods: A retrospective study of 212 consecutive feet undergoing operative management of stage 1 PCFD with adjunctive subtalar arthroereisis between October 2010 and April 2018. The primary outcome was the Foot and Ankle Outcome Score (FAOS). Secondary outcomes included Foot and Ankle Disability Index (FADI), Euroqol-5D-5L Index and implant removal rate. Results: Post-operative clinical FAOS outcomes were collected for 153 feet (72.2%). At mean 2.5-year follow-up, the mean ± standard deviation FAOS for each domain was as follows; Pain: 81.5 ± 18.5, Symptoms: 79.5 ± 12.9, Activities of Daily Living: 82.5 ± 15.4 and Quality of Life: 64.2 ± 23.7. EQ-5D-5L Index was 0.884 ± 0.152. Pre-operative scores were available for 20 of these feet demonstrating a statistically significant improvement in all FAOS, FADI and EQ-5D-5L domains (p < 0.05). The implant removal rate for persistent sinus tarsi pain was 48.1% (n = 102). Conclusion: Use of a subtalar arthroereisis implant as an adjunct to conventional procedures in stage 1 flexible PCFD can result in significant improvement in pain and function. Patients should be counselled as to the relatively frequent rate of subsequent implant removal. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Summary: Fracture-related costs vary by country. A standardized methodology and presentations were proposed to fairly assess the economic burden of osteoporotic fracture. Results indicated substantial costs of osteoporotic fractures for pharmacy, hospitalization, emergency care, and outpatient visits in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA. Purpose: The objective of this multinational, retrospective matched cohort study was to use a standardized methodology across different healthcare systems to estimate the burden of osteoporotic fracture (OF) in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA. Methods: Within each country, healthcare resource utilization and direct costs of care were compared between patients with newly identified OF and a propensity score–matched cohort without OF during follow-up periods of up to 5 years. Results: Across all five countries, the OF cohort had significantly higher rates and length of inpatient admissions compared with the non-OF cohort. In each country, the adjusted total costs of care ratio between OF and non-OF cohorts were significant. The adjusted cost ratios for pharmacy, inpatient care, emergency care, and outpatient visits were similarly higher in the OF cohort across countries. Conclusion: The current study demonstrates the substantial economic burden of OF across different countries when compared with matched non-OF patients. The findings would assist stakeholders and policymakers in developing appropriate health policies. [ABSTRACT FROM AUTHOR]

Background: Postoperative nausea and vomiting (PONV) is a common complication following surgery. Only a few risk factors have consistently been reported to be independent predictors for PONV. Aim: To report Apfel scores for orthopedic patients then correlate these scores to the number of antiemetics prescribed and subsequently administered in both the perioperative and post operative setting and determine if screening for Apfel scores is beneficial to predict PONV. Methods: A retrospective analysis of patients admitted under orthopedic units between 1st July 2020 and 31st July 2020 was conducted at a tertiary teaching hospital in Australia. Patients were screened and allocated an Apfel score and antiemetics agents prescribed and subsequently administered were recorded. Results: A total of 115 patients were screened for inclusion. Of these 4 patients met this exclusion criteria, resulting in a total sample size of 111 patients. An Apfel score of 2 was reported in 45.0% of patients, followed by 28.8% of patients scoring 3, with 12.6% scoring one. Only 5.4% of patients scored the highest risk of 4, with 8.2% of patients with no Apfel score documented. Conclusion: Orthopedic patients tend to score 2 or more in their Apfel score placing them at higher risk of postoperative nausea and/or vomiting according to the collectively validated Apfel's simplified risk score. There was no statistically significant relationship between the Apfel score and the number of antiemetic agents prescribed or administered from both the perioperative and post-operative setting following orthopedic surgery in this cohort of adult patients. [ABSTRACT FROM AUTHOR]

Surgical antibiotic prophylaxis (SAP) reduces the risk of surgical site infections following open reduction internal fixation (ORIF) procedures. Current guidelines recommend the use of single‐dose prophylaxis for ORIF procedures. It is known that adherence to SAP guidelines is suboptimal across multiple surgical disciplines, including orthopaedic surgery. The aim of this study was to identify how Australian orthopaedic surgeons self‐report prescribing of SAP for ORIF of closed fractures and whether practice adheres to recommendations in the Therapeutic Guidelines: Antibioticversion16. An online survey was distributed to Australian orthopaedic surgeons between August 2020 and February 2021. The survey consisted of 10 questions relating to SAP prescribing practice for ORIF of closed fractures, guideline awareness, and factors that influence prescribing. Twenty‐two surgeons participated in the survey. All 22 surgeons reported prescribing the guideline‐adherent agent cefazolin for ORIF procedures, with 68.2% (n = 15) prescribing the non‐adherent agent clindamycin for patients with a severe penicillin allergy. Almost two‐thirds of the surgeons (63.6%) prescribe postoperative antibiotics, with two postoperative doses the most common regimen (57.1%). Although 63.6% of surgeons were aware of guideline content, adherence to guidelines varied. Surgeons noted that multiple factors influence their prescribing practice, including knowledge gained from personal readings (77.3%), habits developed during training (68.2%), and discussion with colleagues (63.6%). Factors that influence SAP decision making for ORIF procedures are multifactorial, with variable levels of guideline adherence. This small cohort of surgeons commonly reported prescribing postoperative antibiotics. Further research is required to understand what influences SAP decision‐making. [ABSTRACT FROM AUTHOR]

The article focuses on Robert Lee's visit to Royal Perth Hospital, where he delivered a lecture on minimally invasive revision surgery techniques for spinal deformities including the importance of adopting a new mindset in surgical approaches and the goal of achieving quicker rehabilitation.

Background: Studies examining trends in revision joint replacement surgery have been quantitative in their design. A qualitative research approach could provide detailed insights into the changing burden of revision surgery from an important stakeholder perspective. This study aimed to investigate orthopaedic surgeons' perceptions around the burden of revision hip and knee replacement surgery in Australia. Methods: A descriptive qualitative study design was used. Highly experienced Australian orthopaedic surgeons specialising in primary and/or revision hip and knee replacement surgery were purposely sampled. Interviews covered the perceived burden of revision joint replacement, factors contributing to revision burden and anticipated future burden. Deductive and inductive coding techniques were used to identify themes. Results: Semi‐structured interviews were conducted with 14 orthopaedic surgeons, who had substantial consultant experience (range 15–30 years) and largely high‐volume practices. Five key themes were identified: (1) Revision burden has decreased over time; (2) Changes in clinical indications; (3) Perceived lack of policies focused on minimising revision surgery; (4) Role of the national registry and (5) Future trends and opportunities. Conclusion: The main indications for revision joint replacement surgery were perceived to have changed over time, moving away from implant failure‐related causes towards infection and periprosthetic fracture. Most participants considered that formal policies designed to reduce revision rates did not exist but acknowledged the positive role of the national registry, particularly within an international context. The improving evidence base and provision of registry feedback on surgeon and implant performance was expected to reduce the proportion of revision procedures. [ABSTRACT FROM AUTHOR]

Background: Communities have better health outcomes when their clinicians reflect the diversity of the communities they serve. More than 50% of Australian medical school graduates are female, yet women represent less than 5% of Australian orthopaedic surgeons. Selection into orthopaedic surgical training in Australia is an annual, nation‐wide process, based on curriculum vitae (CV), referee reports and performance in multiple mini‐interviews (MMI). The influence of applicant gender on these selection scores was examined. Methods: The CV, referee reports and MMI scores used for selection for each year from 2007 to 2019 were analysed from the perspective of the applicant's gender. Results: Over the years of the study, male applicants had higher CV scores and referee report scores, which determined the gender proportions invited to interview. By contrast, the interview process and selection from interview did not demonstrate a gender association. Conclusion: We describe the impact of selection tools, utilized over the past 13 years, on the gender diversity of trainees commencing orthopaedic surgery training in Australia. Leaders in postgraduate training should examine commonly used selection procedures to identify and reduce the unconscious biases that may affect their performance and value. [ABSTRACT FROM AUTHOR]

Background: The Postoperative Quality of Recovery Scale (PostopQRS) is a survey-based tool that measures quality of the postoperative recovery in multiple domains over multiple time periods. The purpose of this study is to validate the Japanese version of the PostopQRS. Methods: A prospective observational study using bilingual healthy volunteers was conducted in Australia to assess equivalence of the test values between the two languages. To assess the feasibility and discriminant validity of the PostopQRS in a Japanese population, an observational study was conducted on patients undergoing ear-nose-throat and orthopedic surgery in Japan, with measurements performed prior to surgery, 2 h, and 1, 3, and 7 days following surgery. The survey was conducted face-to-face while in hospital and via the telephone following discharge. Results: Sixty-eight volunteers participated in the validation study. The scores in the Japanese version were similar to the English version in all domains at all timepoints. In the cognitive domain, there were no differences between the Japanese and English versions for word recall and word generation tasks. For digits forwards and digits backwards the values were skewed to the maximal value, and although significantly different, the absolute difference was <10% at all timepoints between English and Japanese versions. Fifty-one patients, ear-nose-throat (n=22) and orthopedic (n=29), were included in the clinical study. Orthopedic patients had a significantly worse recovery profile over time in overall recovery (p<0.01), physiological (p=0.02), nociceptive (p=0.03), and activities of daily living (ADL, p<0.01) domains, but was not different for emotive (p=0.30) or cognitive domains (p=0.10). Conclusion: The Japanese version of the PostopQRS is similar to the English version and was able to discriminate recovery between different surgery disciplines. Trial registration: UMIN, UMIN000033268, Registered 6 August 2018. [ABSTRACT FROM AUTHOR]

This study will highlight the diagnostic potential that radar plots display for reporting on performance benchmarking from patient admissions to hospital for surgical procedures. Two drawbacks of radar plots – the presence of missing information and ordering of indicators – are addressed. Ten different orthopaedic surgery procedures were considered in this study. Moreover, twelve outcome indicators were provided for each of the 10 surgeries of interest. These indicators were displayed using a radar plot, which we call a scorecard. At the hospital level, we propose a facile process by which to consolidate our 10 scorecards into one. We addressed the ordering of indicators in our scorecards by considering the national median of the indicators as a benchmark. Furthermore, our the consolidated scorecard facilitates concise visualisation and dissemination of complex data. It also enables the classification of providers into potential low and high performers that warrant further investigation. In conclusion, radar plots provide a clear and effective comparative tool for discerning multiple outcome indicators against the benchmarks of patient admission. A case study between two top and bottom performers on a consolidated scorecard (at hospital level) showed that medical provider charges varied more than other outcome indicators. [ABSTRACT FROM AUTHOR]

* OBJECTIVE: To reach consensus among international shoulder experts on the most appropriate assessment and management strategies for posterior shoulder instability (PSI). * DESIGN: Delphi. * METHODS: In phase 1 of the study, we reviewed the literature, generated the Delphi items, created the survey, and identified clinical experts. In phase 2 of the study, clinical shoulder experts (physical therapists, orthopaedic surgeons, sports medicine physicians, and researchers) participated in a 3-round e-Delphi survey. For consensus, we required a minimum of 70% agreement per round. Descriptive statistics were used to present the characteristics of the respondents, the response rate of the experts in each round, and the consensus for PSI classification, assessment, and management. * RESULTS: Round 3 was completed by 47 individuals from 5 different countries. The response rate ranged from 57/70 (81%) to 47/50 (94%) per round. Respondents agreed on 3 subgroups to define PSI: traumatic (100% agreement), microtraumatic (98% agreement), and atraumatic (98% agreement). * CONCLUSION: International shoulder experts agreed that the clinical presentation, management strategy, and outcome expectations differ for traumatic, microtraumatic, and atraumatic PSI. Their recommendations provide a framework for managing these subgroups, with additional consideration of sport and work participation and subsequent risks. [ABSTRACT FROM AUTHOR]

Background: The Australian Orthopaedic Association (AOA) is the peak professional body for orthopaedic surgeons in Australia and is responsible for their training and continuing medical education. The 2012 AOA strategic education review employed a gap analysis to identify issues and generate a roadmap for the enhancement of AOA's education and training activities. This paper describes the process and outcomes of this review, which led to the 'AOA 21' Education Re‐design Project, and the review's relevance to surgical education in Australia. Methods: The AOA strategic education review was undertaken by international clinician education and orthopaedic experts, and involved AOA staff, fellows and trainee members throughout Australia. This review progressed through four phases: a review of current training; a global 'best‐practice' perspective; a set of aspirational goals; and a roadmap for implementation. Results: Seven key strengths (e.g. camaraderie in training and surgical skills teaching) and 15 challenges (e.g. 'non‐technical' skills teaching, subjective methods of decision making and inadequate assessment practices) were identified in the review stage. Sixteen major recommendations for improvements incorporating current or emerging world's best education practices were targeted in an 8‐year implementation framework. Conclusion: The AOA's strategic education review serves as a roadmap for other specialty training organizations to review their programmes and implement contemporary best practices in surgical training. The AOA 21 project has positioned orthopaedic surgery as a leader in competency‐based surgical education and training in Australia. [ABSTRACT FROM AUTHOR]

With current clinical practice, postoperative venous thromboembolism (VTE) risk is not only well controlled, but it is steadily decreasing, especially in orthopaedic surgery, thanks to fast-track and day case procedures, new surgical techniques, and potent antithrombotic agents. Thromboprophylaxis is becoming increasingly adapted to these patients. Aspirin is also extensively prescribed in total hip replacement and total knee replacement procedures in the United States and Australia. Mechanical prophylaxis is sometimes applied alone but most often combined with anticoagulant agents. However, large evidence-based studies are still needed to confirm these optimistic tendencies. In the meantime, physicians have to keep strong control over the VTE risk to prevent the reappearance of pulmonary embolism after admission to the surgical wards. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to calculate the societal economic burden of shoulder pain in patients on the orthopaedic waiting list at an Australian public hospital and calculate the cost (from the government's perspective) of care delivered by the hospital for those patients. Methods: A cost-of-illness analysis was undertaken in a cohort of 277 orthopaedic patients on the Gold Coast in Australia. Outcomes included a health care costs and impacts questionnaire, work absenteeism, presenteeism questionnaires (Work Limitations Questionnaire (WLQ) and Work Productivity and Activity Impairment Questionnaire (WPAI)) and hospital care provision over a 2-year period. Results: The mean societal cost of healthcare and domestic support was AU$20.72 per day (AU$7563 annually) per patient on the orthopaedic waiting list. When absenteeism and presenteeism were included, the cost per patient who was employed was AU$38.04 per day (AU$13 885 annually) calculated with the WLQ and AU$61.31 per day (AU$22 378 annually) calculated with the WPAI. The mean per-patient cost to government of public hospital care was AU$2622 in Year 1 and AU$3835.78 (s.d. 4961.28) over 2 years. The surgical conversion rate was 22%, and 51% of hospital care cost was attributable to outpatient services. Conclusions: Public orthopaedic shoulder waiting lists create a large economic burden for society; few referrals require surgery and just over half the hospital care costs are for out-patient services. New models of care that better manage shoulder pain and identify surgical candidates before orthopaedic referral could reduce this burden. What is known about the topic?: Little is known about the cost of shoulder pain in Australia, or the cost of patients referred for public orthopaedic care. What does this paper add?: This article quantifies the costs of shoulder pain and the value of lost production from shoulder pain. The time spent waiting for public hospital orthopaedic appointments and the costs associated with waiting demonstrate that the time spent on a waiting list is a key driver of the economic burden. What are the implications for practitioners?: Greater resourcing to reduce public orthopaedic shoulder waiting lists may be helpful, but system change is also required. Earlier and more accurate identification of surgical cases could reduce inefficient referrals and improve hospital productivity. Collaboration between clinicians and policy makers is needed to design more economically efficient shoulder care. [ABSTRACT FROM AUTHOR]

Background: To date, little is known about the characteristics of highly cited studies in hand surgery compared with other orthopaedic subspecialties. We aimed to assess the position of hand surgery within the orthopedic surgery literature. Methods: We conducted a bibliographic analysis using the Web of Science database to review 1,568 articles published between January 2012 and December 2012 in 4 relevant general orthopedic and 2 hand surgery journals. We used the number of citations within 3 years of publication to measure the impact of each paper. To analyze prognostic factors using logistic regression analysis, we extracted data on orthopedic subspecialty, published journal, location of authorship, and type of study for all articles. For clinical studies, we also recorded details on study design and sample size. Results: Of eligible hand surgery articles (n = 307), the majority (62%) were case reports/series. Only 19% were comparative studies, comprising a significantly smaller proportion of comparative studies from other subspecialties in general orthopedic journals. Systematic reviews/meta-analyses generated a significantly higher number of average citations, whereas educational reviews were consistently cited less frequently than other study types (14.9 and 6.1 average citations, respectively). Being published in the Journal of Bone and Joint Surgery, American volume, having authorship in North America or Europe and Australia, focusing on subspecialties like hip & knee, sports, or shoulder, utilizing a comparative or randomized clinical trial study design, and having a larger sample size increased the odds of receiving more citations. Conclusions: Clinical studies related to hand surgery published in general orthopedic journals are most often of lower quality study design. Having a larger sample size or using a comparative study or randomized clinical trial design can improve the quality of study and may ultimately increase the impact factor of hand surgery journals. [ABSTRACT FROM AUTHOR]

Major bleeding in noncardiac surgery is common and associated with serious complications. The antifibrinolytic agent tranexamic acid (TXA) reduces bleeding and may reduce the risk of these complications. TXA also may have immunomodulatory effects that could reduce surgical site infection. Clinical trials of TXA in noncardiac surgery have been insufficiently powered to evaluate its efficacy and safety. Therefore, large randomised controlled trials of its use in noncardiac surgery are required. To ensure that future clinical trials are feasible and acceptable, we undertook a survey of Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA). Our aims were to ascertain current patterns of TXA administration and to assess the acceptability of randomising patients to intravenous TXA or placebo. A 12-item survey was electronically mailed to 1001 ANZCA Fellows. Two hundred and eighty nine responses were received and analysed (response rate 29%). Ninety-eight percent of respondents had used intravenous TXA in noncardiac surgery; 67% give TXA routinely for lower limb arthroplasty, with smaller proportions giving TXA for spinal surgery (40%) and other major orthopaedic surgery (28%). Almost half (49%) give TXA routinely for major trauma surgery. Thirty-six percent indicated that they did not give TXA for major vascular, abdominal, pelvic or thoracic surgery. The majority administered TXA as a single, fixed dose. Fifty-seven percent agreed that there is uncertainty about the relative risks and benefits of perioperative TXA in noncardiac surgery and 87% agreed that large definitive trials determining the safety and efficacy of perioperative TXA in noncardiac surgery are required. These results indicate that for ANZCA Fellows the use of TXA in noncardiac surgery is highly variable, that there is uncertainty about the safety and efficacy of TXA, and that a large trial would be acceptable. [ABSTRACT FROM AUTHOR]

Background: Surgical interventions save lives and are important focus for health services research worldwide. Investigating variation in postoperative mortality may improve understanding of unwarranted variations and promote safety and quality in surgical care. We aimed to evaluate trends of in-hospital mortality rates among adult inpatients receiving major elective surgeries and determine the variation in mortality among New South Wales (NSW) public hospitals.Materials and Methods: In this study, we used the all-inclusive population-based NSW Admitted Patient Data from July 2001 to June 2014. We retrospectively included adult patients aged 18+ years receiving Abdominal Aortic Aneurysm (AAA) repair, Peripheral bypass, Colorectal surgeries, Joint replacement, Spinal surgeries, or Cardiac surgeries. The primary outcome was in-hospital mortality for selected surgeries. Changes in mortality rates over time and hospital standardised mortality rates were modelled using multivariate logistic regression models adjusting for case-mix factors.Results: Over 13-year study period, the in-hospital mortality rates declined annually by 6.4% (95% Confidence Interval (CI): 4.3, 8.4) for Colorectal surgery by 5.7% (95%CI: 2.0, 9.3) for Joint replacement and by 4.2% (95%CI: 1.9, 6.4) for Cardiac surgery. After controlling for patient-level factors, little variation was observed among hospitals for in-hospital mortality. There was a greater variability for cardiac surgery compared with the other surgical groups but no outlier hospital was consistently associated with significantly higher than expected mortality rate.Conclusions: Mortality has declined for major surgeries in the past 15 years. There was some variation among hospitals regarding in-hospital mortality that was mostly explained by patients demographic and admission characteristics. Our findings are reassuring for patients and contribute to knowledge that can help further improve surgical care. [ABSTRACT FROM AUTHOR]

Background: Earlier results with porous tantalum acetabular cups in revision THA generally have been favorable. Recently there has been some evidence presented that porous tantalum cups might decrease the risk of rerevision in the setting of revision hip surgery performed owing to prosthetic joint infection (PJI). As the data supporting this assertion come from a study with a limited study population, examining this issue with a large registry approach may be enlightening.Questions/purposes: By combining results from two large, national registries, we asked: (1) Do porous tantalum cups show improved survival after revision THA compared with other cementless designs? (2) Does the use of porous tantalum cups influence survivorship when rerevision for PJI is the endpoint?Methods: A total of 2442 first-time THA revisions with porous tantalum cups and 4401 first-time revisions with other uncemented cups were included in this collaborative study between the Australian and Swedish national joint registries. The mean age of the patients was 69 years (range, 19-97 years), 3754 (55%) of the patients were women, and the mean followup for the porous tantalum and uncemented control groups were 3.0 years (SD, ± 2.1 years) and 3.4 years (SD, ± 2.3 years), respectively. Concomitant stem revision was more common in the porous tantalum group (43% versus 36%). The use of porous tantalum augments also was analyzed as a proxy for more complex acetabular reconstructions. In an attempt to further reduce selection bias, we performed subgroup analysis for primary operations attributable to osteoarthritis and first revision attributable to aseptic loosening.Results: Kaplan-Meier survivorship with rerevisison for any reason up to 7 years was comparable between the porous tantalum cup group and the uncemented cup control group (86% [95% CI, 85%-89%] and 87% [95% CI, 85%-89%], respectively; p = 0.85) and the overall survivorship up to 7 years with a second revision for PJI as the endpoint (97% [95% CI, 95%-98%] and 97% [95% CI, 96%-98%], respectively; p = 0.64). Excluding procedures where augments had been used or studying primary osteoarthritis and first revision owing to aseptic loosening subgroups did not change this result.Conclusions: Implant survival for a porous tantalum cup in first-time THA revision was similar to the survival of the uncemented cup control group. With the numbers available, no benefit in survival with rerevision for infection as the endpoint could be ascribed to the porous tantalum cup group, as has been suggested by earlier work. Further studies with acetabular bone deficiency data, greater insight into host comorbidity factors, and a longer followup are needed to corroborate or refute these results.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

MINI: Trends in lumbar spinal stenosis surgery are largely unknown outside of the United States. This population-based health record linkage study revealed that complex fusion surgery had a four-fold increase from 2003-2013 in Australia. This surgical procedure increased the risk of complications and resource use compared with decompression surgery alone.Study Design: Population-based health record linkage study.Objective: The aim of this study was to determine trends in hospital admissions and surgery for lumbar spinal stenosis, as well as complications and resource use in Australia.Summary Of Background Data: In the United States, rates of decompression surgery have declined, whereas those of fusion have increased. It is unclear whether this trend is also happening elsewhere.Methods: We included patients 18 years and older admitted to a hospital in New South Wales between 2003 and 2013 who were diagnosed with lumbar spinal stenosis. We investigated the rates of hospital admission and surgical procedures, as well as hospital costs, length of hospital stay, and complications. Surgical procedures were: decompression alone, simple fusion (one to two disc levels, single approach), and complex fusion (three or more disc levels or a combined posterior and anterior approach).Results: The rates of decompression alone increased from 19.0 to 22.1 per 100,000 people. Simple fusion rates increased from 1.3 to 2.8 per 100,000 people, whereas complex fusion increased from 0.6 to 2.4 per 100,000 people. The odds of major complications for complex fusion compared with decompression alone was 4.1 (95% confidence interval [CI]: 1.7-10.1), although no significant difference was found for simple fusion (odds ratio 2.0, 95% CI: 0.7-6.1). Mean hospital costs with decompression surgery were AU $12,168, whereas simple and complex fusion cost AU $30,811 and AU $32,350, respectively.Conclusion: In Australia, decompression rates for lumbar spinal stenosis increased from 2003 to 2013. The fastest increasing surgical procedure was complex fusion. This procedure increased the risk of major complications and resource, although recent evidence suggest fusion provides no additional benefits to the traditional decompression surgery.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background: The modified Dunn procedure facilitates femoral capital realignment for slipped capital femoral epiphysis (SCFE) through a surgical hip dislocation approach. Iatrogenic postoperative hip instability after this procedure has not been studied previously; however, we were concerned when we observed several instances of this serious complication, and we wished to study it further.Questions/purposes: The purpose of this study was to evaluate the frequency, timing, and clinical presentation (including complications) associated with iatrogenic instability after the modified Dunn procedure for SCFE.Methods: Between 2007 and 2014, eight international institutions performed the modified Dunn procedure through a surgical dislocation approach in 406 patients. During the period in question, indications varied at those sites, but the procedure was used only in a minority of their patients treated surgically for SCFE (31% [406 of 1331]) with the majority treated with in situ fixation. It generally was performed for patients with severe deformity with a slip angle greater than 40°. Institutional databases were searched for all patients with SCFE who developed postoperative hip instability defined as hip subluxation or dislocation of the involved hip during the postoperative period. We reviewed in detail the clinical notes and operative records of those who presented with instability. We obtained demographic information, time from slip to surgery, type of fixation, operative details, and clinical course including the incidence of complications. Followup on those patients with instability was at a mean of 2 years (range, 1-5 years) after the index procedure. Complications were graded according to the modified Dindo-Clavien classification. Radiographic images were reviewed to measure the preoperative slip angle and the presence of osteonecrosis.Results: A total of 4% of patients treated with the modified Dunn procedure developed postoperative hip instability (17 of 406). Mean age of the patients was 13 years (range, 9-16 years). Instability presented as persistent hip pain in the postoperative period or was incidentally identified radiographically during the postoperative visit and occurred at a median of 3 weeks (range, 1 day to 2 months) after the modified Dunn procedure. Eight patients underwent revision surgery to address the postoperative instability. Fourteen of 17 patients developed femoral head avascular necrosis and three of 17 patients underwent THA during this short-term followup.Conclusions: Anterolateral hip instability after the modified Dunn procedure for severe, chronic SCFE is an uncommon yet potentially devastating complication. Future studies might evaluate the effectiveness of maintaining anterior hip precautions for several weeks postoperatively in an abduction brace or broomstick cast to prevent this complication.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Oxidized zirconium (Oxinium) was introduced as an alternative bearing surface to cobalt-chromium (CoCr) in an attempt to reduce polyethylene wear and decrease aseptic mechanical failure of total knee replacements. While noncomparative reports have been described as promising, we were aware of no short or long-term clinical studies showing the superiority of Oxinium on polyethylene as a bearing surface. Using data from a comprehensive national joint replacement registry, we compared the long-term outcomes after cruciate-retaining total knee arthroplasty (TKA) with an Oxinium femoral component and those with the same prosthetic design but with a CoCr femoral component.Methods: The cohorts consisted of 17,577 cemented Genesis-II cruciate-retaining total knee replacements using non-cross-linked polyethylene, which included 11,608 with CoCr femoral components and 5,969 with Oxinium femoral components. The cumulative percent revision and hazard ratio (HR) for revision risk were estimated for the cemented Genesis-II Oxinium and CoCr cruciate-retaining TKAs performed in Australia from September 1, 1999, to December 31, 2013. In addition, the revision diagnoses and the effects of age and patellar resurfacing were examined.Results: No difference in the HR for revision risk was found between the Oxinium and CoCr cohorts for any age category for all causes of revision (HR = 0.92 [95% confidence interval (CI), 0.92 to 1.29]; p = 0.329), loosening or lysis, or aseptic causes, except for loosening or lysis in the group of patients who were ≥75 years old (p = 0.033). In these patients, TKA with Oxinium femoral components had a higher rate of revision. Younger patients preferentially received Oxinium femoral components. The revision risk was not affected by patellar resurfacing or nonresurfacing. At 12 years, the cumulative percent revision was 4.8% (95% CI, 4.2% to 5.4%) for the CoCr Genesis-II prosthesis compared with 7.7% (95% CI, 6.2% to 9.5%) for the Oxinium Genesis-II prosthesis.Conclusions: In this cohort study involving the same prosthetic design, Oxinium femoral components did not reduce revision rates for all causes, loosening or lysis, or when infection as a cause of revision was removed compared with the same CoCr femoral component across all age groups including patients who were <55 years old. The cumulative percent revision was greater for the Oxinium components than for the CoCr components.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background and purpose - It is unclear whether metal particles and ions produced by mechanical wear and corrosion of hip prostheses with metal-on-metal (MoM) bearings have systemic adverse effects on health. We compared the risk of heart failure in patients with conventional MoM total hip arthroplasty (THA) and in those with metal-on-polyethylene (MoP) THA. Patients and methods - We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs health claims database on patients who received conventional THA for osteoarthritis between 2004 and 2012. The MoM THAs were classified into groups: Articular Surface Replacement (ASR) XL Acetabular System, other large-head (LH) (> 32 mm) MoM, and small-head (SH) (≤ 32 mm) MoM. The primary outcome was hospitalization for heart failure after THA. Results - 4,019 patients with no history of heart failure were included (56% women). Men with an ASR XL THA had a higher rate of hospitalization for heart failure than men with MoP THA (hazard ratio (HR) = 3.2, 95% CI: 1.6-6.5). No statistically significant difference in the rate of heart failure was found with the other LH MoM or SH MoM compared to MoP in men. There was no statistically significant difference in heart failure rate between exposure groups in women. Interpretation - An association between ASR XL and hospitalization for heart failure was found in men. While causality between ASR XL and heart failure could not be established in this study, it highlights an urgent need for further studies to investigate the possibility of systemic effects associated with MoM THA. [ABSTRACT FROM AUTHOR]

Objective: Femoral nerve blocks (FNBs) are commonly administered to patients with a fractured neck of femur (NOF). FNBs reduce complications associated with opioids and are effective for up to 24 h. However, the recognised 'gold standard' time to definitive treatment (surgery) in the patient with a fractured NOF is within 48 h. This leaves a significant period of time in which the patient has no effective analgesia, and might require opioids to alleviate pain. The present study explored the number of NOF patients who received a FNB: their wait for definitive treatment (surgery) and how much opioid analgesia was administered in the preoperative phase. Methods: A retrospective review of electronic patient records was conducted over a 6 month period in 2012. Patients who presented to the ED with a fractured NOF, received a FNB and were transferred to surgery in the same hospital were included in the sample. Results: The median time from FNBs to surgery was 37.5 h. When patients waited more than 20 h for surgery, the volume of opioid received increased significantly (P < 0.001). Conclusion: Even when patients' time to surgery was within the 'gold standard', patients received increasing doses of opioids 20 h after the administration of the FNB. While patients continue to wait extended periods for surgery, the practice of administering a single injection FNB needs to be challenged. ED clinicians might consider FNB infusions rather than single injection FNBs for patients with a fractured NOF. [ABSTRACT FROM AUTHOR]

Delirium is a common, potentially preventable and reversible cause of postoperative functional disability, morbidity, and mortality. It can lead to increased health-care use and also poses a substantial challenge for nurses caring for patients who experience delirium after surgery. Predominantly, the published work concentrates on diagnosis, reduction of the modifiable risk factors, and treatments. Compared with this body of published work, the experience of delirium from a patient's perspective has been largely ignored except for a limited number of qualitative research reports. The importance of researching the lived experience of delirium is that a better understanding may lead to more empathic, therapeutic nursing care and help other sufferers to know they are not alone. The aims of the study were to explore and clarify the lived experience of delirium. Eleven patients were recruited to the study following discharge post-surgery from an orthopaedic ward of a major tertiary hospital. The study used a qualitative descriptive approach and incorporated grounded theory data analysis processes. The findings of this study provide an insight into the incomprehensible emotional pain suffered by patients while they were delirious and the disparate feelings of remorse, guilt, and shame they experienced after the episode of delirium. Following this study, recommendations for nursing practice include formal follow-up support for patients with post-delirium episodes and more research into the long-term impact of the experience of delirium. [ABSTRACT FROM AUTHOR]

There is currently a lack of clear evidence on the impact of non-steroidal anti-inflammatory drugs (NSAIDs) on fracture healing post-operatively. Australian orthopaedic surgeons were surveyed about their perceptions of the relationship between NSAIDs and fracture healing to determine whether equipoise exists within the profession. Results demonstrated divergence of opinion amongst Australian orthopaedic surgeons, lending support to the commencement of randomised controlled trials testing the influence of NSAIDs on fracture healing within Australia. [ABSTRACT FROM AUTHOR]

The Orthopaedic Unit of the Repatriation General Hospital (RGH) in Adelaide, South Australia has implemented a quality care management system for patients with arthritis of the hip and knee. The system not only optimises conservative management but ensures that joint replacement surgery is undertaken in an appropriate and timely manner. This new service model addresses identified barriers to service access and provides a comprehensive, coordinated strategy for patient management. Over 4 years the model has reduced waiting times for initial outpatient assessment from 8 to 3 months and surgery from 18 to 8 months, while decreasing length of stay from 6.3 to 5.3 days for hips and 5.8 to 5.3 days for knees. The service reforms have been accompanied by positive feedback from patients and referring general practitioners in relation to the improved coordination of care and enhanced efficiency in service delivery. [ABSTRACT FROM AUTHOR]

Background To identify enablers and barriers to thromboprophylaxis prescribing following hip and knee arthroplasty, from the perspective of orthopaedic surgeons. Methods An invitation to participate in an online survey was distributed electronically to Arthroplasty Society of Australia members ( n = 103). The survey collected demographic details, thromboprophylaxis attitudes and clinical practice of the orthopaedic surgeons, and explored their familiarity with contemporary national and international guidelines. Results Twenty-five surgeons (24%) completed the survey, all male with a median of 20 years of practice as orthopaedic surgeons (range: 8-27 years). Most surgeons (92%) practised predominantly in the private sector, and conducted both hip and knee arthroplasties each month. While all surgeons prescribed chemoprophylaxis following arthroplasty, most surgeons (64%) were uncertain to what extent it would prevent fatal pulmonary embolism ( PE). The pharmacological agents of choice were low molecular weight heparin (48%) and aspirin (44%). One-third of surgeons were not familiar with the National Health and Medical Research Council recommendations for thromboprophylaxis in hip and knee arthroplasty patients. After reviewing a summary of the recommendations, most surgeons (80%) indicated they were inappropriate, commonly citing that they were grounded on an insufficient evidence base and should include aspirin as a sole chemoprophylaxis option. Conclusion There are clearly strong barriers to the translation of current thromboprophylaxis guidelines into practice. Many surgeons doubt the effectiveness of chemoprophylaxis to prevent fatal PE, perceive the risk of venous thromboembolism following surgery to be low, are unfamiliar with current national guidelines or believe the guidelines are grounded on inappropriate evidence. [ABSTRACT FROM AUTHOR]

The article discusses the legal and ethical issues concerning healthy limb amputation. It notes that surgeons refuse to conduct healthy limb amputation procedures due to ethical reasons and the risks of criminal liability. The article cites the need for Australian law to clarify whether or not the voluntary amputation of a healthy body part is considered harmful and disabling, beneficial to a person. It proposes that consent is a determining factor for the legality of a surgical procedure.

The article offers information on the drug literature of dabigatran etexilate (Pradaxa®) which is used for oral anticoagulant therapy in Australia. It notes that the drug is available through the Pharmaceutical Benefits Scheme (PBS) which is indicated to prevent venous thrombosis in patient who have undergone major orthopaedic surgery of the lower limb. Also, it mentions that the drug can be administered for 28-35 days after hip replacement surgery.

The article focuses on various reports published in previous issues of the "ANZ Journal of Surgery." One report in a 1992 issue examined developments in orthopaedic surgery in Australia. A report in a 1967 issue reviewed 280 tracheostomies performed at St. Vincent's Hospital in Sydney, New South Wales to determine complications associated with the procedure.

Background: In Australia, approval by the Medical Services Advisory Committee (MSAC) is an important step in the implementation of new health technologies. The MSAC considers health technology assessments (HTA) when submitting a recommendation to the Minister of Health on a new technology's suitability for public funding. Despite being such a critical tool in formulating policy, there has been little scrutiny on the impact of limited evidence on the performance of a national HTA agency's mandate. We aim to determine the proportion of HTAs of orthopaedic technologies prepared for the MSAC that were supported by higher levels of evidence for effectiveness, and whether this affected the MSAC's ability to conclude on efficacy. We also investigated whether the availability of higher level evidence affected the performance of cost-effectiveness analyses.Methods: We performed a cohort study of all HTAs prepared for the MSAC from 1998 to 2017 with regards to new technologies in orthopaedic surgery.Results: We identified seven HTAs encompassing nine orthopaedic technologies for inclusion. Higher levels of evidence were available for assessing the technology's effectiveness in six out of the nine technologies. The results did not show a statistically significant relationship between the availability of higher level evidence and MSAC's ability to make a clear conclusion on the assessment of effectiveness (P = 0.5). The proportion of HTAs where a cost-effectiveness analysis was performed was significantly higher (P < 0.05) when higher levels of evidence were available for the assessment of effectiveness.Conclusions: The results indicate that there is a paucity of high quality evidence in the formulation of health policy with regards to the implementation of new orthopaedic technologies in the public healthcare system. This represents an opportunity for strong leadership from surgeons to help develop the tools needed for effective clinical decision-making. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to determine patient satisfaction with procedural sedation as a function of nature of the procedure and depth of sedation. Method We undertook a prospective observational study of adult patients who received procedural sedation in two EDs (20 month period). The level of sedation was determined by an investigator, using the Observers Assessment of Anaesthesia/Sedation Scale (1 = awake to 6 = no response to noxious stimuli). Patient satisfaction was measured with the Iowa Satisfaction with Anaesthesia Scale after full recovery. This was self-administered, comprised 11 items (e.g. 'I felt pain') and has a score range of −3 (poor satisfaction) to +3 (very satisfied). Results A total of 163 patients were enrolled (51.2% men, mean age 50.7 years). The median (interquartile range) satisfaction score was 2.7 (0.7). Patient satisfaction was lower among patients who had orthopaedic procedures (median 2.6 vs 2.8, P < 0.01) and among patients who had a pre-sedation opioid (2.6 vs 2.8, P = 0.03). Satisfaction was positively correlated with deeper sedation (Spearman's correlation coefficient 0.49, P < 0.001). Satisfaction also differed significantly between the four most common sedation regimens ( P < 0.001). It was greatest among those who were administered propofol with or without fentanyl and least among those who were administered nitrous oxide with or without opioid. Patients sedated with propofol with or without fentanyl had the greatest depths of sedation. There was no difference in satisfaction among patients who were and were not sedated by a consultant (median 2.6 and 2.7, respectively, P = 0.84). Conclusion Generally, the level of patient satisfaction is high. Greater satisfaction is associated with deeper sedation, sedation with propofol and non-orthopaedic procedures. [ABSTRACT FROM AUTHOR]

Background: Chronic radicular pain can be effectively treated with spinal cord stimulation, but this therapy is not always sufficient for chronic back pain. Subcutaneous nerve stimulation (SQS) refers to the placement of percutaneous leads in the subcutaneous tissue within the area of pain. Case series data show that failed back surgery syndrome (FBSS) patients experience clinically important levels of pain relief following SQS and may also reduce their levels of analgesic therapy and experience functional well-being. However, to date, there is no randomized controlled trial evidence to support the use of SQS in FBSS.Methods/design: The SubQStim study is a multicenter randomized controlled trial comparing SQS plus optimized medical management ('SQS arm') versus optimized medical management alone ('OMM arm') in patients with predominant back pain due to FBSS. Up to 400 patients will be recruited from approximately 33 centers in Europe and Australia and will be randomized 1:1 to the SQS or OMM arms. After 9 months, patients who fail to reach the primary outcome will be allowed to switch treatments. Patients will be evaluated at baseline (prior to randomization) and at 1, 3, 6, 9, 12, 18, 24, and 36 months after randomization. The primary outcome is the proportion of patients at 9 months with a ≥50% reduction in back pain intensity compared to baseline. The secondary outcomes are: back and leg pain intensity score, functional disability, health-related quality of life, patient satisfaction, patient global impression of change, healthcare resource utilization/costs, cost-effectiveness analysis and adverse events. Outcomes arms will be compared between SQS and OMM arms at all evaluation points up to and including 9 months. After the 9-month assessment visit, the main analytic focus will be to compare within patient changes in outcomes relative to baseline.Discussion: The SubQStim trial began patient recruitment in November 2012. Recruitment is expected to close in late 2014.Trial Registration: ClinicalTrials.gov NCT01711619. [ABSTRACT FROM AUTHOR]

Background. The Orthopaedic Podiatry Triage Clinic (OPodTC) is a 'skill mix' model of care developed in Queensland Health to address the problem of lengthy waiting times for orthopaedic surgery on foot and ankle pathologies. It is based on the recognition that many orthopaedic surgery referrals can be identified early and treated conservatively with podiatry, averting the need for more costly and invasive surgical interventions. The model is collaborative and relies on screening and triage by the podiatrist, rather than delegation by the orthopaedic surgeon. Methods. Screening and triage through OPodTC was trialled at three Queensland Health hospital facilities during 2009 and 2010 to improve service timeliness. Patients identified by the OPodTC podiatrist as suitable for conservative management were provided with non-surgical podiatry interventions and discharged if appropriate. Those identified as still requiring surgical intervention after the benefit of interim conservative treatment provided by the podiatrist (or who chose to remain on the list) were returned to their previous place on the orthopaedic waiting list. This paper presents a summary and description of waiting list changes in association with this trial. Results. The OPodTC intervention resulted in a reduction in the non-urgent category of the waiting list across the three hospitals of between 23.3% and 49.7%. Indications from wait-list service data demonstrated increased timeliness and improved patient flow, which are core goals of these skill mix initiatives. Conclusions. This study highlights the potential of screening and triage functions in the skill mix debate. In this example, conservative treatment options were considered first, suitable patients did not have to wait long periods to receive timely and appropriate interventions, and those for whom surgery was indicated, were provided with a more targeted service. [ABSTRACT FROM AUTHOR]

Purpose: To determine the rate of orthopaedic follow-up of Aboriginal patients and the implications of this on fracture management. Aboriginal patients are at a high risk of complications after fracture given the high incidence of fractures, co-morbidities and later presentation. There is no information in the literature on follow-up of Aboriginal patients after fracture. Methodology: Retrospective review of patients presenting to Kalgoorlie Hospital with a fracture over 12 months. Attendance at follow-up, injury type, treatment type (surgical or non-surgical), indigenous status, and distance from hospital were recorded. Results: A total of 267 patients were identified over a 12 month period, 20% were Aboriginal. Aboriginal patients were ten-fold more likely to be lost to follow-up when compared to non-Aboriginal patients (40% and 4% respectively). Follow-up was further reduced in the Aboriginal group treated surgically (45%) and improved in the conservative group (17%). This pattern was reversed for non-Aboriginal patients where the surgically treated group more likely to present for follow-up. Conclusion: The follow-up of Aboriginal patients is very poor. Our study clearly demonstrates that low follow-up rates are not only related to geographical isolation but the hospital experience itself and mode of management. The failure of Aboriginal patients to present for follow-up has major implications for the management of fractures in this high risk population. We discuss the implications of more conservative treatment to increase follow-up and the conflicting evidence to aggressively internally fix fractures in patients with poor compliance and co-morbidities such as diabetes, common in Aboriginal patients. [ABSTRACT FROM AUTHOR]