Search

OBJECTIVES Assess outcomes of acetabular open-reduction and internal fixation (ORIF) in the elderly; 2) Investigate factors influencing outcome; 3) Compare outcomes following low and high energy mechanisms of injury. DESIGN Retrospective case series. SETTING Level 1 trauma center. PATIENTS Seventy-eight patients over 60 (age:70.1±7.4; 73.1% males). INTERVENTION ORIF for acetabular fractures. MAIN OUTCOME MEASUREMENTS Complications, re-operation rates, and Oxford Hip Score (OHS), joint preservation and development of symptomatic OA. Cases with OA and OHS

Periprosthetic joint infection (PJI) following total hip and total knee arthroplasty continues to be a leading cause of re-operation and revision arthroplasty. Not only is the treatment of PJI notoriously challenging, but success rates are variable. Regardless of the surgical strategy used, successful management of PJI requires a comprehensive surgical debridement focused at eradicating the underlying biofilm followed by appropriate antimicrobial therapy. Although systemic antimicrobial delivery continues to be a cornerstone in the treatment of PJI, many surgeons have started using local antibiotics to deliver higher concentrations of antibiotics directly into the vulnerable joint and adjacent soft tissues, which often have compromised vascularity. Available evidence on the use of topical powder, bone cement, and calcium sulphate carriers for local delivery of antibiotics during the initial treatment of PJI is limited to studies that are extremely heterogeneous. There is currently no level-1 evidence to support routinely using these products. Further, appropriately powered, prospective studies are needed to quantify the safety and efficacy of antibiotic-located calcium-sulphate carriers to justify their added costs. These products should not encourage surgeons to deviate from best practice guidelines, such as those recommended during the International Consensus Meeting on Musculoskeletal Infections.

Most work-place based assessment relies on physician supervisors making observations of residents. Many areas of performance are not directly observed by physicians but rather by other healthcare professionals, most often nurses. Assessment of resident performance by nurses is captured with multi-source feedback tools. However, these tools combine the assessments of nurses with other healthcare professionals and so their perspective can be lost. A novel tool was developed and implemented to assess resident performance on a hospital ward from the perspective of the nurses.Through a nominal group technique, nurses identified dimensions of performance that are reflective of high-quality physician performance on a hospital ward. These were included as items in the Ottawa Resident Observation Form for Nurses (O-RON). The O-RON was voluntarily completed during an 11-month period. Validity evidence related to quantitative and qualitative data was collected.The Orthopedic Surgery Residency Program at the University of Ottawa.49 nurses on the Orthopedic Surgery wards at The Ottawa Hospital (tertiary care).The O-RON has 15 items rated on a 3-point frequency scale, one global judgment yes/no question regarding whether they would want the resident on their team and a space for comments. 1079 O-RONs were completed on 38 residents. There was an association between the response to the global judgment question and the frequency of concerns (p0.01). With 8 forms per resident, the reliability of the O-RON was 0.80. Open-ended responses referred to aspects of interpersonal skills, responsiveness, dependability, communication skills, and knowledge.The O-RON demonstrates promise as a work-place based assessment tool to provide residents and training programs with feedback on aspects of their performance on a hospital ward through the eyes of the nurses. It appears to be easy to use, has solid evidence for validity and can provide reliable data with a small number of completed forms.

With the rapid uptake of entrustable professional activties and entrustment decision-making as an approach in undergraduate and graduate education in medicine and other health professions, there is a risk of confusion in the use of new terminologies. The authors seek to clarify the use of many words related to the concept of entrustment, based on existing literature, with the aim to establish logical consistency in their use. The list of proposed definitions includes independence, autonomy, supervision, unsupervised practice, oversight, general and task-specific trustworthiness, trust, entrust(ment), entrustable professional activity, entrustment decision, entrustability, entrustment-supervision scale, retrospective and prospective entrustment-supervision scales, and entrustment-based discussion. The authors conclude that a shared understanding of the language around entrustment is critical to strengthen bridges among stages of training and practice, such as undergraduate medical education, graduate medical education, and continuing professional development. Shared language and understanding provide the foundation for consistency in interpretation and implementation across the educational continuum.

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).46 U.S. and Canadian hospitals.Patients aged 50 years or older undergoing hip fracture surgery.Spinal or general anesthesia.Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.Missing outcome data and multiple outcomes assessed.Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.Patient-Centered Outcomes Research Institute

OBJECTIVES: The outcome of emergency medicine (EM) training is to produce physicians who can competently run an emergency department (ED) shift. However, there are few tools with supporting validity evidence specifically designed to assess multiple key competencies across an entire shift. The investigators developed and gathered validity evidence for a novel entrustment‐based tool to assess a resident’s ability to safely run an ED shift. METHODS: Through a nominal group technique, local and national stakeholders identified dimensions of performance that are reflective of a competent ED physician and are required to safely manage an ED shift. These were included as items in the Ottawa Emergency Department Shift Observation Tool (O‐EDShOT), and each item was scored using an entrustment‐based rating scale. The tool was implemented in 2018 at the University of Ottawa Department of Emergency Medicine, and quantitative data and qualitative feedback were collected over 6 months. RESULTS: A total of 1,141 forms were completed by 78 physicians for 45 residents. An analysis of variance demonstrated an effect of training level with statistically significant increases in mean O‐EDShOT scores with each subsequent postgraduate year (p

Nearly 700,000 total hip arthroplasties (THAs) are annually performed in North America, costing the healthcare system$15 billion and creating over 5 million tons of waste. This study aims to (1) assess satisfaction of current THA setup; (2) determine economic cost, energy cost, and waste cost of current setup and apply lean methodology to improve efficiency; and (3) design and test "Savings through Lowering of Instrumentation Mass (SLIM) setup" based on lean principles and its ability to be safely implemented into practice.A Needs Assessment Survey was performed. After review and surgeon input, the "SLIM" set was designed, significantly reducing redundancy. Eighty patients were randomized to either Standard or SLIM setup. Operating room time, blood loss, perioperative adverse events and complications, cost/case, instrument weight (kg/case), total waste (kg/case), case setup time, and number of times and number of extra trays required were compared between groups.The SLIM setup was associated with the following savings: Cost = -$408.19/case; Energy = -7.16 kWh/case; Waste = -1.61 kg/case; Trays = -6 (758 kg/case). No differences in operating room time, blood loss, and complication rate were detected (P.05) between groups. Setup time was significantly shorter with SLIM (P.05) and extra instrumentation was opened in5% of cases.A more "minimalist approach" to THA can be safely implemented. The SLIM setup is efficient and has been openly accepted by our allied staff. Such setup can lead to 1,610 kg reduction in waste, 7,160 kWh, and $408,190 in savings per 1,000 THAs performed.

Background Surgical observation is an integral part of surgical training. Junior residents, who have limited understanding of the procedures being performed, use observation to gain an initial exposure to surgical techniques. This study explores the challenges junior residents face from a cognitive standpoint when they are observing surgery. Methods Four focus groups were conducted with 18 general surgery junior residents. Transcripts from these focus groups were analyzed using a qualitative interpretative approach and the findings were explored through the lenses of discovery learning and cognitive load theory. Results Surgical observation is perceived by residents as a learning activity with rich potential. However, two main challenges were identified: directing their attention to the most pertinent element during observation and making sense of what is happening during procedures. Conclusions This study can inform strategies to help junior residents observe surgeries more efficiently to help make surgical observation a better learning experience.

Background Research suggests that workplace-based assessment (WBA) tools using entrustment anchors provide more reliable assessments than those using traditional anchors. There is a lack of evidence describing how and why entrustment anchors work. Objective The purpose of this study is to better understand the experience of residents and faculty with respect to traditional and entrustment anchors. Methods We used constructivist grounded theory to guide data collection and analysis (March–December 2017) and semistructured interviews to gather reflections on anchors. Phase 1 involved residents and faculty (n = 12) who had only used assessment tools with traditional anchors. Phase 2 involved participants who had used tools with entrustment anchors (n = 10). Data were analyzed iteratively. Results Participants expressed that the pragmatic language of entrustment anchors made WBA (1) concrete and justifiable; (2) transparent as they explicitly link clinical assessment and learning progress; and (3) align with training outcomes, enabling better feedback. Participants with no prior experience using entrustment anchors outlined contextual concerns regarding their use. Participants with experience described how they addressed these concerns. Participants expressed that entrustment anchors leave a gap in assessment information because they do not provide normative data. Conclusions Insights from this analysis contribute to a theoretical framework of benefits and challenges related to the adoption of entrustment anchors. This richer understanding of faculty and resident perspectives of entrustment anchors may assist WBA developers in creating more acceptable tools and inform the necessary faculty development initiatives that must accompany the use of these new WBA tools.

Purpose: Early femoral component migration is a useful indicator for identifying implants at risk of failure due to aseptic loosening. The goal of this retrospective study was to identify if anterior approach (AA) treated hips are at a higher risk of failure due to aseptic loosening caused by early migration compared to hips operated on using the traditional posterior approach (PA). Methods: A total of 388 hips were included in this study, 139 AA and 249 PA treated hips. Femoral component migration was evaluated using EBRA-FCA and radiographs were assessed for radiolucency at latest follow-up. Preoperative and 2-year clinical outcomes were reported. Results: The 1- and 2-year migration rates (mm/year), and total migration (mm) at 2-year follow-up were comparable between AA and PA hips, respectively: 0.52 versus 0.41, 0.18 versus 0.19, and 0.64 versus 0.63 (all p > 0.05). Though not statistically significant, a higher percentage of AA hips passed 2-year total migration thresholds that have been associated with aseptic loosening compared to PA hips: 25.4% versus 16.5% for 1.5 mm threshold, and 11.3% versus 4.1% for the 2.7 mm threshold. Migration was not associated with the presence of radiolucent lines. All clinical outcomes improved significantly between preoperative and 2-year follow-up. Conclusions: There was no association between the AA and any significant increase in femoral component migration. A higher percentage of AA hips exceeded the migration thresholds associated aseptic loosening; however, these stems had no other indications of instability and therefore suggests that this may be a difference in migration pattern.

The presence of lumbar spine arthrodesis (SA) is associated with abnormal spinopelvic characteristics and inferior outcome post total hip arthroplasty (THA). However, whether patients with upper segment SA are also at increased risk of complications is unknown. This study aims to (1) determine if upper segment SA is associated with inferior THA outcomes; (2) assess spino-pelvic characteristics; and (3) test whether static or dynamic spinopelvic characteristics correlate with outcome post-THA.In this retrospective, case-matched, cohort study from a tertiary referral centre, 40 patients (59 hips) that had undergone both THA and any level of spinal arthrodesis (49 THA-Lumb and 10 THA-Cerv) were compared with 41 patients (59 hips) who had THA-only without known spinal pathology. Spino-pelvic characteristics [including severity of Degenerative-Disc-Disease (DDD); spinal balance and stiffness] and outcome, including patient reported outcome measures (PROMs), at minimum of 1-year post-THA were assessed.THA-Lumb and THA-Cerv groups had greater number of complications and inferior hip and spinal PROMs compared to THA-Only (p 0.001). Similar spinopelvic characteristics were seen between the THA-Cerv and THA-Lumb, which were significantly different to the THA-only group. The presence of DDD and unbalanced or stiff spine was associated with increased dislocation and inferior PROMs in the whole cohort.THA in the presence of SA, regardless of level, is associated with inferior outcomes and an increased risk for dislocation. The presence of a SA is associated with increased risk of adverse spinopelvic characteristics. Such characteristics were strongly associated with increased dislocation-risk and inferior PROMs. It is likely that these adverse characteristics are the most important adverse predictor, rather than segment of SA per se.

The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.

Summary Engaging patients—defined broadly as individuals with lived experience of a given condition, family members, caregivers, and the organisations that represent them—as partners in research is a priority for policymakers, funders, and the public. Nonetheless, formal efforts to engage patients are absent from most studies, and models to support meaningful patient engagement in clinical anaesthesia research have not been previously described. Here, we review our experience in developing and implementing a multifaceted patient engagement strategy within the Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN) surgery trial, an ongoing randomised trial comparing spinal vs general anaesthesia for hip fracture surgery in 1600 older adults across 45 hospitals in the USA and Canada. This strategy engaged patients and their representatives at both the level of overall trial oversight and at the level of individual recruiting sites. Activities spanned a continuum ranging from events designed to elicit patients' input on key decisions to longitudinal collaborations that empowered patients to actively participate in decision-making related to trial design and management. Engagement activities were highly acceptable to participants and led to concrete changes in the design and conduct of the REGAIN trial. The REGAIN experience offers a model for future efforts to engage patients as partners in clinical anaesthesia research, and highlights potential opportunities for investigators to increase the relevance of anaesthesia studies by incorporating patient voices and perspectives into the research process.

Optimum management for the elderly acetabular fracture remains undefined. Open reduction and internal fixation (ORIF) in this population does not allow early weight-bearing and has an increased risk of failure. This study aimed to define outcomes of total hip arthroplasty (THA) in the setting of an acetabular fracture and compared delayed THA after acetabular ORIF (ORIF delayed THA) and acute fixation and THA (ORIF acute THA).All acetabular fractures in patients older than 60 years who underwent ORIF between 2007 and 2018 were reviewed (n = 85). Of those, 14 underwent ORIF only initially and required subsequent THA (ORIF delayed THA). Twelve underwent an acute THA at the time of the ORIF (ORIF acute THA). The ORIF acute THA group was older (81 ± 7 vs 76 ± 8; P.01) but had no other demographic- or injury-related differences compared with the ORIF delayed THA group. Outcome measures included operative time, length of stay, complications, radiographic assessments (component orientation, leg-length discrepancy, heterotopic ossification), and functional outcomes using the Oxford Hip Score (OHS).Operative time (P = .1) and length of stay (P = .5) for the initial surgical procedure (ORIF only or ORIF THA) were not different between groups. Four patients had a complication and required further surgeries; no difference was seen between groups. Radiographic assessments were similar between groups. The ORIF acute THA group had a significantly better OHS (40.1 ± 3.9) than the ORIF delayed THA group (33.6 ± 8.5) (P = .03).In elderly acetabulum fractures, ORIF acute THA compared favorably (a better OHS, single operation/hospital visit, equivalent complications) with ORIF delayed THA. We would thus recommend that in patients with risk factors for failure requiring delayed THA (eg, dome or roof impaction) that ORIF acute THA be strongly considered.

The most effective surgical approach to total hip replacement (THR) remains controversial. Most studies that have compared approaches have reported only short-term outcome data. It is therefore unclear in the literature if a particular surgical approach offers long-term advantages. The aim of this study was to determine the effect of the 3 main surgical approaches to THR on patient-reported outcomes 5 years after surgery.All patients who underwent a THR for osteoarthritis or osteonecrosis between 2008 and 2012 by an anterior, posterior or lateral approach at The Ottawa Hospital in Ontario, Canada, were included in the study. All preoperative and postoperative scores for the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) questionnaires were recorded. Analysis of covariance was used to study the relationship between the amount of change in scores on the HOOS and WOMAC subscales (dependent variables) and the surgical approach. The confounding factors of age, sex, American Society of Anesthesiologists (ASA) class, Charnley classification and body mass index were included in the analysis.There were 138 patients (37.6%) in the posterior approach group, 104 (28.3%) in the lateral approach group and 125 (34.1%) in the anterior approach group. There were no significant differences among the 3 groups in terms of Charnley classification, body mass index, sex, ASA class, surgical side and preoperative functional scores. We did not observe any significant differences in the amount of change in the scores for HOOS and WOMAC subscales among the 3 groups. There were also no differences in the final postoperative scores.Our findings suggest that the choice of surgical approach in primary THR surgery without revision has no influence on functional outcomes and quality of life after 5 years. Further studies are needed to assess how patient age and sex may influence the functional outcome of individual surgical approaches.L’approche chirurgicale la plus efficace pour l’arthroplastie totale de la hanche (ATH) n’a pas été déterminée. La plupart des études qui ont comparé les différentes approches n’ont fait état que de données à court terme. Donc, la littérature nous renseigne peu sur leurs bienfaits à long terme. Le but de cette étude est de vérifier l’effet des 3 principales approches chirurgicales pour l’ATH sur les paramètres rapportés par les patients 5 ans après la chirurgie.Tous les patients soumis à une ATH pour arthrose ou ostéonécrose entre 2008 et 2012 par approche antérieure, postérieure ou latérale à l’Hôpital d’Ottawa, en Ontario, au Canada, ont été inclus dans l’étude; et tous les scores préopératoires et postopératoires des questionnaires HOOS (Hip Disability and Osteoarthritis Outcome Score) et WOMAC (Western Ontario and MacMaster Universities Osteoarthritis Index) ont été enregistrés. L’analyse de covariance a servi à étudier le lien entre l’ampleur des changements aux scores des sous-échelles HOOS et WOMAC (variables dépendantes) et l’approche chirurgicale. L’analyse a aussi tenu compte de facteurs de confusion tels que l’âge, le sexe, la classe ASA (American Society of Anesthesiologists), classification de Charnley et indice de masse corporell.Le groupe soumis à l’approche postérieure comptait 138 patients (37,6 %), à l’approche latérale 104 (28,3 %) et à l’approche antérieure 125 (34,1 %). Il n’y avait pas de différences significatives entre les 3 groupes aux plans de la classification de Charnley, de l’indice de masse corporelle, du sexe, de la classe ASA, du côté où la chirurgie a été effectuée et des paramètres fonctionnels préopératoires. Nous n’avons observé aucune différence significative quant à l’ampleur du changement aux scores des sous-échelles HOOS et WOMAC entre les 3 groupes; il en est allé de même pour les scores postopératoires finaux.Selon nos observations, le choix de l’approche chirurgicale pour l’ATH primaire sans révision n’exerce aucune influence sur les paramètres fonctionnels et la qualité de vie après 5 ans. Il faudra procéder à d’autres études pour évaluer l’influence potentielle de l’âge et du sexe sur les paramètres fonctionnels des différentes approches.

Background Fully immersive virtual reality (VR) uses headsets to situate a surgeon in a virtual operating room to perform open surgical procedures. The aims of this study were to determine (1) if a VR curriculum for training residents to perform anterior approach total hip replacement (AA-THR) was feasible, (2) if VR enabled residents' performance to be measured objectively, and (3) if cognitive and motor skills that were learned with use of VR were transferred to the physical world. Methods The performance of 32 orthopaedic residents (surgical postgraduate years [PGY]-1 through 4) with no prior experience with AA-THR was measured during 5 consecutive VR training and assessment sessions. Outcome measures were related to procedural sequence, efficiency of movement, duration of surgery, and visuospatial precision in acetabular component positioning and femoral neck osteotomy, and were compared with the performance of 4 expert hip surgeons to establish competency-based criteria. Pretraining and post-training assessments on dry bone models were used to assess the transfer of visuospatial skills from VR to the physical world. Results Residents progressively developed surgical skills in VR on a learning curve through repeated practice, plateauing, on average, after 4 sessions (4.1 ± 0.6 hours); they reached expert VR levels for 9 of 10 metrics (except femoral osteotomy angle). Procedural errors were reduced by 79%, assistive prompts were reduced by 70%, and procedural duration was reduced by 28%. Dominant and nondominant hand movements were reduced by 35% and 36%, respectively, and head movement was reduced by 44%. Femoral osteotomy was performed more accurately, and acetabular implant orientation improved in VR assessments. In the physical world assessments, experts were more accurate than residents prior to simulation, but were matched by residents after simulation for all of the metrics except femoral osteotomy angle. The residents who performed best in VR were the most accurate in the physical world, while 2 residents were unable to achieve competence despite sustained practice. Conclusions For novice surgeons learning AA-THR skills, fully immersive VR technology can objectively measure progress in the acquisition of surgical skills as measured by procedural sequence, efficiency of movement, and visuospatial accuracy. Skills learned in this environment are transferred to the physical environment.

Background Acetabular fractures in the elderly frequently involve segmental quadrilateral plate injury, yet no consensus exists on how to best control the femoral head medial displacement. Quadrilateral surface plates (QSP) were developed to help buttress these challenging fractures. The study aims to 1) Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2) Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome. Methods This was a retrospective study conducted at a level-1 trauma centre. . All patients over 60-years that sustained an acetabular fracture between 2007 and 2019 were reviewed. Pre-operative pelvic radiographs and CT imaging were reviewed for 96 patients, to assess for SQPF. From the 96 patients reviewed, over one third of patients (n = 40, 41.6%) sustained a SQPF. Patients that had an acute-THA (n = 7) were excluded as were patients that underwent an ORIF but did not have a QSP or an anterior column buttress plate (n = 3). The remaining 30 formed the study’s cohort. We assessed the ability to achieve and maintain reduction in this elderly population, and compared outcomes using traditional anterior column buttress plates (ilioingual or intra-pelvic approach) versus an intra-pelvic pre-contoured buttress suprapectineal plate (QSP). Outcome measures included: fracture reduction using the Matta classification (desirable: anatomical/imperfect and poor), re-operations, conversion to THA and Oxford Hip Score (OHS) (for the preserved hips). Results Ten patients had an ORIF with utilization of a QSP (QSP-group), and 20 had an ORIF but did not have the QSP (non-QSP-group). There was no difference in patient demographics between groups. Fracture patterns were also similar (p = 0.6). Postoperative fracture reduction was desirable (anatomical/imperfect) in 17 patients and poor in 13. Improved ability to achieve a desirable reduction was seen in the QSP-group (p = 0.02). Conversion to THA was significantly lower in patients that had a desirable fracture reduction (appropriate: 3/17; poor: 7/13). No patients in the QSP-group have required a THA to-date, compared to 10/20 patients in the non-QSP-group (p = 0.01). The mean time to THA was 1.6 ± 2.1 year. There was no difference in OHS between the two groups (34.4 ± 10.3). Conclusion Elderly acetabulum fractures have a high incidence (approaching 40%) of segmental QPF. Desirable (anatomical/imperfect) fracture reduction was associated with improved outcome. The use of a QSP was associated with improved ability to achieve an appropriate reduction. A QSP should be considered as they are both reliable and reproducible with a significantly improved fracture reduction and lower conversion to THA.

Copyright © 2018 by the American Society of Plastic Surgeons. Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

Background The anterior approach (AA) to total hip arthroplasty (THA) has advantages for patients and healthcare providers. However, some studies have reported high rates of adverse events when introducing AA-THA. This was not consistent with our center’s experience, where 4 senior surgeons safely introduced AA-THA into practice. The purpose of this study is to define the adverse event rates associated with the introduction of AA-THA by a group of experienced surgeons at a single tertiary care center and define experiential factors that may modify adverse event rates. Methods Retrospective review of prospectively collected data for an observational cohort of all patients undergoing a THA between 2006 and 2017 was conducted. Four senior surgeons at a single institution operated on 1087 primary elective hips using AA-THA. Results Between 2006 and 2016, AA-THA rose from 1.5% to 53.2% of annual THA. Adverse events included intraoperative events, early postoperative periprosthetic fractures, dislocation, implant failure, early infection, and wound complications. We observed an overall 90-day adverse event rate of 6.4% (of 1087 hips). The adverse event rate was 41.6% (of 12 hips) in the first 12 months of the study period and 3.6% (of 166 hips) in the final 12 months of the study period reviewed. Sixty hips (5.5%) required a reoperation with or without revision of components, 1 (8.3%) in the first 12 months of the study period and 1 (0.6%) in the final 12 months of the study period. Infection and wound complications were the most common causes of reoperation at 1.8% for all cases (20 hips). Higher rates of adverse events are associated with early procedures (n ≤ 15) for all surgeons but showed no statistically significant impact on 5-year survival rate. Conclusion Our experience demonstrates that AA-THA can be introduced into practice with an acceptable adverse event rate when compared with other approaches to THA. As expected the incidence of adverse events is higher in the early part of the learning curve. Surgeon mentoring in the first 20 cases should be considered to minimize risk of adverse events. Level of Evidence Therapeutic Level III.

OBJECTIVE To determine if geriatric intertrochanteric hip fracture patients achieve equivalent postoperative functional status after management with either a short (180-200 mm) or a long (260-460 mm) InterTAN intramedullary device. DESIGN Retrospective review of a prospective randomized control trial. SETTING Four Level I Trauma Centers. PATIENTS/PARTICIPANTS One hundred eight patients with OTA/AO classification 31A-1 and 31A-2 intertrochanteric hip fractures were included in the study. INTERVENTION Internal fixation using an IT device. MAIN OUTCOMES MEASURES Primary outcomes included Functional Independence Measure and Timed Up and Go. Secondary outcomes included blood loss, surgical time, length of stay, adverse events, and mortality. RESULTS Seventy-one short and 37 long IT patients met study inclusion criteria. Demographics were similar between groups. There was no difference in Functional Independence Measure or Timed Up and Go scores between the 2 IT groups at any of the time points collected. Mean operative time was lower in the short IT group than in the long IT group (60 vs. 73 minutes; P = 0.021). A higher proportion of long IT patients had reamed constructs (95% vs. 48% short IT, P < 0.001). Postoperative blood loss was significantly higher in the long IT group without a significant influence on the number of patients requiring transfusion (P = 0.582) or average units transfused (P = 0.982). There was no significant difference in the proportion of postoperative adverse events between the 2 cohorts despite a higher number of peri-implant femur fractures in the short IT group than in the long IT group (5 vs. 1, P = 0.350). CONCLUSIONS Postoperative functional status was not influenced by the length of IT device in the management of geriatric intertrochanteric hip fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Construct: We compared a single-item performance score with the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) for their ability in assessing surgical competency.Surgical programs are adopting competency-based frameworks. The adoption of these frameworks for assessment requires tools that produce accurate and valid assessments of knowledge and technical performance. An assessment tool that is quick to complete could improve feasibility, reduce delays, and result in a higher volume of assessments of learners. Previous work demonstrated that the 9-item O-SCORE can produce valid results; the goal of this study was to determine if a single-item performance rating (Is candidate competent to independently complete procedure: yes or no) completed at a separate viewing would correlate to the O-SCORE, thus increasing feasibility of procedural competence assessment.Nineteen residents and 2 staff orthopedic surgeons from the University of Ottawa volunteered for a 2-part OSCE-style station including a written questionnaire and videotaped simulated open reduction and internal fixation midshaft radius fracture. Each performance was rated independently by 3 orthopedic surgeons using a single-item performance score (Time 1). The performances were assessed again 6 weeks later by the 3 raters using the O-SCORE (Time 2). Correlation between the single-item performance score and the O-SCORE were evaluated.Three orthopedic surgeons completed 21 ratings each resulting in 63 orthopedic ratings. There was a high level of correlation and agreement between the single-item performance score at Time 1 and Time 2 (κ correlation =0.72-1.00; p .001; percentage agreement =90%-100%). The reliability of the O-SCORE at Time 2 with three raters was 0.83 and the internal consistency was 0.89. There was a tendency for each rater to assign more yes responses to the more senior trainees.A single-item performance score correlated highly with the O-SCORE in an orthopedic setting. A single-item score could be used to supplement a multi-item score with similar results in orthopedics. There is still benefit in completing multi-item scores such as the O-SCORE evaluations to guide specific areas of improvement and direct feedback.

Aims This study aims to: determine the difference in pelvic position that occurs between surgery and radiographic, supine, postoperative assessment; examine how the difference in pelvic position influences subsequent component orientation; and establish whether differences in pelvic position, and thereafter component orientation, exist between total hip arthroplasties (THAs) performed in the supine versus the lateral decubitus positions. Patients and Methods The intra- and postoperative anteroposterior pelvic radiographs of 321 THAs were included; 167 were performed with the patient supine using the anterior approach and 154 were performed with the patient in the lateral decubitus using the posterior approach. The inclination and anteversion of the acetabular component was measured and the difference (Δ) between the intra- and postoperative radiographs was determined. The target zone was inclination/anteversion of 40°/20° (± 10°). Changes in the tilt, rotation, and obliquity of the pelvis on the intra- and postoperative radiographs were calculated from Δinclination/anteversion using the Levenberg–Marquardt algorithm. Results The mean postoperative inclination/anteversion was 40° (± 8°)/23° (± 9°) with Δinclination and/or Δanteversion > ± 10° in 74 (21%). Intraoperatively, the pelvis was anteriorly tilted by a mean of 4° (± 10°), internally rotated by a mean of 1° (± 10°) and adducted by a mean of 1° (± 5°). Having Δinclination and/or Δanteversion > ± 10° was associated with a 3.5 odds ratio of having the acetabular component outside the target zone. A greater proportion of THAs that were undertaken with the patient in the lateral decubitus position had Δinclination and/or Δanteversion > ± 10° (35.3%, 54/153) compared with those in the supine position (4.8%, 8/167; p < 0.001). A greater number of acetabular components were within the target zone in THAs undertaken with the patient in the supine position (72%, 120/167), compared with those in the lateral decubitus position (44%, 67/153; p < 0.001). Intraoperatively, the pelvis was more anteriorly tilted (p < 0.001) and more internally rotated (p = 0.04) when the patient was in the lateral decubitus position. Conclusion The pelvic position is more reliable when the patient is in the supine position, leading to more consistent orientation of the acetabular component. Significant differences in pelvic tilt and rotation are seen with the patient in the lateral decubitus position. Cite this article: Bone Joint J 2018;100-B:1280–8.

Background The shift toward competency-based medical education has created a demand for feasible workplace-based assessment tools. Perhaps, more important than competence to assess an individual patient is the ability to successfully manage a surgical clinic. Trainee performance in clinic is a critical component of learning to manage a surgical practice, yet no assessment tool currently exists to assess daily performance in outpatient clinics for surgery residents. The development of a competency-based assessment tool, the Ottawa Clinic Assessment Tool (OCAT), is described here to address this gap. Study Design A consensus group of experts was gathered to generate dimensions of performance reflective of a competent “generalist” surgeon in clinic. A 6-month pilot study of the OCAT was conducted in orthopedics, general surgery, and obstetrics and gynecology with quantitative and qualitative evidence of validity collected. In all, 2 subsequent feedback sessions and a survey for staff and residents evaluated the OCAT for clarity and utility. Results The OCAT is a 9-item tool, with a global assessment item and 2 short-answer questions. Among the 2 divisions, 44 staff surgeons completed 132 OCAT assessments of 79 residents. Psychometric data was collected as evidence of validity. Analysis of feedback indicated that the entrustability rating scale was useful for surgeons and residents and that the items could be correlated with individual competencies. Conclusions Multiple sources of validity evidence collected in this study demonstrate that the OCAT can measure resident clinic competency in a valid and feasible manner.

Author(s): Braman, Jonathan P; Bernthal, Nicholas; Freedman, Brett; Gofton, Wade; Hsu, Joseph; Sheps, David; Strauss, Eric

Clinical trials and meta-analyses have suggested that aspirin may be effective for the prevention of venous thromboembolism (proximal deep-vein thrombosis or pulmonary embolism) after total hip or total knee arthroplasty, but comparisons with direct oral anticoagulants are lacking for prophylaxis beyond hospital discharge.We performed a multicenter, double-blind, randomized, controlled trial involving patients who were undergoing total hip or knee arthroplasty. All the patients received once-daily oral rivaroxaban (10 mg) until postoperative day 5 and then were randomly assigned to continue rivaroxaban or switch to aspirin (81 mg daily) for an additional 9 days after total knee arthroplasty or for 30 days after total hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism (the primary effectiveness outcome) and bleeding complications, including major or clinically relevant nonmajor bleeding (the primary safety outcome).A total of 3424 patients (1804 undergoing total hip arthroplasty and 1620 undergoing total knee arthroplasty) were enrolled in the trial. Venous thromboembolism occurred in 11 of 1707 patients (0.64%) in the aspirin group and in 12 of 1717 patients (0.70%) in the rivaroxaban group (difference, 0.06 percentage points; 95% confidence interval [CI], -0.55 to 0.66; P0.001 for noninferiority and P=0.84 for superiority). Major bleeding complications occurred in 8 patients (0.47%) in the aspirin group and in 5 (0.29%) in the rivaroxaban group (difference, 0.18 percentage points; 95% CI, -0.65 to 0.29; P=0.42). Clinically important bleeding occurred in 22 patients (1.29%) in the aspirin group and in 17 (0.99%) in the rivaroxaban group (difference, 0.30 percentage points; 95% CI, -1.07 to 0.47; P=0.43).Among patients who received 5 days of rivaroxaban prophylaxis after total hip or total knee arthroplasty, extended prophylaxis with aspirin was not significantly different from rivaroxaban in the prevention of symptomatic venous thromboembolism. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT01720108 .).

CONSTRUCT: The competence of a trainee to perform a surgical procedure was assessed using an electronic tool."Going paperless" in healthcare has received significant attention over the past decades given the numerous potential benefits of converting to electronic health records. Not surprisingly, medical educators have also considered the potential benefits of electronic assessments for their trainees. What literature exists on the transition from paper-based to electronic-based assessments suggests a positive outcome. In contrast, work done examining the transition to and implementation of electronic health records has noted that hospitals who have implemented these systems have not gone paperless despite the benefits of doing so.This study sought to transition a paper-based assessment tool, the Ottawa Surgical Competency Operating Room Evaluation (which has strong evidence for validity) to an electronic version, in three surgical specialties (Orthopedic Surgery, Urology, General Surgery). However, as the project progressed, it became necessary to change the focus of the study to explore the issues of transitioning to a paperless assessment tool as we identified an extremely low participation rate.Over the first 3 months 440 assessment cases were logged. However, only a small portion of these cases were assessed using the electronic tool (Orthopedic Surgery = 16%, Urology = 5%, General Surgery = 0%). Participants identified several barriers in using the electronic assessment tool such as increased time compared to the paper version and technological issues related to the log-in procedure.Essentially, users want the tool to be as convenient as paper. This is consistent with research on electronic health records implementation but different from previous work in medical education. Thus, we believe our study highlights an important finding. Transitioning from a paper-based assessment tool to an electronic one is not necessarily a neutral process. Consideration of potential barriers and finding solutions to these barriers will be necessary in order to realize the many benefits of electronic assessments.

There have been no studies assessing the optimal biomechanical tension of suture button constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a stress computed tomography (CT) model.Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified ankle load frame that allowed for the application of sustained torsional axial or combined torsional/axial loads. The syndesmosis and the deep deltoid ligaments complex were sectioned and the limbs were randomized to receive a suture button construct tightened at 4, 8, or 12 kg. The specimens were loaded under the 3 loading scenarios with CT scans performed after each and at the conclusion of testing. Multiple measurements of translation and rotation were compared with baseline CT scan taken before sectioning.Significant lateral (maximum 5.26 mm) and posterior translation (maximum 6.42 mm) and external rotation (maximum 11.71 degrees) was noted with the 4 kg repair. Significant translation was also seen with both the 8 and the 12 kg repairs; however, the incidence was less than with the 4 kg repair. Significant overcompression (ML = 1.69 mm, B = 2.69 mm) was noted with the 12 kg repair and also with the 8 kg repair (B = 2.01 mm).Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. These constructs also demonstrate overcompression of the syndesmosis; however, the clinical effect of this remains to be determined.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Objectives: To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT). Design: Prospective, randomized, multicenter clinical trial. Setting: Five level 1 trauma centers. Patients: Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months. Intervention: Computer generated randomization to either IT (n = 123) or SHS (n = 126). Main Outcome Measurements: The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality. Results: Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT. Conclusions: Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Negative-pressure wound therapy (NPWT) can improve fasciotomy wound closure, but its effects on skeletal muscle are largely unknown. The purpose of this study was to evaluate NPWT effects on skeletal muscle after fasciotomy for compartment syndrome in an animal model and to assess regional variability in muscle fiber regeneration. Methods: Compartment syndrome was induced in the hindlimb of twenty-two adult female pigs with use of a continuous intracompartmental serum-infusion model. Fasciotomy was performed after six hours, and animals were randomized to receive either wet-to-dry gauze dressings (control group) or NPWT dressings (−125 mm Hg, continuous suction) for seven days. Delayed primary wound closure was attempted at seven days, and the peroneus tertius was harvested for analysis seven days or twenty-one days after fasciotomy. Muscles were weighed, and hematoxylin and eosin-stained samples from four regions of the muscle (superficial central, deep central, lateral, and proximal) were mapped for different cellular morphologies. Results: Muscle weight was greater in the affected limb at all time points with no difference between treatment groups. At seven days, only the deep central samples in the NPWT group had a significantly greater cross-sectional area containing normal fibers as compared with that found in the controls. By twenty-one days, the deep central, lateral, and proximal regions of the NPWT-treated muscles had a smaller cross-sectional area containing normal fiber morphology and a greater cross-sectional area containing only mononucleated cells as compared with the controls. Conclusions: NPWT did not decrease muscle weight. At twenty-one days, the extent of muscle fiber regeneration after fasciotomy for compartment syndrome was reduced in muscles treated with NPWT for seven days compared with the values in the control group treated with wet-to-dry gauze dressings. Clinical Relevance: NPWT may be harmful to skeletal muscle after compartment syndrome requiring fasciotomy and local wound care.

Periprosthetic femoral fracture after total hip arthroplasty (THA) is an increasing clinical problem and a challenging complication to treat surgically. The aim of this retrospective study was to review the treatment of periprosthetic fractures and the complication rate associated with treatment at our institution.We reviewed the cases of patients with periprosthetic femoral fractures treated between January 2004 and June 2009. We used the Vancouver classification to assess fracture types, and we identified the surgical interventions used for these fracture types and the associated complications.We treated 45 patients with periprosthetic femoral fractures during the study period (15 men, 30 women, mean age 78 yr). Based on Vancouver classification, 2 patients had AL fractures, 9 had AG, 15 had B1, 24 had B2, 2 had B3 and 4 had C fractures. Overall, 82% of fractures united with a mean time to union of 15 (range 2-64) months. Fourteen patients (31%) had complications; 11 of them had a reoperation: 6 to treat an infection, 6 for nonunion and 2 for aseptic femoral component loosening.Periprosthetic fractures are difficult to manage. Careful preoperative planning and appropriate intraoperative management in the hands of experienced surgeons may increase the chances of successful treatment. However, patients should be counselled on the high risk of complications when presenting with this problem.La fracture périprothétique du fémur après prothèse totale de la hanche (PTH) est un problème clinique croissant et une complication difficile à traiter chirurgicalement. Le but de cette étude rétrospective était de passer en revue le traitement des fractures périprothétiques et le taux de complications associées à leur traitement dans notre établissement.Nous avons passé en revue les cas de fractures périprothétiques du fémur traitées entre janvier 2004 et juin 2009. Nous avons utilisé la classification de Vancouver pour évaluer les types de fractures et nous avons recensé les interventions chirurgicales utilisées pour corriger ces types de fractures et leurs complications respectives.Nous avons traité 45 patients victimes de fractures périprothétiques du fémur durant la période de l’étude (15 hommes, 30 femmes, âge moyen de 78 ans). Selon la classification de Vancouver, la répartition des fractures était la suivante : 2 patients avaient une fracture de type AL; 9, un type AG; 15, un type B1; 24, un type B2; 2, un type B3; et 4 un type C. Dans l’ensemble, 82 % des fractures ont repris dans un intervalle de temps moyen de 15 mois (entre 2 et 64 mois). Quatorze patients (31 %) ont présenté des complications; 11 ont dû être réopérés : 6 pour traiter une infection, 6 pour non soudure et 2 pour descellement aseptique de la composante fémorale.Les fractures périprothétiques sont difficiles à soigner. Une planification préopératoire soigneuse et une prise en charge peropératoire appropriée par des chirurgiens d’expérience peuvent augmenter les chances de succès. Toutefois, il faut informer les patients du risque élevé de complications lorsqu'ils se présentent avec ce type de problème.

Background Femoral neck fractures are common injuries in the geriatric population associated with high morbidity and mortality rates. Studies have shown outcomes can be positively influenced by early postoperative mobilization. The supercapsular percutaneously assisted total hip (SuperPath) surgical technique has been shown to lead to early mobilization for osteoarthritic total hip replacement patients and as such has the potential to provide similar benefits in fracture patients. This manuscript provides a detailed description of this technique using hemiarthroplasty to treat femoral neck fractures and presents the first case series of this application. Methods Seventeen patients with femoral neck fractures managed with this technique at two separate institutions were reviewed. In an attempt to minimize blood loss and enhance early mobilization, hemiarthroplasty utilizing the SuperPath technique was performed. The authors noticed decreased blood loss, operative time, and postoperative narcotic usage when compared to their previous experiences using traditional techniques. Conclusions Early mobilization following femoral neck fractures has been shown to decrease mortality and morbidity. There is little existing literature on the use of tissue-sparing surgical techniques for this application, and none details the use of the SuperPath technique for it. The described case reports suggest the technique is a viable option for bipolar hemiarthroplasty to treat femoral neck fractures. Appropriately designed future studies are needed to confirm findings and definitively compare outcomes to traditional approaches.

Background For total hip arthroplasty (THA), cognitive training prior to performing real surgery may be an effective adjunct alongside simulation to shorten the learning curve. This study sought to create a cognitive training tool (CTT) to perform anterior approach (AA)-THA, which was validated by expert surgeons, and test its use as a training tool compared with conventional material. Methods We employed a modified Delphi method with 4 expert surgeons from 3 international centers of excellence. Surgeons were independently observed performing THA before undergoing semistructured cognitive task analysis (CTA) and before completing successive rounds of surveys until a consensus was reached. Thirty-six surgical residents (postgraduate year [PGY]-1 through PGY-4) were randomized to cognitive training or training with a standard operation manual with surgical videos before performing a simulated AA-THA. Results The consensus CTA defined THA in 11 phases, in which were embedded 46 basic steps, 36 decision points, and 42 critical errors and linked strategies. This CTA was mapped onto an open-access web-based CTT. Surgeons who prepared with the CTT performed a simulated THA 35% more quickly (time, mean 28 versus 38 minutes) with 69% fewer errors in instrument selection (mean 29 versus 49 instances), and required 92% fewer prompts (mean 13 versus 25 instances). They were more accurate in acetabular cup orientation (inclination error, mean 8° versus 10°; anteversion error, mean 14° versus 22°). Conclusions This validated CTT for arthroplasty provides structure for competency-based learning. It is more effective at preparing orthopaedic trainees for a complex procedure than conventional materials, as well as for learning sequence, instrumentation utilization, and motor skills. Clinical relevance Cognitive training combines education on decision-making, knowledge, and technical skill. It is an inexpensive technique to teach surgeons to perform hip arthroplasty and is more effective than current preparation methods.

Most assessment of surgical trainees is based on measures of knowledge, with limited evaluation of their competence to actually perform various surgical procedures. In this study, the authors evaluated a tool they designed to assess a trainee's competence to perform an entire surgical procedure independently, regardless of procedure type or postgraduate year (PGY).In phase 1, the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) was piloted in the University of Ottawa's Division of Orthopaedic Surgery. In phase 2, the refined 11-item tool (8 items rated on a 5-point competency scale, 1 item assessing procedural competence, 2 feedback items) was used in the Divisions of Orthopaedic Surgery and General Surgery to assess residents' performance on 11 common procedures. Quantitative and qualitative analyses were conducted.In phase 2, 34 orthopaedic and general surgeons assessed the performance of 37 residents in 163 procedures. ANOVA demonstrated an effect of PGY. Post hoc analysis found that total procedure scores for PGYs 1 and 2 were lower than those for PGY 3 (P.001), and PGY 3 scores were lower than those for PGYs 4 and 5 (P.02). Analysis of qualitative data indicated that the rating scale was practical and useful for surgeons and residents.This novel evaluation tool successfully discriminated between junior and senior residents and identified surgical competency across various PGY levels regardless of procedure type. Multiple sources of evidence support the O-SCORE as a valid tool for the assessment of trainee operative competency.

Background Added modular junction has been associated with implant-related failures. We report our experience with a titanium-titanium modular neck-stem interface to assess complications, possible clinical factors influencing use of neck modularity, and whether modularity reduced the incidence of dislocation. Methods A total of 809 total hip arthroplasties completed between 2005 and 2012 from a prospectively collected database were reviewed. The mean follow-up interval was 5.7 years (3.3-10.3 years). Forty-five percent were male (360 of 809), and 55% were female (449 of 809). All stems were uncemented PROFEMUR TL (titanium, flat-tapered, wedge) or PROFEMUR Z (titanium, rectangular, dual-tapered) with a titanium neck. Results Increased modularity (anteverted/retroverted and anteverted/retroverted varus/valgus (anteverted/retroverted + anteverted/retroverted varus/valgus) was used in 39.4% (135 of 343) of cases using the posterior approach compared with 6.8% (20 of 293) of anterior and 23.7% (41 of 173) of lateral approaches. Four males sustained neck fractures at a mean of 95.5 months (69.3-115.6 months) after primary surgery. Overall dislocation rate was 1.1% (9 of 809). The posterior approach had both the highest utilization of increased modularity and the highest dislocation rate (2.3%), of which the most were recurrent. The anterior (0.3%) and lateral (0%) approaches had lower dislocation rates with no recurrences. Conclusion At a mean 5.7 years, our experience demonstrates a low neck fracture (0.5%) and a low dislocation rate (1.1%). Use of increased modularity may not improve dislocation risk for the posterior approach. Continued surveillance of this group will be necessary to determine long term survivorship of this modular titanium implant.

CONSTRUCT: The Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) is a 9-item surgical evaluation tool designed to assess technical competence in surgical trainees using behavioral anchors.The initial development of the O-SCORE produced evidence for valid results. Further work is required to determine if the use of a single surgeon or an unblinded rater introduces bias. In addition, the relationship of the O-SCORE to other currently used technical assessment tools should be explored to provide validity evidence related to the relationship to other measures. We have designed this project to provide continued validity evidence for the O-SCORE related to these two issues.Nineteen residents and 2 staff Orthopedic Surgeons from the University of Ottawa volunteered to participate in a 2-part OSCE style station. Participants completed a written questionnaire followed by a videotaped 10-minute simulated open reduction and internal fixation of a midshaft radius fracture. Videos were rated individually by 2 blinded staff orthopedic surgeons using an Objective Structured Assessment of Technical Skills (OSATS) global rating scale, an OSATS checklist, and the O-SCORE in random order.O-SCORE results appeared sensitive to surgical training level even when raters were blinded. In addition, strong agreement between two independent observers using the O-SCORE suggests that the measure captures a performance easily recognized by surgical observers. Ratings on the O-SCORE also were strongly associated with global ratings on the currently most validated technical evaluation tool (OSATS). Collectively, these results suggest that the O-SCORE generates accurate, reproducible, and meaningful results when used in a randomized and blinded fashion, providing continued validity evidence for using this tool to evaluate surgical trainee competence.The O-SCORE was able to differentiate surgical trainee level using blinded raters providing further evidence of validity for the O-SCORE. There was strong agreement between two independent observers using the O-SCORE. Ratings on the O-SCORE also demonstrated equivalence to scores on the most validated technical evaluation tool (OSATS). These results suggest that the O-SCORE demonstrates accurate and reproducible results when used in a randomized and blinded fashion providing continued validity evidence for this tool in the evaluation of surgical competence in the trainees.

Meaningful residency education occurs at the bedside, along with opportunities for situated in-training assessment. A necessary component of workplace-based assessment (WBA) is the clinical supervisor, whose subjective judgments of residents' performance can yield rich and nuanced ratings but may also occasionally reflect bias. How to improve the validity of WBA instruments while simultaneously capturing meaningful subjective judgment is currently not clear. This Perspective outlines how "entrustability scales" may help bridge the gap between the assessment judgments of clinical supervisors and WBA instruments. Entrustment-based assessment evaluates trainees against what they will actually do when independent; thus, "entrustability scales"-defined as behaviorally anchored ordinal scales based on progression to competence-reflect a judgment that has clinical meaning for assessors. Rather than asking raters to assess trainees against abstract scales, entrustability scales provide raters with an assessment measure structured around the way evaluators already make day-to-day clinical entrustment decisions, which results in increased reliability. Entrustability scales help raters make assessments based on narrative descriptors that reflect real-world judgments, drawing attention to a trainee's readiness for independent practice rather than his/her deficiencies. These scales fit into milestone measurement both by allowing an individual resident to strive for independence in entrustable professional activities across the entire training period and by allowing residency directors to identify residents experiencing difficulty. Some WBA tools that have begun to use variations of entrustability scales show potential for allowing raters to produce valid judgments. This type of anchor scale should be brought into wider circulation.

Background: Assessing the adequacy of bone resection when correcting cam-type femoroacetabular impingement can be difficult when the surgeon is inexperienced or when less-invasive arthroscopic surgical techniques are used. The primary purpose of the present study was to compare, using a Sawbones model, the results of computer-assisted navigated osteochondroplasty of the femoral neck junction with correction with use of femoral head spherometer gauges. The second objective was to compare the results of computer-assisted osteochondroplasty performed by surgeons who had varied experience with the procedure. Methods: We calculated and compared the post-resection alpha angle in custom-molded Sawbones models with cam-type impingement following both surgical techniques, performed by three surgeons with varied experience with the procedure. The alpha angle was measured at two positions (the three o’clock and one-thirty positions of the femoral head-neck junction) before and after resection. Results: At the three o’clock position, there were no significant differences between the computer-navigation and spherometer groups (p = 0.83). There was undercorrection at the one-thirty position, with the median alpha angle being greater in the navigation group as compared with the spherometer group (71.0 compared with 58.6; p = 0.05). In the navigation group, there were no significant differences in the post-resection mean alpha angle among the three surgeons at either the one-thirty plane or the three o’clock plane. Conclusions: Navigation enabled the inexperienced surgeon to perform an equivalent amount of bone resection as the more experienced surgeons. However, all surgeons did not sufficiently resect the cam deformity as compared with the gold-standard open technique at the one-thirty position. Clinical Relevance: The limitations of computer-assisted surgery should be understood, and adequate training for surgical correction of cam-type femoroacetabular impingement remains essential.

The results of metal-on-metal hip resurfacing arthroplasty have been very encouraging. However, extensile approaches such as the posterior have been recommended to ensure proper component placement. This article evaluates the safety and the learning curve with the less invasive Hueter hip resurfacing using an anterior approach on an orthopedic traction table. The first 50 hip resurfacings using this approach are compared with the previous 50 procedures performed through a surgical dislocation approach. The authors conclude that it is a reasonable alternative to more extensile surgical approaches for a high-volume resurfacing arthroplasty surgeon. Further long-term studies and comparisons to other approaches will determine if the anterior approach provides advantages in terms of patient function and time to recovery.

Background: While computer-assisted orthopaedic surgery technology may facilitate performance and learning in the expert, its effects on the trainee are unclear. Motor learning theory suggests that, while the real-time feedback provided by computer-assisted orthopaedic surgery should improve performance, it may be detrimental to learning. The purpose of this study was to assess the effects of computer-assisted orthopaedic surgery on the learning of surgical skills by trainees. Methods: Forty-five participants were randomized to one of three training groups—conventional training, computer navigation, or knowledge of results—in which they learned technical skills related to total hip replacement. Outcomes were assessed in a pretest session and in ten-minute and six-week retention and transfer tests. Results: All groups demonstrated improved accuracy and precision in the determination of the abduction angle and the version angle of the acetabular cups during training (p < 0.001). The computer navigation group demonstrated significantly better accuracy and precision in early training (p < 0.05) and better precision throughout training (p < 0.05). No significant degradation in performance was observed between the immediate and the delayed testing for any group, suggesting that there was task learning in all groups with no negative effects of the tested training modalities on learning. Conclusions: In this study, the concurrent augmented feedback provided by computer-assisted orthopaedic surgery resulted in improved early performance and equivalent learning. While we did not observe a compromise in learning, further investigation is required to ensure that computer-assisted orthopaedic surgery does not compromise trainee learning in more complex tasks. Clinical Relevance: As the utilization of computer-assisted orthopaedic surgery techniques increases, it is essential that we develop an understanding of its effects on performance and learning in both the primary and continuing education environments.

Acetabular fracture patterns in the elderly, with increased involvement of the anterior column, quadrilateral plate comminution, medialization of the femoral head, and marginal impaction, differ from those noted among a younger cohort. Poor prognostic factors for open reduction and internal fixation (ORIF) are posterior wall comminution, marginal impaction of the acetabulum, a femoral head impaction fracture, a so-called gull sign, and hip dislocation. The rate of conversion to total hip arthroplasty following formal ORIF has been reported to be 22% at a mean of twenty-nine months. Total hip replacement after an acetabular fracture generally yields good clinical results; however, in the acute setting, it must be combined with proper stable fracture fixation.

The goal of this study is to evaluate serum levels of chromium (Cr), cobalt (Co), and titanium (Ti) within the first two years following total hip arthroplasty using a Ti modular neck system. Twenty-five patients were randomized to a metal-on-metal (MoM) bearing with an all CoCr shell, and the remaining 25 received a metal-on-polyethylene (MoP) with a Ti shell. Serum levels demonstrated increases for Cr, Co, and Ti at 1 year (P < .001). MoM had similar Ti levels to MoP hips at 1 year (P=0.11) but lower at 2 years (P=0.03). Results suggest that the passive corrosion (i.e., chemical, pitting, and crevice corrosion) of exposed non-articular metal surfaces may be a greater source of ions than the neck-stem or head-neck interfaces.