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Purpose: The management of geriatric femoral neck fractures, which includes options like hemiarthroplasty (HA), total hip arthroplasty (THA), and fixation, exhibits regional and healthcare setting variations. However, there is a lack of information on global variations in practice patterns and surgical decision factors for this injury. Methods: Survey data were collected from April 2020 to June 2023 via Orthobullets Case Studies, a global clinical case collaboration platform hosted on a prominent orthopedic educational website. Collaboratively developed standardized polls, based on the best available evidence and a comprehensive, peer-reviewed, evidence-based item list, were used to capture surgeons' treatment preferences worldwide. Subsequent analyses explored preferences within subspecialties and practice settings. Multivariable regression analysis identified associations between subspecialty, practice type, the likelihood of choosing THA, and the preferred femoral fixation method. Results: Our study encompassed 2595 respondents from 76 countries. Notably, 51.5% of participants (n = 1328; 51.5%, 95% CI 49.6–53.4%) leaned towards THA and 44.9% for HA, while 3.6% favoured surgical fixation. Respondents affiliated with academic institutions and large non-university-affiliated hospitals were 1.74 times more likely to favour THA, and arthroplasty specialists exhibited a 1.77-fold preference for THA. There was a 19-fold variation for cemented femoral fixation between the United Kingdom (UK) and USA with the UK favouring cemented fixation. Conclusion: Our study reveals a significant shift towards THA preference for managing geriatric femoral neck fractures, influenced by subspecialty and practice settings. We also observed a pronounced predominance of cement fixation in specific geographic locations. These findings highlight the evolving fracture management landscape, emphasizing the need for standardization and comprehensive understanding across diverse healthcare settings. [ABSTRACT FROM AUTHOR]

This research presents the results of a study about people with failed metal-on-metal hip implants, and draws on the STS concept of the technological imperative alongside research on the value of patient knowledge in clinical settings and the legitimacy of embodied stories. Popularly understood as positive and life changing, hip replacement surgery was hailed as 'the operation of the century', until a series of widespread failures of hundreds of thousands of hip implants, known collectively as metal-on-metal (MoM) hips, drew attention to the poor regulation of medical implants. This paper argues that poor regulation intersects with narratives of patients' pain, which are obstructed by surgeons and the UK regulatory body, with the effect of denying both patients' embodied experiences of implant failure, and their restitution to good health. Patient narratives about problems with their hip implant are the wellspring from which scientific evidence emerges which can indicate widespread implant failure. By obstructing these narratives the regulatory system undermines the very evidence it needs to operate effectively. [ABSTRACT FROM AUTHOR]

The aim of this article is to provide frailty education that is relevant to the orthopaedic surgeon. An ageing population has led to an increase in the number of orthopaedic operations in patients living with frailty. Accumulating evidence suggests that a patient's outcome is better estimated by measuring their frailty score rather than their chronological age. If a patient lives with frailty, they are much more susceptible to complications and mortality. This article will explain how to identify frailty, what complications are associated with frailty and when, and what, interventions can be used to help reduce complications. It will also educate on current British Orthopaedic Association and Centre for Perioperative Guidelines for patients living with frailty, for both trauma and elective patients. [ABSTRACT FROM AUTHOR]

This review presents the principal features of paediatric femoral shaft fractures including the contemporary management strategies and relevant supporting evidence. The article is an overview of information relevant to clinical practice, in addition to preparation for the FRCS (Orth) examination. [ABSTRACT FROM AUTHOR]

This integrative literature review examined the role of an anaesthetic nurse specialist (ANS) in the perioperative anaesthetic nursing management of morbidly obese patients associated with elective orthopaedic surgery. The responsibility of the ANS is to provide high-quality perioperative anaesthetic care to ensure patient safety. Morbid obesity is increasing globally, with significant implications for healthcare delivery, care and treatment, including perioperative care. The Association of Anaesthetists of Great Britain and Ireland emphasises that the perioperative management of these patients presents significant organisational and practical issues. However, there are limited data or guidelines on whether surgeons, anaesthetists and nurses routinely take special precautions in managing morbidly obesity patients undergoing elective orthopaedic operative procedures. The authors carried out a search of databases, followed by an integrated literature review and synthesis of 11 studies. The main findings revealed significant clinical challenges and resource requirements for perioperative anaesthetic management of this patient group. Recommendations are made to prepare for and manage these surgical patients, from preoperative assessment to postoperative care. [ABSTRACT FROM AUTHOR]

Background: Physiotherapists are often key decision‐makers on when to refer patients with recurrent patellar dislocation for surgical opinion. Limited guidance exists to aid this decision. Differences in orthopaedic surgeons' and physiotherapists' views on which patients and when to refer people for surgical consideration or non‐operative care may affect outcome. This study aimed to explore orthopaedic surgeons and physiotherapists decision‐making surrounding treatment opinions for patients with recurrent patellar dislocation. Methods: An online survey performed. UK registered and practicing orthopaedic surgeons and physiotherapists were invited to participate. The survey utilised two vignettes and a series of related questions to ascertain respondents' views on decision‐making to surgical referral for people with recurrent patellar dislocation. Data were analysed using descriptive statistics and inferential statistical tests to explore factors related to responses. Results: Eighty four respondent surveys were analysed (38 surgeons, 46 physiotherapists). Overall, there was a low level of agreement amongst respondents for the management of the vignettes (k = 0.215, p = < 0.0005). Some disparity existed between the professions on the definition of recurrent patellar dislocations and the clinical features which may require an early surgical assessment. Physiotherapists were three times more likely to delay a surgical opinion for the vignettes presented in this study than the surgeons. Conclusion: This is the first study to investigate orthopaedic surgeons' and physiotherapists' views on decision‐making around surgical or non‐operative management for recurrent patellar dislocations. High‐quality research is required to underpin explicit guidance on decision‐making regarding management of recurrent patellar dislocation. [ABSTRACT FROM AUTHOR]

Purpose: In treating distal third tibial fractures, restoration of the axial alignment and therefore accurate reduction of the distal fragment minimise the risk of tibiotalar joint malalignment. The aim of this study is to investigate whether there was a difference in accuracy of reduction and axial alignment, when nailing distal third tibial fractures using either the suprapatellar or the infrapatellar tibial nailing entry technique. Methods: This retrospective cohort study compared alignment of intramedullary nails performed for distal third tibial fractures between 2015 and 2018 through the suprapatellar and infrapatellar approach at a UK Level 1 trauma centre. It compared a consecutive series of 74 suprapatellar nails and 51 infrapatellar nails, with radiographic assessment of tibial alignment in the antero-posterior and sagittal planes. It included inter- and intra-observer analyses of radiographic measurements. Results: In the coronal plane, mean malalignment in the suprapatellar technique group was 2.8 ± 0.7° and 4.7 ± 0.9° in the infrapatellar technique group (P < 0.01). In the sagittal plane, mean malalignment in the suprapatellar technique group was 4.0 ± 0.8° and 3.5 ± 0.9° in the infrapatellar technique group (P = 0.42). Intra- and inter-observer analysis showed strongly positive correlations between observers. Conclusions: We suggest that the suprapatellar technique may improve coronal plane alignment when intramedullary nailing distal tibial fractures. There was no significant difference in alignment in the sagittal plane. We conclude that the suprapatellar technique may be superior in preventing malalignment when treating distal third tibial fractures, potentially improving clinical outcome. [ABSTRACT FROM AUTHOR]

Introduction: Even though nearly 20 patients undergo hip replacement every hour just in Italy and the United Kingdom, it is unclear what are the most appropriate oral hydration practices that patients should follow before and after surgery. Improper administration can cause postoperative fluid disturbances or exacerbate pre-existing conditions, which are not an uncommon find in older subjects. Significance: Considering that the number of hip operations is expected to increase in the next years as well as the age of patients, it is important to recall the notions behind water balance, especially in light of modern surgical and anesthetic practices. This technical perspective discusses the perioperative changes in the hydration status that occur during hip replacement and provides the concepts that help clinicians to better manage how much water the patient can drink. Results: The points of view of the surgeon, the anesthetist, and the nurse are offered together with the description of mineral waters intended for human consumption. Before surgery, water should be always preferred over caffeinated, sugar-sweetened, and alcoholic beverages. The drinking requirements on the day of surgery should consider the water output from urine, feces, respiration, exudation, and bleeding along with the water input from metabolic production and intravenous administration of fluids and medications. Healthy eating habits provide water and should be promoted before and after surgery. Conclusions: The judgment on which is the most appropriate approach to oral hydration practices must be the responsibility of the multidisciplinary perioperative team. Nevertheless, it is reasonable to argue that, in the presence of a patient with no relevant illness and who follows a healthy diet, it is more appropriate to stay closer to dehydration than liberalizing water intake both prior to surgery and in the early postoperative hours until the resumption of normal physiological functions. [ABSTRACT FROM AUTHOR]

Optimal thromboprophylaxis in orthopaedic procedures is crucial in an attempt to lower the risk of venous thromboembolism, including deep vein thrombosis and pulmonary embolism. We aim to: 1) identify clinical practice guidelines (CPGs) and recommendations (CPRs) on thromboprophylaxis in adult patients undergoing orthopaedic procedures, and 2) assess the methodological quality and reporting clarity of these guidelines. The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered on the international prospective register of systematic reviews (PROSPERO) under the registration number (CRD42023406988). An electronic search was conducted using Medline, Embase, Cochrane, Web of Science, Google Scholar and medRxiv. The search terms used were ""adults", "orthopedic surgery", "orthopedic surgeries", "orthopedic surgical procedure", "orthopedic surgical procedures" "english language", "venous thromboembolism", in all possible combinations (January 2013 to March 2023). The eligible studies were evaluated by four blind raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. The literature research resulted in 931 studies. Finally, a total of 16 sets of guidelines were included in the current analysis. There were 8 national and 8 international CPGs. Eight CPGs made specific recommendations for orthopaedic surgery and referred mostly to joints; one guideline focused on pelvi-acetabular trauma, while the rest were more inclusive and non-specific. Four guidelines, one from the American Society of Hematology (ASH), two from the United Kingdom (UK) and one from India were found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. Inter-rater agreement was very good with a mean Cohens Kappa 0.962 (95 % CI, 0.895–0.986) in the current analysis. So, the reliability of the measurements can be interpreted as good to excellent. Optimal thromboprophylaxis in orthopaedic procedures is crucial. The available guidelines were found to be mostly of high methodological quality and inter-rater agreement was very good, according to our study. [ABSTRACT FROM AUTHOR]

Objective: Virtual Consultations may reduce the need for face-to-face outpatient appointments, thereby potentially reducing the cost and time involved in delivering health care. This study reports a discrete choice experiment (DCE) that identifies factors that influence patient preferences for virtual consultations in an orthopaedic rehabilitation setting. Methods: Previous research from the CONNECT (Care in Orthopaedics, burdeN of treatmeNt and the Effect of Communication Technology) Project and best practice guidance informed the development of our DCE. An efficient fractional factorial design with 16 choice scenarios was created that identified all main effects and partial two-way interactions. The design was divided into two blocks of eight scenarios each, to reduce the impact of cognitive fatigue. Data analysis were conducted using binary logit regression models. Results: Sixty-one paired response sets (122 subjects) were available for analysis. DCE factors (whether the therapist is known to the patient, duration of appointment, time of day) and demographic factors (patient qualifications, access to equipment, difficulty with activities, multiple health issues, travel costs) were significant predictors of preference. We estimate that a patient is less than 1% likely to prefer a virtual consultation if the patient has a degree, is without access to the equipment and software to undertake a virtual consultation, does not have difficulties with day-to-day activities, is undergoing rehabilitation for one problem area, has to pay less than £5 to travel, is having a consultation with a therapist not known to them, in 1 weeks' time, lasting 60 minutes, at 2 pm. We have developed a simple conceptual model to explain how these factors interact to inform preference, including patients' access to resources, context for the consultation and the requirements of the consultation. Conclusions: This conceptual model provides the framework to focus attention towards factors that might influence patient preference for virtual consultations. Our model can inform the development of future technologies, trials, and qualitative work to further explore the mechanisms that influence preference. [ABSTRACT FROM AUTHOR]

Background: While evidence indicates that familial predisposition influences the risk of developing degenerative rotator cuff disease (RCD), knowledge of specific genetic markers is limited. We conducted a genome-wide association study of RCD surgery using the UK Biobank, a prospective cohort of 500,000 people (40 to 69 years of age at enrollment) with genotype data.Methods: Cases with surgery for degenerative RCD were identified using linked hospital records. The cases were defined as an International Classification of Diseases, Tenth Revision (ICD-10) code of M75.1 determined by a trauma/orthopaedic specialist and surgery consistent with RCD treatment. Cases were excluded if a diagnosis of traumatic injury had been made during the same hospital visit. For each case, up to 5 controls matched by age, sex, and follow-up time were chosen from the UK Biobank. Analyses were limited to European-ancestry individuals who were not third-degree or closer relations. We used logistic regression to test for genetic association of 674,405 typed and >10 million imputed markers, after adjusting for age, sex, population principal components, and follow-up.Results: We identified 2,917 RCD surgery cases and 14,158 matched controls. We observed 1 genome-wide significant signal (p < 5 × 10-8) for a novel locus tagged by rs2237352 in the CREB5 gene on chromosome 7 (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.11 to 1.24). The single-nucleotide polymorphism (SNP) rs2237352 was imputed with a high degree of confidence (info score = 0.9847) and is common, with a minor allele frequency of 47%. After expanding the control sample to include additional unmatched non-cases, rs2237352 and another SNP in the CREB5 gene, rs12700903, were genome-wide significant. We did not detect genome-wide significant signals at loci associated with RCD in previous studies.Conclusions: We identified a novel association between a variant in the CREB5 gene and RCD surgery. Validation of this finding in studies with imaging data to confirm diagnoses will be an important next step.Clinical Relevance: Identification of genetic RCD susceptibility markers can guide understanding of biological processes in rotator cuff degeneration and help inform disease risk in the clinical setting.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Surgical repair of proximal hamstring avulsion injuries can enable the return to preinjury levels of sporting function and minimize the risk of recurrence in both professional and recreational athletes. While venous thromboembolism (VTE) is a recognized complication of surgical repair, the incidence thereof is poorly reported in the literature. Purpose/Hypothesis: To report the incidence of symptomatic VTE after proximal hamstring avulsion repair and assess the efficacy of our thromboprophylaxis protocol. It was hypothesized that the incidence of VTE after proximal hamstring avulsion repair is low and that aspirin is an adequate choice of chemical prophylaxis. Study Design: Cohort study; Level of evidence, 2. Methods: We performed a prospective cohort study of 2 groups of patients who underwent proximal hamstring avulsion (partial and complete) repair between 2000 to 2020 with different thromboprophylaxis protocols. No patients were routinely screened for VTEs, and VTE was investigated only if clinically indicated. Prospectively collected data included demographics, the mechanism and sport that caused injury, use of bracing, and clinical diagnosis of deep vein thrombosis (DVT) or pulmonary embolism (PE). The first cohort (n = 380) was given mechanical prophylaxis in the form of compression stockings for 6 weeks postoperatively. The second cohort (n = 600) was given compression stockings and aspirin 150 mg once daily routinely, or prophylactic low–molecular weight heparin in high-risk individuals, until the 6-week follow-up. Patients in both cohorts underwent early mobilization after surgery; a hinged knee brace locked at 60° to 120° was provided if the tendon repair was under significant tension. The surgical technique and rehabilitation protocol remained consistent throughout the study. Results: The overall incidence of symptomatic VTE was 0.51%. A total of 5 patients developed symptomatic VTEs (3 DVTs, 2 PEs) in the first cohort, and no patients developed symptomatic VTEs in the second cohort (1.32% vs 0%; P =.0048). Conclusion: The incidence of symptomatic VTE after proximal hamstring avulsion repairs was extremely low. A combination of aspirin, early mobilization despite bracing, compression stockings, and good hydration was an effective thromboprophylaxis strategy. [ABSTRACT FROM AUTHOR]

Introduction: Approaches to rehabilitation following rotator cuff repair are variable but typically include 4–6 weeks of immobilisation followed by a gradual introduction of movement and activity. However, research has questioned whether such an approach is optimal. The aim of this study was to undertake an updated survey to understand whether practice has evolved in line with contemporary research. Methods: An electronic survey was developed describing three case scenarios (medium‐sized rotator cuff repair [2 cm], large‐sized rotator cuff repair [4 cm] and large‐sized rotator cuff repair with biceps tenodesis). Clinicians involved with rehabilitation following rotator cuff repair were invited to participate. Results: 129 responses were received (United Kingdom = 87, other regions [ORs] = 42). Respondents would most commonly recommend four to six weeks of immobilisation for all case scenarios. Passive movement would commence during this period, with active movement recommended from four to six weeks. Resisted exercise would commence between seven to 12 weeks along with return to driving. There were some minor differences in recommendations between respondents from the United Kingdom and ORs, including a greater proportion from the United Kingdom recommending sling immobilisation rather than abduction brace immobilisation. Conclusion: For many respondents to this survey, rehabilitation for the three case scenarios was similar and has not evolved in line with contemporary research evidence. The reasons behind this need to be explored and incorporated into the design of future research evaluating rehabilitation following rotator cuff repair. [ABSTRACT FROM AUTHOR]

Objective: Single-use negative pressure wound therapy (sNPWT) following closed surgical incisions has a demonstrable effect in reducing surgical site complications (SSC). However, there is little health economic evidence to support its widespread use. We sought to evaluate the cost-effectiveness of sNPWT compared with standard care in reducing SSCs following closed surgical incisions. Method: A decision analytic model was developed to explore the total costs and health outcomes associated with the use of the interventions in patients following vascular, colorectal, cardiothoracic, orthopaedic, C-section and breast surgery from the UK National Health Service (NHS) and US payer perspective over a 12-week time horizon. We modelled complications avoided (surgical site infection (SSI) and dehiscence) using data from a recently published metaanalysis. Cost data were sourced from published literature, NHS reference costs and Centers for Medicare and Medicaid Services. We conducted subgroup analysis of patients with diabetes, an American Society of Anesthesiologists (ASA) score ≥3 and body mass index (BMI) ≥30kg/m2. A sensitivity analysis was also conducted. Results: sNPWT resulted in better clinical outcomes and overall savings of £105 per patient from the UK perspective and $637 per patient from the US perspective. There were more savings when higher-risk patients with diabetes, or a BMI ≥30kg/m2 or an ASA≥3 were considered. We conducted both one-way and probabilistic sensitivity analysis, and the results suggested that this conclusion is robust. Conclusion: Our findings suggest that the use of sNPWT following closed surgical incisions saves cost when compared with standard care because of reduced incidence of SSC. Patients at higher risk should be targeted first as they benefit more from sNPWT. This analysis is underpinned by strong and robust clinical evidence from both randomised and observational studies. Declaration of interest: LN, CS, SV and PT are employees of Smith + Nephew Inc., and may own shares of Smith + Nephew. FF is a consultant of Smith + Nephew. underclosed [ABSTRACT FROM AUTHOR]

Isolated patellofemoral arthritis is an increasingly recognized entity, and is usually associated with previous patellofemoral dysplasia or instability. Patellofemoral arthroplasty (PFA) has evolved significantly in recent years, both in terms of implant design and importantly in the understanding of appropriate patient selection. This review outlines the indications and investigations for PFA, provides a brief history of the development of contemporary implants, and presents the clinical outcomes for the prostheses most commonly used in the UK. In addition, it provides a detailed surgical technique for implantation of an onlay implant, with tips on how to optimize patellofemoral biomechanics and thus achieve a consistently good outcome. [ABSTRACT FROM AUTHOR]

Background and purpose — The COVID-19 pandemic has been recognised as an unprecedented global health crisis. This study assesses the impact on a large acute paediatric hospital service in London, evaluating the trends in the acute paediatric orthopaedic trauma referral caseload and operative casemix before (2019) and during (2020) COVID-19 lockdown. Patients and methods — A longitudinal retrospective observational prevalence study of both acute paediatric orthopaedic trauma referrals and operative caseload was performed for the first 6 "golden weeks" of lockdown. These data were compared with the same period in 2019. Statistical analyses included median (± median absolute deviation), risk and odds ratios as well as Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results — Acute paediatric trauma referrals in 2020 were reduced by two-thirds compared with 2019 (n = 302 vs. 97) with a halving risk (RR 0.55) and odds ratios (OR 0.43) of sporting-related mechanism of injuries (p = 0.002). There was a greater use of outpatient telemedicine in the COVID-19 period with more Virtual Fracture Clinic use (OR 97, RR 84, p < 0.001), and fewer patients being seen for consultation and followed up face to face (OR 0.55, RR 0.05, p < 0.001). Interpretation — The impact of the COVID-19 pandemic has led to a decline in the number of acute paediatric trauma referrals, admissions, and operations during the COVID period. There has also been a significant change in the patient pathway with more being reviewed via the means of telemedicine to reduce the risk of COVID-19 transmission and exposure. More work is required to observe for similar trends nationwide and globally as the pandemic has permanently affected the entire healthcare infrastructure. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has had a major impact on global healthcare systems, has drastically affected patient care, and has had widespread effects upon medical education. As plans are being devised to reinstate elective surgical services, it is important to consider the impact that the pandemic has had and will continue to have on surgical training. We describe the effect COVID-19 has had at all levels of training in the UK within trauma and orthopaedics and evaluate how training might change in the future. We found that the COVID-19 pandemic has significantly impacted trainees within trauma and orthopaedics at all levels of training. It had led to reduced operative exposure, cancellations of examinations and courses, and modifications to speciality recruitment and annual appraisals. This cohort of trainees is witnessing novel methods of delivering orthopaedic services, which will continue to develop and become part of routine practice even once the pandemic has resolved. It will be important to observe the extent to which the rapid changes currently being introduced will impact the personal health, safety, and career progression of current trainees. [ABSTRACT FROM AUTHOR]

Introduction: The COVID -19 outbreak has had a profound effect on the management of healthcare service provision in the UK. Orthopaedic departments have been no exception to this and have needed to adapt to the changing circumstances by releasing resources and focusing on 'essential' activity. The aim of this study is to quantify the reduction in trauma and, in addition, describe any changes in the type of referrals to the trust which may have been affected by the pandemic itself and the social distancing measures employed by the UK government.Methods: The study was performed in a UK District Hospital which is also a Trauma Unit providing trauma and orthopaedic care to a population of 625,000 people. The trust based electronic database of trauma referrals was used to compare the numbers of, and types of referral to our trauma service during the COVID-19 pandemic and the corresponding time periods in the previous 3 years.Results: The mean number of referrals per week to the service reduced by 33% in the time period following the confirmation of the outbreak as a pandemic (p<0.0001). Number of operations performed per week reduced by 26% (p = 0.001). There was no change in the number of referrals relating to domestic abuse or non-accidental injury. In addition, numbers of hip fractures, periprosthetic fractures and prosthetic joint dislocations were unchanged. There was a significant reduction in the number of referrals for simple fractures, native joint dislocations, wounds and soft tissue injuries. Within the paediatric population, similarly, a reduction in simple fracture referrals was demonstrated.Discussion: An association between the outbreak of the pandemic and a reduction in referral numbers to our department has been demonstrated. The direct cause of this may be multifactorial but proposing that it is, in part, due to the social distancing measures introduced by the government is certainly conceivable. The patterns of injury would reflect this also with low energy and fragility trauma persisting whilst injuries associated with younger people have reduced. We would suggest that information such as this could be useful in healthcare planning and resource allocation in future pandemic situations. [ABSTRACT FROM AUTHOR]

Background and purpose — The COVID-19 pandemic has been recognized as an unprecedented global health crisis. This is the first observational study to evaluate its impact on the orthopedic workload in a London level 1 trauma center (i.e., a major trauma center [MTC]) before (2019) and during (2020) the "golden month" post-COVID-19 lockdown. Patients and methods — We performed a longitudinal observational prevalence study of both acute orthopedic trauma referrals, operative and anesthetic casemix for the first "golden" month from March 17, 2020. We compared the data with the same period in 2019. Statistical analyses included median (median absolute deviation), risk and odds ratios, as well as Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results — Acute trauma referrals in the post-COVID period were almost halved compared with 2019, with similar distribution between pediatric and adult patients, requiring a significant 19% more admissions (RR 1.3, OR 2.6, p = 0.003). Hip fractures and polytrauma cases accounted for an additional 11% of the modal number of injuries in 2020, but with 19% reduction in isolated limb injuries that were modal in 2019. Total operative cases fell by a third during the COVID-19 outbreak. There was a decrease of 14% (RR 0.85, OR 0.20, p = 0.006) in aerosol-generating anesthetic techniques used. Interpretation — The impact of the COVID-19 pandemic has led to a decline in the number of acute trauma referrals, admissions (but increased risk and odds ratio), operations, and aerosolizing anesthetic procedures since implementing social distancing and lockdown measures during the "golden month." [ABSTRACT FROM AUTHOR]

Introduction: Major Trauma Centres (MTCs) should ideally have all key surgical specialities on site. This may not always be the case since trauma is only one factor influencing speciality location. The implications of this can only be understood when the demands on specific specialities are established and this is not well documented. We investigated surgical speciality demand by quantifying the frequency and urgency of surgical trauma interventions. Patients and methods: Data on adult trauma admissions for a UK MTC were retrieved from the UK Trauma Audit and Research Network for a 2-year period and analysed to establish the frequency and urgency of surgical interventions. Results: Of 1285 trauma patients with an ISS > 15 presenting in the study year period 713 (55.5%) required surgery. Neurosurgical (59.9%) and orthopaedic (55.1%) operations were most frequent. Cardiothoracic, general surgery, plastic surgery and maxillofacial operations were required infrequently. General surgery was commonly needed urgently, 45% within 4 h of MTC arrival. Urgency was also common in interventional radiology and vascular surgery. Cardiothoracic interventions were mainly urgent interventions (thoracotomy 1/3) and less urgent (rib fixation 2/3). Discussion: Neurosurgery and orthopaedic surgery are key on-site trauma specialities and required frequently. General surgery, interventional radiology and cardiothoracic interventions are required less frequently but often urgently. This confirms a need for MTC on-site capability and possibly training to maintain competency in occasional trauma operators, particularly in general surgery. Maxillofacial surgery, ENT and urology are required neither frequently nor urgently and on-site presence may be less critical. Conclusion: Demand for specific surgical specialities was reported in a cohort of UK trauma patients. This confirmed the need for rapid on-site capability in key specialities and highlights possible training requirements for occasional trauma operators in specialities with low frequency but high urgency. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE) is a serious, preventable disease occurring frequently in the UK and globally. The costs to NHS related to VTE are likely to be underestimated but the risk of developing VTE is significant in surgical patients. The overall incidence of VTE in orthopaedic patients is up to 40–60%. Patients following orthopaedic surgery have multiple risk factors making them vulnerable to developing VTE. VTE prophylaxis can be divided into general, mechanical and pharmacological methods. General methods, including early mobilization and optimizing hydration, are simple approaches widely. Mechanical methods include anti-embolism stockings, intermittent pneumatic compression devices and foot pumps. These are commonly used in combination with pharmacological agents. The latter include antiplatelet and anticoagulant drugs such as aspirin, unfractionated heparin, low-molecular-weight heparin (LMWH), vitamin K antagonists, factor Xa inhibitors and direct thrombin inhibitors. Chemical thromboprophylaxis and antithrombotic drugs continue to be an area of debate and controversy within orthopaedics. There is no single universal answer to thromboprophylaxis but, in the UK, The National Institute for Health and Care Excellence (NICE) has produced guidelines and every surgeon and hospital should have an evidence-based protocol to adhere to. [ABSTRACT FROM AUTHOR]

The NHS routinely evaluates the quality of life of patients receiving hip or knee replacement surgery using patient-reported outcome measures (PROMs), but some hospital completion rates are only 30%, restricting data usefulness. Statistics limit insights into how and why data are missing, so qualitative methods were used to explore this issue. Observation periods preceded semistructured interviews with 34 preoperative patients attending an orthopedic outpatient clinic. Interview themes covered: completion time/timing, orientation, setting, measures, and practicalities. Triangulated against observations, pragmatic barriers, and facilitators were considered. Refined themes included completion conditions, patient support, and national delivery. Simple improvements (e.g., quiet zone) could improve completion rates and reducing missing data. Reorganizing preoperative leaflets and their systematic distribution via standardized procedures could reassure patients, enhancing PROMs acceptance, while reducing inquiries and subsequent staff burden. Findings have implications for interpreting national statistics. They indicate that further debate about mandating preoperative PROMs is due. [ABSTRACT FROM AUTHOR]

Introduction: Diabetes mellitus (DM) is present in 10–15% of the surgical population. It is a known risk factor for adverse postoperative outcomes. UK perioperative guidance recommends optimizing glycemic control preoperatively, aiming for a target glycated hemoglobin (HbA1c) of < 69 mmol/mol. However, real-world compliance with this guidance remains unknown. The aim of our study was to determine how many patients with DM undergoing elective orthopedic and vascular surgery had a preoperative HbA1c of < 69 mmol/mol. We also reviewed the surgical reasons for non-concordance with the recommended preoperative HbA1c target. Methods: This was a retrospective observational study of 1000 consecutive patients who had been referred for elective vascular and orthopedic surgery at a large tertiary center. Data were collected on these patients, both those with and without DM, between January 2016 and February 2017. Electronic databases were used to collect information on the patients' preoperative HbA1c concentration and to determine whether there was a resulting delay in surgery when the preoperative HbA1c target of < 69 mmol/mol was exceeded. Results: Of the 1000 patients referred for surgery (500 orthopedic and 500 vascular patients) included in the study, 201 (20%) had diabetes. Among these 201 people with DM, 155 (77%) had a preoperative HbA1c < 69 mmol/mol. Among the 46 people with DM whose HbA1c exceeded the recommended target, 41 were operated on despite the high HbA1c level, and only five had their surgery deferred or canceled due to suboptimal preoperative glycemic control. Conclusions: Our data shows that the majority (77%) of people undergoing elective vascular and orthopedic surgery were able to achieve a target HbA1c of < 69 mmol/mol. The current preoperative guidance is therefore achievable in a real-life setting. However, as is stated in the national guidance, this target should only be used where it is safe to do so and a degree of clinical discretion is necessary. [ABSTRACT FROM AUTHOR]

Objectives: To improve surgical planning and reduce fasting times with a tool designed to predict average surgical times for the commonest orthopaedic trauma operations.Methods: A prospective cohort study comprising two 2-week periods before and after introduction of a surgical planning tool. The tool was used in the post-intervention group to predict surgical times for each patient and the predicted end-time for each list. The study was conducted in a UK trauma unit with consecutive orthopaedic trauma patients listed for surgery with no exclusions.Intervention: A surgical planning tool was generated by analysing 5146 electronic records for trauma procedure times. Average surgical times for the commonest 20 procedures were generated with 95% confidence intervals. The primary outcome measure was number of patients fasted for a single day. The secondary outcome measures were the day of surgery and total fast times for food and fluids.Results: After introduction of the planning tool, patients were more likely to fast for only one day (65% 46/71 vs 53% 40/75, p < 0.05). Day of surgery food fast was significantly lower with use of the surgical planning tool (13:11 h to 11:44 h, p < 0.05). Fast times were lower for patients with hip fractures after the intervention, with a reduction in day of surgery fast from 8:25 h to 4:28 h (p < 0.05) and a total fluid fast of 13:00 h to 4:31 h (p < 0.001).Conclusions: Introduction of a surgical planning tool was associated with a decrease in fasting times for orthopaedic trauma patients with no patient cancelled for not being adequately fasted. [ABSTRACT FROM AUTHOR]

Abstract Ankle sprains are amongst the most common injuries presenting to emergency departments in the UK. They are not one single entity but a heterogeneous group of injuries with a wide spectrum of severity. Most injuries will involve the lateral ankle ligament complex but it is important to ensure injuries to the syndesmotic ligaments or the deltoid ligaments are not missed. Missed injuries or poor management can cause disabling consequences and may occur in as many as 40% of inadequately treated patients. This article focuses on the basic anatomy and biomechanics of the ankle joint, common mechanisms of injury, appropriate diagnostic techniques and the indications for non-operative and operative management. [ABSTRACT FROM AUTHOR]

Objective: We report the largest case series of shoulder injuries among paddlers so far to establish common mechanisms and patterns of injury. We also discuss how these injuries were managed and report the proportion of paddlers that return to paddlesport. Design: Case series. Setting: Upper Limb Unit, Wrightington Hospital, United Kingdom. Manchester Arm Clinic, United Kingdom. Patients: Fifty-seven shoulder injuries to professional and recreational paddlers were reviewed at a mean follow-up time of 55 months from the first consultation. The patient cohort had a mean age of 36 years and consisted of 56% males. Assessment of Risk Factors: Sex, mechanism of injury, acute/nonacute injury, and level of sport participation. Main Outcome Measures: Patient data were analyzed with regards to Constant score, QuickDASH score, and VAS satisfaction score before and after treatment. Results: The most common mechanism of injury was a capsize which accounted for 15 (26%) injuries. Ten injuries caused by a capsize were labral tears all of which needed surgery. A significant improvement in patient outcome scores was noted. Patients were able to return to a high level of paddling such as 3 slalom paddlers who returned to international competition; one of whom had bilateral surgery. Conclusions: Paddlers most commonly injure their shoulder when preventing a capsize, during a capsize or while rolling. The paddles strokes performed at these times often require paddlers to place their shoulder in a dangerous abducted and externally rotated position. We believe this is one of the commonest causes of serious shoulder injuries to paddlers. [ABSTRACT FROM AUTHOR]

Background Deep prosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. It is difficult to treat, and patients often require multiple major revision surgeries to eradicate the infection. Treatment can have negative and long-term impact on patients' quality of life. Understanding current service provision provides valuable information needed to design and evaluate support interventions for patients. Aim This survey aimed to identify usual care pathways and support in UK National Health Service (NHS) orthopaedic centres for patients receiving revision surgery for PJI after hip or knee replacement. Methods The 20 highest volume NHS orthopaedic centres treating prosthetic joint infection after hip or knee replacement were approached. Consultant orthopaedic surgeons specializing in treating PJI were invited to participate in a telephone or email survey about usual care provision and support for PJI. Findings Sixteen centres completed the survey. Findings showed a high degree of variation nationally in follow-up time-points after revision surgery. Multidisciplinary approaches to care focused more on clinical care and physical rehabilitation than social and psychological care. Patient management and referral to support services also varied and barriers to referrals included lack of availability or access to services, lack of knowledge of services, shortage of staff, and complexities of referring outside of the hospital catchment area. Conclusions Our findings suggest that future development of interventions should focus on more inclusive and patient-centred multidisciplinary approaches to care. Such interventions could more completely address psychological and social as well as physical aspects of patients' recovery. [ABSTRACT FROM AUTHOR]

This article deals with the main issues of surgical management of acute spinal cord injury patients - discussing the importance of timing of surgery with physiologic stability of the cord, and indications for surgery - absolute and relative. The importance of the type of injury to the spinal column, besides the cord injury, is also discussed. A brief review of relevant literature has been performed to try and answer the question whether early or late surgical treatment for acute spinal cord injury is better than conservative management, reflecting the ethos of treatment for these problems in RJ&AH Orthopaedic Hospital in Oswestry. [ABSTRACT FROM AUTHOR]

Registries can be useful in both trauma and elective orthopaedic practices. The information acquired can be used to monitor clinical practice, ameliorating patient outcomes. Cross-linking between registries also ensures the highest level of data quality and amasses increasing quantities of data for analysis. Successful registries depend on a variety of factors including adequate funding, trained staff and local leadership with engagement of key local stakeholders. Registries should have a clear purpose, be meticulous about data quality and ensure good utilization of the data held. Hip and knee arthroplasty and fracture registries have become well established in the UK, proving to be valuable resources for data assessment, reviewing outcome measures and benchmarking of the implementation of best practice guidelines. In more recent years, some registries have been used to highlight and compare the outcomes of surgical practices of individual practitioners. Data from individual organizations have also been published and opened to public scrutiny. The publication and interpretation of registry data can have a significant effect on the public's interpretation of individual as well as collective clinical practice and hence it is imperative that clinicians be familiar with the principles and practices of registries including data entry, analysis and interpretation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hip hemiarthroplasty and dynamic hip screw (DHS) fixation are common procedures performed in trauma units, but there is little information regarding perioperative pain experience with respect to these treatment modalities. PURPOSE: To evaluate the relationship between pain, analgesia requirements, and type of procedure for hip fracture surgery. METHODS: An analysis was performed on consecutive patients presenting with a hip fracture in 2 hospitals over 2 years. Patients with a diagnosis of dementia were excluded because of the limitations of pain assessment. Postoperative pain scores were taken from standardized patient observation charts. Perioperative opiate consumption was calculated from inpatient drug charts. RESULTS: A total of 357 patients were studied; 205 patients (53%) underwent a cemented hemiarthroplasty and 152 (47%) had fixation with a DHS. Patients who underwent a DHS fixation had more pain than those who had a hemiarthroplasty and required almost double the amount of opiates. CONCLUSION: The reason for the elevated pain scores and higher morphine requirement in the DHS group (DG) remains unclear. It could be related to highly sensitive periosteum reaction in the DG. It is important to recognize the difference in pain experienced between the groups, and analgesia should be tailored toward the individual based upon clinical assessment and knowledge of the surgery performed. A comprehensive understanding of this principle will allow for improved perioperative surgical care and patient experience. [ABSTRACT FROM AUTHOR]

Most total hip arthroplasties (THAs) in the UK are performed through a posterior or lateral surgical approach. We aimed to investigate any difference in outcome from revision THA according to the approach at primary and revision THA surgery.~Introduction~Background~A retrospective cohort study of 205 patients who underwent revision THA for aseptic loosening. Patients rated their pain from 0-10 and completed the Self-Administered Patient Satisfaction Scale (SAPS), Oxford Hip Score (OHS), WOMAC and Short form-12 questionnaires.~Methods~Methods~205 patients (209 hips) from a cohort of 238 patients (243 hips, 86%) were available for analysis. The mean follow-up was 5 years (SD 1.71). Grouping by approach 20% (43/209) had both primary and revision procedures via a lateral approach, 20% (43/209) had their primary surgery via a lateral approach and their revision surgery via a posterior approach, whilst 60% (123/209) had both procedures via a posterior approach.The WOMAC and OHS were significantly better in patients who had a posterior approach for both primary and revision surgery, compared to those that did not (OHS p = 0.028, WOMAC p = 0.026). We found no significant differences in pain, satisfaction or health-related quality of life between the groups.~Results~Results~Choice of approach for revision hip arthroplasty is influenced by a number of factors, but in clinical situations where either a lateral or posterior approach could be used, the posterior approach appears to be associated with better joint-specific outcomes. Registry data may help further explore the associations between surgical approach and the outcome from revision THA.~Discussion~Conclusions [ABSTRACT FROM AUTHOR]

Background: Total hip replacement (THR) is one of the most common orthopaedic procedures in the United Kingdom (UK). Historically, people following THR have been provided with hip precautions and equipment such as: raised toilet seats and furniture rises, in order to reduce the risks of dislocation post-operation. The purpose of this study was to determine current practices in the provision of these interventions in the UK for people following primary THR.Methods: A 27-question, self-administered online survey was developed and distributed to UK physiotherapists and occupational therapists involved in the management of people following primary THR (target respondents). The survey included questions regarding the current practices in the provision of equipment and hip precautions for THR patients, and physiotherapist's and occupational therapist's attitudes towards these practices. The survey was disseminated through print and web-based/social media channels.Results: 170 health professionals (87 physiotherapists and 83 occupational therapists), responded to the survey. Commonly prescribed equipment in respondent's health trusts were raised toilet seats (95 %), toilet frames and rails (88 %), furniture raises (79 %), helping hands/grabbers (77 %), perching stools (75 %) and long-handled shoe horns (75 %). Hip precautions were routinely prescribed by 97 % of respondents. Hip precautions were most frequently taught in a pre-operative group (52 % of respondents). Similarly equipment was most frequently provided pre-operatively (61 % respondents), and most commonly by occupational therapists (74 % respondents). There was variability in the advice provided on the duration of hip precautions and equipment from up to 6 weeks post-operatively to life-time usage.Conclusions: Current practice on hip precautions and provision of equipment is not full representative of clinician's perceptions of best care after THR. Future research is warranted to determine whether and to whom hip precautions and equipment should be prescribed post-THR as opposed to the current 'blanket' provision of equipment and movement restriction provided in UK practice. [ABSTRACT FROM AUTHOR]

The care of the elderly with hip fractures and their outcomes might be improved with resources targeted by the accurate calculation of risks of mortality and morbidity. We used a multicentre national dataset to evaluate and recalibrate the Nottingham Hip Fracture Score and Surgical Outcome Risk Tool. We split 9,017 hip fracture cases from the Anaesthesia Sprint Audit of Practice into derivation and validation data sets and used logistic regression to derive new model co-efficients for death at 30 postoperative days. The area (95% CI) under the receiver operator characteristic curve of 0.71 (0.67-0.75) indicated acceptable discrimination by the Nottingham Hip Fracture Score and acceptable calibration fit (Hosmer-Lemeshow test), p = 0.23, with a similar discrimination by the Surgical Outcome Risk Tool, 0.70 (0.66-0.74), which was miscalibrated to the observed data, p = 0.001. We recommend that studies test these scores for patients with hip fractures in other countries. We also recommend these models are compared with case-mix adjustment tools used in the UK. [ABSTRACT FROM AUTHOR]

OBJECTIVES To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are systematic inequalities. DESIGN Observational cohort study using the National Hip Fracture Database (NHFD). setting All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland. PARTICIPANTS Patients within the national database (all aged >60) who received operative treatment for a non-pathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015. MAIN OUTCOME MEASURES Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE). RESULTS 114119 patients with hip fracture were included, 11683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780) received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition ^borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least inmost deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98). CONCLUSIONS There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital. [ABSTRACT FROM AUTHOR]

The Bristow-Latarjet procedure is a well-known surgical technique designed to treat shoulder instability. In this procedure, the coracoid process is transferred to the glenoid rim, to serve as augmentation of an associated bony defect. Because long-term results following a soft tissue procedure (Bankart repair) reveal that up to 21 and 33 % of the patients might experience recurrent instability and with the advent of the arthroscopic coracoid transfer, there is renewed interest in this procedure to treat shoulder instability. The aim of this study is to provide a historical overview, with emphasis on the original inventors Bristow and Latarjet, the complications and following modifications regarding the surgical approach, the coracoid transfer and the arthroscopic technique. Level of evidence V. [ABSTRACT FROM AUTHOR]

Abstracts of presentations made during the international combined meeting of the British Hip Society and the Societa Italiana dell'Anca on November 26-27, 2015 in Milan, Italy are presented including "Registry Data Errors in the National Hip Fracture Database" by Duncan Cundall-Curry et al, "FAI and Lumbar Stiffness" by Alessandra Aprato et al and "Infection and Failure Rates Following Thr in Septic Arthritis: A Case Controlled Study" by Madhavan C. Papanna et al.

Background and purpose —Virtual-reality (VR) simulation in orthopedic training is still in its infancy, and much of the work has been focused on arthroscopy. We evaluated the construct validity of a new VR trauma simulator for performing dynamic hip screw (DHS) fixation of a trochanteric femoral fracture. Patients and methods —30 volunteers were divided into 3 groups according to the number of postgraduate (PG) years and the amount of clinical experience: novice (1–4 PG years; less than 10 DHS procedures); intermediate (5–12 PG years; 10–100 procedures); expert (> 12 PG years; > 100 procedures). Each participant performed a DHS procedure and objective performance metrics were recorded. These data were analyzed with each performance metric taken as the dependent variable in 3 regression models. Results —There were statistically significant differences in performance between groups for (1) number of attempts at guide-wire insertion, (2) total fluoroscopy time, (3) tip-apex distance, (4) probability of screw cutout, and (5) overall simulator score. The intermediate group performed the procedure most quickly, with the lowest fluoroscopy time, the lowest tip-apex distance, the lowest probability of cutout, and the highest simulator score, which correlated with their frequency of exposure to running the trauma lists for hip fracture surgery. Interpretation —This study demonstrates the construct validity of a haptic VR trauma simulator with surgeons undertaking the procedure most frequently performing best on the simulator. VR simulation may be a means of addressing restrictions on working hours and allows trainees to practice technical tasks without putting patients at risk. The VR DHS simulator evaluated in this study may provide valid assessment of technical skill. [ABSTRACT FROM PUBLISHER]

Background: Personal protection equipment, improved early medical care, and rapid extraction of the casualty have resulted in more injured service members who served in Afghanistan surviving after severe military trauma. Many of those who survive the initial trauma are faced with complex wounds such as multiple amputations. Although costs of care can be high, they have not been well quantified before. This is required to budget for the needs of the injured beyond their service in the armed forces. Question/purposes: The purposes of this study were (1) to quantify and describe the extent and nature of traumatic amputations of British service personnel from Afghanistan; and (2) to calculate an estimate of the projected long-term cost of this cohort. Methods: A four-stage methodology was used: (1) systematic literature search of previous studies of amputee care cost; (2) retrospective analysis of the UK Joint Theatre Trauma and prosthetic database; (3) Markov economic algorithm for healthcare cost and sensitivity analysis of results; and (4) statistical cost comparison between our cohort and the identified literature. Results: From 2003 to 2014, 265 casualties sustained 416 amputations. The average number of limbs lost per casualty was 1.6. The most common type of amputation was a transfemoral amputation (153 patients); the next most common amputation type was unilateral transtibial (143 patients). Using a Markov model of healthcare economics, it is estimated that the total 40-year cost of the UK Afghanistan lower limb amputee cohort is £288 million (USD 444 million); this figure estimates cost of trauma care, rehabilitation, and prosthetic costs. A sensitivity analysis on our model demonstrated a potential ± 6.19% variation in costs. Conclusions: The conflict in Afghanistan resulted in high numbers of complex injuries. Our findings suggest that a long-term facility to budget for veterans' health care is necessary. Clinical Relevance: Estimates here should be taken as the start of a challenge to develop sustained rehabilitation and recovery funding and provision. [ABSTRACT FROM AUTHOR]

The article presents a research paper on the use of adaptive equipment after a total knee replacement. Studied population include total knee replacement patients from a general hospital through the assessment from occupational therapy staff. Also evaluated are optimal functional outcomes after surgery.

Dermabond® is a tissue adhesive commonly used for wound or surgical incision closure. Its use has previously been associated with a reduction in wound infection, and it has been thought to act as a physical barrier to bacteria accessing the wound. This study aimed to establish whether the Dermabond® adhesive demonstrated any intrinsic antimicrobial properties. Solidified pellets of Dermabond® were placed on standardised Agar plates cultured with a variety of pathogens. Inhibition of growth was demonstrated against Gram-positive bacteria. Culture swabs taken from the inhibition rings demonstrated no growth, suggesting that Dermabond has a bactericidal mechanism of action.Based on the design of this study, the results suggest that Dermabond® demonstrates bactericidal properties against Gram-positive bacteria. Its use for wound closure following surgical intervention may reduce postoperative wound infection by Gram-positive organisms. [ABSTRACT FROM AUTHOR]

Training in orthopaedic surgery, as in other specialities, is facing a great dilemma as new regulations in most countries limit the number of training hours for new trainees. In this paper, we briefly overview the new regulations and their impact on training schemes in the UK but they are also applicable to other countries tackling similar issues. We reiterate the ethical principles that set the limits beyond which training would be neither acceptable nor safe. We also review the evidence in the literature that suggests that Computer Assisted Surgery (CAS) could help in training and answer the problems concerning both training regulations and ethical constraints. We focus our review on CAS as a surgical guiding tool rather than as a simulation technology. Several aspects are evaluated: reduction of learning curve, improving cognitive skills, immediate feedback, accuracy and precision in surgical techniques and the educational role of CAS. It seems that CAS fulfils the criteria in assisting trainees and trainers with new regulations without impinging on the ethical principles. However the ultimate role of CAS in training still needs to be assessed. Finally we explore the role that CAS could play in the Patient Reported Outcome Measures (PROMS). [ABSTRACT FROM AUTHOR]

The article discusses orthopaedic surgery education in Great Britain, with information on the influence of the European Work Time Directive of the European Union. Topics discussed include medical school in Great Britain, the Foundation Years and Core Specialty Training programs, and the Member Royal College of Surgeons exam. The author argues that the European Work Time Directive presents obstacles in surgical training.

Objective To assess whether there have been any secular changes in orthopedic interventions in patients with rheumatoid arthritis (RA) since 1986, as examined in 2 early rheumatoid arthritis (RA) inception cohorts with up to 25 years of followup. Methods The study examined orthopedic data from the UK Early RA Study (1986-1999, 9 centers; n = 1,465) and the UK Early RA Network (2002-2012, 23 centers; n = 1,236) with linkage to national data sets (Hospital Episode Statistics, National Joint Registry, and Office of National Statistics). Clinical and laboratory measures and hand and foot radiographs were standardized and obtained yearly in both cohorts. The use of disease-modifying antirheumatic drugs (DMARDs), corticosteroids, and biologic therapies reflected the contemporary conventional practices and guidelines of the time frames examined. Recruitment years were grouped into 6 periods, and interventions were classified into major, intermediate, and minor categories. Results A total of 1,602 orthopedic surgical procedures were performed in 770 patients (29%) over a maximum of 25 years of followup. The 25-year cumulative incidence rate of major interventions was 21.7% (range 19.4-24.0%), and that of intermediate interventions was 21.5% (range 17.8-25.5%). There was a decline in the 10-year cumulative incidence of intermediate surgeries over time ( P < 0.001), but not of major/minor surgery. This decline coincided with a gradual shift from sequential monotherapy to combination DMARD therapies and biologic agents in recent recruitment periods. Conclusion Orthopedic surgery is an important and common outcome in RA. Only the rates of hand/foot surgery showed a consistent decline from 1986 to 2011. Possible explanations include differences in the pathophysiologic processes affecting the joints, variations in the responses to therapy between large-joint and small-joint destructive processes, and changes in service provision and thresholds for surgery over time. [ABSTRACT FROM AUTHOR]

Objectives: To survey surgeons on their beliefs and attitudes towards the use of placebo in surgery. Methods: British orthopedic shoulder surgeons, attending a national conference in the United Kingdom, were asked to complete a self-report online questionnaire about their beliefs and attitudes towards the use of placebo related to surgical intervention. The survey included questions about ethical issues, the mechanism of placebo effects, and any concerns regarding its use. Results: 100 surgeons who participated in the survey believed that placebo surgery is ethically acceptable (96%), especially as a part of a clinical trial (46%). Respondents thought that a placebo effect in surgery is real i.e. has a scientific basis (92%), that placebo can be therapeutically beneficial (77%), and that it involves psychological mechanisms (96%). Over half of the respondents (58%) have used a surgical procedure with a significant placebo component at least once in their professional career. Their main concern about placebo use in surgery was that it might involve an element of deception. Conclusions and Implications: Surgeons generally agreed that a placebo component to surgical intervention might exist. They also supported placebo use in clinical trials and considered it ethical, providing it does not involve deception of patients. More studies are needed, particularly among other surgical specialties and with larger numbers of participants, to better understand the use of placebo in surgery. [ABSTRACT FROM AUTHOR]

Causative agents of wound infections and the routes by which they access surgical incision sites have been recognised for more than a century. Despite knowledge of the factors that influence the risks of surgical site infections ( SSIs) and the means to prevent and/or control them, surgical patients still get infections. Traditional systems of classifying and diagnosing SSIs and the diversity of microbial flora reported in contemporary SSIs will be described. Strategies available to prevent and control SSIs will be critically reviewed and the need to develop alternative approaches will be discussed. [ABSTRACT FROM AUTHOR]

The article discusses the use of anterior talofibular ligament Broström repair for the management of chronic lateral ankle instability. It includes a study conducted on athletes who were assessed for their level of sport activity and the development of degenerative changes to the ankle. It concludes that combination of Broström repair and ankle arthroscopy allows athletes to return to their normal sports activities.