[Predatory journals in Orthopedics and Traumatology]

Predatory journals are distinguished from legitimate journals by their lack of adequate reviews and editorial processes, compromising the quality of published content. These journals do not conduct peer reviews or detect plagiarism, and accept manuscripts without requiring substantial modifications. Their near 100% acceptance rate is driven by profit motives, regardless of the content they publish. While they boast a prestigious editorial board composed of renowned researchers, in most cases, it is a facade aimed at impressing and attracting investigators. Furthermore, these journals lack appropriate ethical practices and are non-transparent in their editorial processes. Predatory journals have impacted multiple disciplines, including Orthopedics and Traumatology, and their presence remains unknown to many researchers, making them unwitting victims. Their strategy involves soliciting articles via email from authors who have published in legitimate journals, promising quick, easy, and inexpensive publication. The implications and negative consequences of predatory journals on the scientific community and researchers are numerous. The purpose of this work is to provide general information about these journals, specifically in the field of Orthopedics and Traumatology, offering guidelines to identify and avoid them, so that authors can make informed decisions when publishing their manuscripts and avoid falling into the hands of predatory journals or publishers.

Establishing a consensus on research priorities in orthopaedic trauma within South Africa

BACKGROUND

Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low- and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK healthcare practitioners within SA.

METHOD

Members from the Orthopaedic Research Collaboration in Africa (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA.

RESULTS

Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups-clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures.

CONCLUSION

This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts.

The Renaissance of Unicompartmental Knee Arthroplasty appears rational - A radiograph-based comparative Study on adverse Events and patient-reported Outcomes in 353 TKAs and 98 UKAs

PURPOSE

Total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) are both considered suitable for antero-medial osteoarthritis and spontaneous osteonecrosis of the knee. National registry data are consistent in showing higher revision rates for UKA. Adequately adjusted, these findings may be challenged by differences in adverse events and patient-reported outcomes, as both can have serious long-term implications. Based on preoperative radiographs, the aim was to retrospectively compare the two principle surgeries in these respects.

METHODS

All TKA procedures in 2016 in one Swedish county council were, according to certain radiograph-based consensus criteria, visually evaluated for medial UKA suitability. Then, using different regression models, they were compared with the corresponding medial UKAs performed in 2015-2017 regarding complications and patient-reported outcomes one year after surgery.

RESULTS

The UKA group showed an 82% reduced risk (OR 0.2; 95% CI 0.0-0.6) of any complications, whereas the 55% reduced risk of severe complication did not reach statistical significance (OR 0.5; 95% CI 0.1-2.1). These findings corresponded in high-volume surgeries to an absolute complication rate of 0% in the UKA group and 10% in the TKA group (p = 0.005) and to a severe complication rate of 0% and 5% respectively (p = 0.05). Though no differences were seen in any general patient-reported outcomes, the pain and function based OMERACT-OARSI responder criteria indicated in both around a 60% better chance of any response (OR 1.6 CI % 0.6-4.5) and a high response (OR 1.6; 95% CI 0.7-3.4) in the UKA group.

CONCLUSION

No differences were shown in patient-reported outcomes but a clear difference in risk of complications, favoring the UKA procedure.

The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey

INTRODUCTION

Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP).

METHODS

Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids.

RESULTS

569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP.

CONCLUSION

While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.

Radiation Reduction Strategies in Pediatric Orthopaedics

INTRODUCTION

Pediatric orthopaedic patients have the potential for significant radiation exposure from the use of imaging studies, such as computed tomography and bone scintigraphy. With the potential for long-term treatment, such as is required for scoliosis or osteogenesis imperfecta, patients are at even greater risk of radiation-induced carcinogenesis.

DISCUSSION

Although an association between radiation and cancer risk is evident, causation is difficult to prove because comorbidities or genetic predispositions may play a role in the higher baseline rates of malignancy later in life. Efforts have been made over the years to reduce exposure using more modern imaging techniques and simple radiation reduction strategies. Educational efforts and clinical practice guidelines are decreasing the rate of computed tomography scan use in pediatrics. Although considerable work is being done on the development of radiation-free imaging modalities, imaging that uses ionizing radiation will, in the near term, be necessary in specific circumstances to provide optimal care to pediatric orthopaedic patients.

CONCLUSION

Knowledge of the ionizing radiation exposure associated with commonly used tests as well as radiation-reduction strategies is essential for the optimal and safe care of pediatric orthopaedic patients.

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry

BACKGROUND

Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions.

QUESTION/PURPOSE

We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States?

METHODS

The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively.

RESULTS

There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth.

CONCLUSION

We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains.

CLINICAL RELEVANCE

Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.

Effect of malpractice claims on orthopedic and traumatology physicians in Turkey: A survey study

OBJECTIVE

This study aimed to investigate the malpractice claims experienced by orthopedic and traumatology physicians and to determine their effects on burnout, job satisfaction, and clinical practice.

METHODS

A questionnaire survey was conducted on orthopedic and traumatology specialists between May 2019 and February 2020. Data collection was carried out via e-survey at "turk-ortopedi" mail group, which is an electronic communication network of orthopedic and traumatology physicians. For data collection, sociodemographic data forms were used including the general characteristics, working conditions, and the malpractice claim events along with the Maslach Burnout Inventory scale to evaluate burnout and the Minnesota Satisfaction Questionnaire to investigate job satisfaction.

RESULTS

In total, 353 orthopedic and traumatology physicians (348 men, 5 women), including 37 professors, 41 associate professors, and 275 surgeons, completed the questionnaire. In total, 65.4% of the participants (231 physicians and 471 relevant dossiers) stated that they were currently facing a malpractice claim. Emotional burnout and hesitant behavior in medical practices were significantly higher among the physicians who had undergone an investigation/trial with the claim of malpractice (p<0.05), whereas intrinsic job satisfaction was significantly lower (p<0.05). It was determined that orthopedic and traumatology physicians dealing with arthroplasty, vertebral surgery, hand surgery, and foot/ankle surgeries had undergone significantly more trials (p<0.05). In the evaluation of the burnout levels and job satisfaction scores of the physicians according to the age, academic title, seniority, and institution, it was determined that burnout level decreased with age, those between the ages of 25 and 34 years were exhausted the most, and job satisfaction increased with age. It was also found that burnout level decreased and job satisfaction increased as the academic title became higher, and attending physicians were the most exhausted. Moreover, burnout level decreased as seniority increased, the most senior ones were the ones most exhausted, and job satisfaction increased with seniority.

CONCLUSION

Evidence from this study has revealed that malpractice claims cause emotional burnout, low intrinsic job satisfaction, and a hesitant behavior in medical practice for the orthopedic and traumatology physicians. The concept of malpractice alone may result in unnecessary analyses/examinations for patients.

LEVEL OF EVIDENCE

Level IV, Diagnostic Study.

Inter-rater and Intrarater Reliabilities of the Identification of a "Gothic Arch" in the Acetabulum of Children With Cerebral Palsy

BACKGROUND

Progressive hip displacement in children with cerebral palsy (CP) is monitored by measuring migration percentage (MP) on anteroposterior (AP) pelvis radiographs. Accurate measurement of MP requires the lateral margin of the ossified acetabulum to be identified for the placement of Perkin's line. It has been suggested that when there is an erosion of the acetabular rim, described as a gothic arch, the midpoint of the arch be used for the placement of Perkin's line. However, this requires that there be agreement on what constitutes a gothic arch. The purpose of this study was to evaluate the inter-rater and intrarater reliabilities of identifying a gothic arch on pelvis radiographs.

METHODS

An online survey with 100 AP pelvis images (200 hips) of children with CP was sent to international experts. Participants were asked to identify which hip(s) had a gothic arch (left, right, both, and neither). The Fleiss κ statistic for inter-rater reliability was calculated. Eight weeks later, the images were shuffled and redistributed to calculate intrarater reliability.

RESULTS

The initial survey was completed by 10 participants with 9 participants completing the second survey. The average inter-rater κ value was 0.18 [95% confidence interval (CI), 0.14-0.23] and 0.19 (95% CI, 0.14-0.24) for the 2 surveys, respectively. Among the pediatric orthopaedic surgeons subgroup, the κ values were 0.06 (95% CI, 0.02-0.1) and 0.08 (95% CI, 0.03-0.13). The average intrarater reliability κ value was 0.61 (95% CI, 0.2-1), ranging from 0.32 to 0.86.

CONCLUSIONS

There were poor inter-rater and moderate intrarater reliabilities in identifying a gothic arch on AP pelvis radiographs in children with CP. Further characterization and clarification of what constitutes a gothic arch are required. The lack of agreement on the identification of a gothic arch may negatively impact the measurement of MP and referrals to a pediatric orthopaedic surgeon.

The new 'normal': Rapid adoption of telemedicine in orthopaedics during the COVID-19 pandemic

BACKGROUND

Telemedicine provides a safe and effective means for the delivery of care by physicians amongst many subspecialties. Historically, orthopaedic practices in the United States have not widely utilized telemedicine for the delivery of orthopaedic care. As technology improves the adoption and utilization of telemedicine will likely grow, especially in light of the novel coronavirus (COVID-19) pandemic. Our study aims to assess patient and surgeon satisfaction and efficacy of telemedicine during a rapid adoption due to the global pandemic.

METHODS

All patients who completed a telemedicine encounter (telephone or video) with an orthopaedic surgeon were contacted. Patients were individually contacted after their visit, and a standardized validated post-visit satisfaction survey was completed. Orthopaedic surgeons completed a standardized post-encounter survey after each visit. Pre-COVID-19 patient satisfaction data was used for comparison.

RESULTS

Orthopaedic surgeons completed 612 telehealth encounters either via phone or video consultation between April 6, 2020 and May 22, 2020. 95% of patients rated both surgeon sensitivity to their needs and response to their concerns as 'good' or 'very good.' 93% of patients reported they would participate in a telemedicine encounter again. Surgeons reported high satisfaction with telemedicine encounters (80%, 86% phone and video respectively), and that 78.4% of the time a telemedicine encounter was successful in replacing an in-person visit.

CONCLUSION

Patients and orthopaedic surgeons documented high levels of satisfaction with telehealth encounters during the novel coronavirus (COVID-19) pandemic. Telemedicine does not appear to be a replacement for all in-person clinic encounters, however, when used in the appropriate context demonstrated favourable results.

LEVEL OF EVIDENCE

Level 4 Study.

Virtual Fracture Clinics in Orthopaedic Surgery - A Systematic Review of Current Evidence

AIMS

Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic visits. In 2014, the Glasgow Fracture Pathway offered an alternative virtual fracture clinic (VFC) pathway with the potential to reduce traditional fracture clinic visits, waiting times and overall costs. Many units have implemented this style of pathway in the non-operative management of simple, undisplaced fractures. This study aims to systematically review the clinical outcomes, patient reported outcomes and cost analyses for VFCs.

MATERIALS AND METHODS

Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and COCHRANE Library databases. Studies reporting outcomes following the use of VFC were included. Outcomes analysed were: 1) clinical outcomes, 2) patient reported outcomes, and 3) cost analysis.

RESULTS

Overall, 15 studies involving 11,921 patients with a mean age of 41.1 years and mean follow-up of 12.6 months were included. In total, 65.7% of patients were directly virtually discharged with protocol derived conservative management, with 9.1% using the Helpline and 15.6% contacting their general practitioner for advice or reassurance. A total of 1.2% of patients experienced fracture non-unions and 0.4% required surgical intervention. The overall patient satisfaction rate was 81.0%, with only 1.3% experiencing residual pain at the fracture site. Additionally, the mean cost per patient for VFC was £71, with a mean saving of £53 when compared to traditional clinic models. Subgroup analysis found that for undisplaced fifth metatarsal or radial head/neck fractures, the rates of discharge from VFC to physiotherapy or general practitioners were 81.2% and 93.7% respectively.

DISCUSSION AND CONCLUSION

This study established that there is excellent evidence to support virtual fracture clinic for non-operative management of fifth metatarsal fractures, with moderate evidence for radial head and neck fractures. However, the routine use of virtual fracture clinics is presently not validated for all stable, undisplaced fracture patterns.

LEVEL OF EVIDENCE

IV; Systematic Review of all Levels of Evidence.

An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013

BACKGROUND

The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials.

METHODS

A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted.

RESULTS

A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment.

CONCLUSIONS

The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

Cognitive training for the prevention of skill decay in temporarily non-performing orthopedic surgeons

Surgical tasks are prone to skill decay. During unprecedented circumstances, such as an epidemic, personal illness, or injury, orthopedic surgeons may not be performing surgical procedures for an uncertain period of time. While not being able to execute regular surgical tasks or use surgical simulators, skill decay can be prevented with regular mental practice, using a scientifically proven skill acquisition and retaining tool. This paper describes different theories on cognitive training answering the question on how it works and offers a brief review of its application in surgery. Additionally, practical recommendations are proposed for performing mental training while not performing surgical procedures.

Shoulder and Elbow Injuries in the Adolescent Throwing Athlete

Shoulder and elbow injuries in the adolescent population can be generally divided into skeletally immature and skeletally mature. Skeletally immature injuries refer to damage to the open growth plate (physis) in the young athlete, which have distinct differences in long-term risks if not managed correctly due to the potential for growth disturbance. Skeletally mature injuries occur in athletes with closed growth plates and are less likely to limit growth potential. It is important to recognize these different types of injuries, as well as the patients most at risk for each type because treatment may vary significantly between the two groups. The main skeletally immature injuries covered by this review will include: medial epicondyle apophysitis ("Little Leaguer's elbow), medial epicondyle fractures, olecranon stress fractures, capitellar osteochondritis dissecans (OCD), and proximal humeral apophysitis ("Little Leaguer's shoulder"). The skeletally mature injuries discussed will include: valgus extension overload syndrome (VEOS), ulnar collateral ligament (UCL) tear, shoulder instability, and superior labral anterior-posterior (SLAP) tears. We will review the history and presentation of the injuries as well as different treatment strategies and return to play guidelines for both primary care sports physicians as well as orthopedic surgeons.

Pandemic response protocol of a non-frontline specialty in a multispecialty tertiary health care centre-a pilot model in orthopaedics

BACKGROUND

3,181,642 cases and 224,301 deaths in 212 regions of the world-this is the status of COVID-19 (Coronavirus Disease 2019) pandemic as of May 1, 2020. This pandemic has managed to overwhelm the health care system of the most advanced countries in the world. As the whole of the medical fraternity stands robed as health care professionals to fight against COVID-19, specialty emergencies like trauma continue to pester the already overburdened health care community. This situation calls for the need for a pandemic response protocol (PREP) in each specialty that helps the doctors to manage specialty emergencies without chaos and at the same time allowing them to play their part in pandemic management.

CONCLUSION

PREP as an integrated pragmatic approach is essential in containing pandemics as they need international cooperation at various levels starting from knowledge sharing to monetary support. PREP which is in line with the WHO action plan, will be an essential minimum response of a non-frontline pandemic response specialty like orthopedics to combat and curtail the effects of a pandemic in a multispecialty tertiary health care centre.

Medically Necessary Orthopaedic Surgery During the COVID-19 Pandemic: Safe Surgical Practices and a Classification to Guide Treatment

BACKGROUND

Coronavirus disease 2019 (COVID-19) has rapidly evolved as a viral pandemic. Countries worldwide have been affected by the recent outbreak caused by the SARS (severe acute respiratory syndrome)-CoV-2 virus. As with prior viral pandemics, health-care workers are at increased risk. Orthopaedic surgical procedures are common in health-care systems, ranging from emergency to elective procedures. Many orthopaedic surgical procedures are life or limb-saving and cannot be postponed during the COVID-19 pandemic because of potential patient harm. Our goal is to analyze how orthopaedic surgeons can perform medically necessary procedures during the pandemic and to help guide decision-making perioperatively.

METHODS

We performed a review of the existing literature regarding COVID-19 and prior viral outbreaks to help guide clinical practice in terms of how to safely perform medically necessary orthopaedic procedures during the pandemic for both asymptomatic patients and high-risk (e.g., COVID-19-positive) patients. We created a classification system based on COVID-19 positivity, patient health status, and COVID-19 prevalence to help guide perioperative decision-making.

RESULTS

We advocate that only urgent and emergency surgical procedures be performed. By following recommendations from the American College of Surgeons, the Centers for Disease Control and Prevention, and the recent literature, safe orthopaedic surgery and perioperative care can be performed. Screening measures are needed for patients and perioperative teams. Surgeons and perioperative teams at risk for contracting COVID-19 should use appropriate personal protective equipment (PPE), including N95 respirators or powered air-purifying respirators (PAPRs), when risk of viral spread is high. When preparing for medically necessary orthopaedic procedures during the pandemic, our classification system will help to guide decision-making. A multidisciplinary care plan is needed to ensure patient safety with medically necessary orthopaedic procedures during the COVID-19 pandemic.

CONCLUSIONS

Orthopaedic surgery during the COVID-19 pandemic can be performed safely when medically necessary but should be rare for COVID-19-positive or high-risk patients. Appropriate screening, PPE use, and multidisciplinary care will allow for safe medically necessary orthopaedic surgery to continue during the COVID-19 pandemic.

LEVEL OF EVIDENCE

Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Operating in a Pandemic: Lessons and Strategies from an Orthopaedic Unit at the Epicenter of COVID-19 in Singapore

➤With severe limitations in manpower, facilities, and equipment, and the concern for nosocomial transmission, operating in a pandemic is fraught with danger from multiple fronts. ➤Strategies to mitigate nosocomial spread include prioritization of existing patients, triaging and treatment of new patient encounters, infection control protocols, perioperative considerations, manpower management, and novel strategies for interdisciplinary interaction and education. ➤The decision to proceed with or postpone surgery should be based on the urgency of the surgical procedure and the physiological health of the patient. ➤When performing an operation on a patient who has suspected or confirmed infection with novel coronavirus disease 2019 (COVID-19), personal protection equipment should include hair covers, face shields or goggles, N95 respirator masks, a blood-borne pathogen-resistant surgical gown, shoe covers, and double-gloving with single-use gloves. ➤Loose-fitting, powered air-purifying respirators should be considered for prolonged surgeries. ➤An astutely formulated and comprehensive business continuity plan is an orthopaedic unit’s best strategy for maintaining critical standards, discipline, and morale in severe and prolonged outbreaks.

[Orthopedics between reason and passion. Guidelines and shadow lines.]

For over 20 years the Evidence-Based Orthopaedics Working Group (GLOBE) has been promoting evidence-based medicine (EBM) in orthopaedics and traumatology. However, despite a constant and wide-ranging editorial production and fruitful collaborations with colleagues and institutions at national and international level, the orthopaedic scientific community finds it difficult to recognize the EBM model as a solid reference: there are few guidelines available, there is little awareness of their usefulness, and the complexity of the methodology of production and adaptation of documents widens the gap between the orthopaedic real world and that of clinical epidemiology. After a quick analysis of the causes of this contrast, the authors reflect on the possible solutions to the problem, and propose to collaborate for a simplification of the guidelines production methodology, using innovative models of literature review, which have proved to be effective to make the best knowledge available quickly during the CoViD-19 pandemic.

Using Evidence for Hand Surgery: How to Practice Evidence-Based Hand Surgery Care

Each step of the evidence-based practice process is critical and requires clear understanding for accurate application. To practice evidence-based care, providers must acquire a specific skillset that facilitates translation of a patient problem into an answerable research question. Additional requirements are understanding of electronic databases, critical appraisal of the available evidence, and integration of the findings to generate a specific, individualized treatment plan. Although this process is demanding, evidence-based practice is essential in the delivery of optimal patient care.

[Responsible use of screens: recommendations to limit myopia in children and young people]

The excessive use of screens is a contemporary problem that can have a number of effects on health. It is of particular influence on the onset and exacerbation of myopia, and for these reasons a group of professionals decided to draw up recommendations on a more sensible use of screens. The group comprised an ophthalmologist-epidemiologist, an orthoptist, paediatric and adolescent physicians, a youth health care nurse, an orthopaedic surgeon, a movement therapist-epidemiologist, health scientists and psychologists. They recommend that on history-taking, standard questions concerning screen use and its associated problems should be asked. The parents can then be given targeted lifestyle advice for the child, i.e. after 20-30 minutes continuous screen use there should be a change of activity, and that the child should spend 2 hours a day outdoors. These recommendations will promote the health of children's eyes as well as their general development.

Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters

BACKGROUND

Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system.

METHODS

Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method.

RESULTS

Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them.

CONCLUSION

This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.

Evaluation of the Clarity and Completeness of Reporting in Orthopedic Clinical Practice Guidelines

Background

Clinical practice guidelines (CPGs) can positively affect the quality of patient care offered by physicians because they decrease variability in clinical practice and may help reduce unnecessary testing, promoting a more responsible use of resources. Building on existing framework for reporting guideline development, including the work of the Enhancing the Quality and Transparency of Health Research Network, the Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group created a 2016 checklist of 35 items considered essential for high-quality reporting of CPGs.

Objectives

To evaluate how many previously published CPGs in orthopedic surgery met the RIGHT criteria and assess how improvements can be made in future orthopedic CPGs based on any found deficiencies.

Methods

All 18 CPGs published before January 1, 2018, by the American Academy of Orthopedic Surgeons (AAOS) are publicly available on orthoguidelines.org. Two authors downloaded each file and both of those authors independently scored each CPG using piloted abstraction RIGHT checklist forms.

Results

Of the 35 RIGHT criteria outlined in 22 checklist items, 23 (65.7%) were met across all AAOS guidelines, 6 (17.1%) were not met by any of the AAOS guidelines, and 6 (17.2%) were met by some of the AAOS guidelines.

Conclusion

Overall, the AAOS guidelines addressed many important recommendations within the RIGHT checklist. Assessing adherence to the RIGHT checklist can help ensure that future guidelines are more effectively communicated, hopefully assisting end users in efficient implementation and increasing the level of evidence-based patient care.

Factors Influencing Complication Rates in the Orthopaedic Theatre

PURPOSE OF THE STUDY The prevalence of complications in surgical units is available in the literature. The aim of this study was to compare the "rotational" (more than one surgeon) and "full-time single surgeon" use of the orthopedic theater. MATERIAL AND METHODS We retrospectively evaluated patients who underwent orthopedic surgery in 2016 in different theaters. A total of 604 of 1973 patients were excluded from the study, and 1369 patients were analyzed. The follow-up period was 1 year. While evaluating the cases, the duration and order of each case, the total operation time on the table, the number of surgeons, the total number of cases, the number of residents, and the experiences of the surgeons were investigated, and the effects of these parameters on the complication rates were analyzed. The Dindo-Clavien system was used to classify the complications. RESULTS When comparing the methods, the complication rate of the full-time single-surgeon method (12.9%) was less than that of the rotational method (21.7%) (p: 0.022). A higher rate of complications (8.5%) was observed in operations with a duration of 115 minutes or more compared to other operations (p <0.001). A higher complication rate (23.7%) was observed in cases lasting more than 345 minutes (p = 0.002). CONCLUSIONS According to our study, full-time use of the orthopedic theater by a single surgeon was found to be safer than rotational use. In addition, the duration of surgeries lasting longer than 115 minutes or longer than 345 minutes during the day increased the rate of surgical complications. Key words: patient safety, surgical planning, operation time, operation order, orthopedic complication.

Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument?

BACKGROUND

Health systems and payers use patient-reported outcome measures (PROMs) to inform quality improvement and value-based payment models. Although it is known that psychosocial factors and priming influence PROMs, we sought to determine the effect of having patients complete functional tasks before completing the PROM questionnaire, which has not been extensively evaluated.

QUESTIONS/PURPOSES

(1) Will QuickDASH scores change after patients complete the tasks on the questionnaire compared with baseline QuickDASH scores? (2) Will the change in QuickDASH score in an intervention (task completion) group be different than that of a control group? (3) Will a higher proportion of patients in the intervention group than those in the control group improve their QuickDASH scores by greater than a minimally clinically important difference (MCID) of 14 points?

METHODS

During a 2-month period, 140 patients presented at our clinic with a hand or upper-extremity problem. We approached patients who spoke and read English and were 18 years old or older. One hundred thirty-two (94%) patients met the inclusion criteria and agreed to participate (mean ± SD age, 52 ± 17 years; 60 men [45%], 72 women [55%]; 112 in the intervention group [85%] and 20 in the control group [15%]). First, all patients who completed the QuickDASH PROM (at baseline) were recruited for participation. Intervention patients completed the functional tasks on the QuickDASH and completed a followup QuickDASH. Control patients were recruited and enrolled after the intervention group completed the study. Participants in the control group completed the QuickDASH at baseline and a followup QuickDASH 5 minutes after (the time required to complete the functional tasks). Paired and unpaired t-tests were used to evaluate the null hypotheses that (1) QuickDASH scores for the intervention group would not change after the tasks on the instrument were completed and (2) the change in QuickDASH score in the intervention group would not be different than that of the control group (p < 0.05). To evaluate the clinical importance of the change in score after tasks were completed, we recorded the number of patients with a change greater than an MCID of 14 points on the QuickDASH. Fisher's exact test was used to evaluate the difference between groups in those reaching an MCID of 14.

RESULTS

In the intervention group, the QuickDASH score decreased after the intervention (39 ± 24 versus 25 ± 19; mean difference, -14 points [95% CI, 12 to 16]; p < 0.001). The change in QuickDASH scores was greater in the intervention group than that in the control group (-14 ± 11 versus -2 ± 9 [95% CI, -17 to -7]; p < 0.001). A larger proportion of patients in the intervention group than in the control group demonstrated an improvement in QuickDASH scores greater than the 14-point MCID ([43 of 112 [38%] versus two of 20 [10%]; odds ratio, 5.4 [95% CI, 1 to 24%]; p = 0.019).

CONCLUSIONS

Reported disability can be reduced, thereby improving PROMs, if patients complete QuickDASH tasks before completing the questionnaire. Modifiable factors that influence PROM scores and the context in which scores are measured should be analyzed before PROMs are broadly implemented into reimbursement models and quality measures for orthopaedic surgery. Standardizing PROM administration can limit the influence of context, such as task completion, on outcome scores and should be used in value-based payment models.

LEVEL OF EVIDENCE

Level II, therapeutic study.

High reported rate of return to play following bone marrow stimulation for osteochondral lesions of the talus

PURPOSE

The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return to play guidelines and subsequent rates and timing of return to play following bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT).

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched according to the PRISMA guidelines in September 2017. The rate and timing of return to play was assessed. The rehabilitation protocols were recorded, including time to start range of motion, partial weight-bearing and complete weight-bearing.

RESULTS

Fifty-seven studies with 3072 ankles were included, with a mean age of 36.9 years (range 23-56.8 years), and a mean follow-up of 46.0 months (range 1.5-141 months). The mean rate of return to play was 86.8% (range 60-100%), and the mean time to return to play was 4.5 months (range 3.5-5.9 months). There was large variability in the reported rehabilitation protocols. Range of motion exercises were most often allowed to begin in the first week (46.2%), and second week postoperatively (23.1%). The most commonly reported time to start partial weight-bearing was the first week (38.8%), and the most frequently reported time of commencing full weight-bearing was 6 weeks (28.8%). Surgeons most often allowed return to play at 4 months (37.5%).

CONCLUSIONS

There is a high rate of return following BMS for OLT with 86.8% and the mean time to return to play was 4.5 months. There is also a significant deficiency in reported rehabilitation protocols, and poor quality reporting in return to play criteria. Early weightbearing and early postoperative range of motion exercises appear to be advantageous in accelerated return to sports.

LEVEL OF EVIDENCE

Level IV.

Full-endoscopic transforaminal procedure to treat the single-level adjacent segment disease after posterior lumbar spine fusion: 1-2 years follow-up

Adjacent segment disease (ASD) is one of the potential risks after lumbar spine surgery with instrumentation. Revision surgery needs to be performed on patients suffered from ASD. The traditional open surgery takes severe injury to the body. We investigated the clinical outcome of using full-endoscopic transforaminal procedure to treat the single-level adjacent segment diseases after posterior lumbar fusion. 33 patients (average 71 years, ranged 65-84 years old) underwent full-endoscopic transforaminal procedure were involved. The Oswestry Disability Index (ODI), Modified Japanese Orthopedic Association (mJOA) score and visual analogue scale (VAS) score were used to evaluate the clinical effect. The complication, hospital stay, hospitalization costs and blood loss were investigated according to the patient's records. The mean VAS score was 1.8 and mJOA score was 5.4 postoperatively. Improvement rate was 78%. The mean ODI was 14.6 postoperatively. The mean length of hospital stay, hospitalization costs and blood loss was 2.5 days, $3500 and 15 mL, respectively. No complication or recurrence was observed in any of the patients at the final follow-up. Full-endoscopic transforaminal procedure is a safe and effective technique. It is economical, acceptable and mini-invasive. Of course, it also can shorten the length of hospital stay and decrease bleeding. For revision surgery to treat ASD, this technique can achieve good clinical effects.

Implementation of simulation modelling to improve service planning in specialist orthopaedic and neurosurgical outpatient services

BACKGROUND

Advanced physiotherapist-led services have been embedded in specialist orthopaedic and neurosurgical outpatient departments across Queensland, Australia, to ameliorate capacity constraints. Simulation modelling has been used to inform the optimal scale and professional mix of services required to match patient demand. The context and the value of simulation modelling in service planning remain unclear. We aimed to examine the adoption, context and costs of using simulation modelling recommendations to inform service planning.

METHODS

Using an implementation science approach, we undertook a prospective, qualitative evaluation to assess the use of discrete event simulation modelling recommendations for service re-design and to explore stakeholder perspectives about the role of simulation modelling in service planning. Five orthopaedic and neurosurgical services in Queensland, Australia, were selected to maximise variation in implementation effectiveness. We used the consolidated framework for implementation research (CFIR) to guide the facilitation and analysis of the stakeholder focus group discussions. We conducted a prospective costing analysis in each service to estimate the costs associated with using simulation modelling to inform service planning.

RESULTS

Four of the five services demonstrated adoption by inclusion of modelling recommendations into proposals for service re-design. Four CFIR constructs distinguished and two CFIR constructs did not distinguish between high versus mixed implementation effectiveness. We identified additional constructs that did not map onto CFIR. The mean cost of implementation was AU$34,553 per site (standard deviation = AU$737).

CONCLUSIONS

To our knowledge, this is the first time the context of implementing simulation modelling recommendations in a health care setting, using a validated framework, has been examined. Our findings may provide valuable insights to increase the uptake of healthcare modelling recommendations in service planning.

Stratum-Specific Likelihood Ratio Analysis: An Evidence-Based and Pragmatic Approach to Meaningful Thresholds in Lower Extremity Arthroplasty

BACKGROUND

With the transition toward a value-based care delivery model, an evidence-based approach to quantify the effect of procedural volume on outcomes and cost presents an opportunity to understand and optimize the delivery of lower extremity arthroplasty. Stratum-specific likelihood ratio (SSLR) analysis has been recently applied to define benchmarks which confer a significant advantage in value at the hospital or surgeon level.

MATERIALS AND METHODS

In this report, the role, statistical technique, and future applications of SSLR analysis are described with an example outlined for total hip arthroplasty (THA).

RESULTS

SSLR analysis provides multiple significant value-based thresholds, providing an advantage over previous methods used to describe the effects of surgeon and hospital volume. These benchmarks have been developed for THA, total knee arthroplasty (TKA), hip fracture, and several other orthopaedic procedures. Current SSLR analyses are limited by the databases employed, and the study of a national database may provide more generalizable benchmarks, which may be applied by hospitals and orthopaedic residencies to define minimum competency thresholds.

CONCLUSION

The use of SSLR analysis provides a pragmatic, data-driven approach to understanding and communicating the volume-value relationship in orthopaedic surgery, particularly lower-extremity arthroplasty.

Generating evidence and understanding the treatment of osteoarthritis in Brazil: a study through Delphi methodology

OBJECTIVES

This study aimed to provide evidence for understanding how to treat osteoarthritis (OA) in our country. Therefore, it was necessary to match information and investigations related to the treatment of the disease from the three main types of specialists involved: physiatrists, orthopedists and rheumatologists.

METHODS

The authors acted as a scientific advisory committee. From the initial discussions, a structured questionnaire was developed for use with a group of specialists on OA using the Delphi technique. The questionnaire was sent to 21 experts appointed by the authors, and the results obtained were critically analyzed and validated.

RESULTS

The prevalence of OA was 33% in Brazil, corresponding to one-third of the individuals in the reference population, which included individuals over 25 years of age. Another significant finding was that most patients did not receive any form of treatment in the early stages of OA.

CONCLUSION

The committee pointed to the need for early intervention and that the available medicinal resources can fulfil this important role, as is the case with SYSADOA treatments. Glucosamine-based medicinal products with or without chondroitin could also fulfill this need for early treatment. The other generated evidence and included investigations were then grouped together and are the subject of this publication.

Implementation of an Orthopedic Trauma Program to Safely Promote Resident Autonomy

BACKGROUND

There is ongoing tension in graduate medical education between progressive resident autonomy with entrustable professional activities and the need for supervision to ensure patient safety.

OBJECTIVE

We implemented a pediatric orthopedic surgical trauma safety program that utilized a postcall review conference to provide residents graduated responsibility learning opportunities during overnight trauma call without compromising patient safety.

METHODS

In the program, all orthopedic trauma cases seen in our main tertiary hospital emergency department by the overnight orthopedic resident were reviewed in a case conference. For 1 year, we performed an analysis of all fracture patients who were treated in the emergency department by our orthopedic surgery residents. From June 1, 2016, through June 30, 2017, all care delivery encounters were reviewed for decision-making errors, technical errors, and complication rates. Two resident groups rotated through our institution over the course of the study.

RESULTS

During the year of analysis, all 1298 fracture patients seen overnight in the main tertiary hospital emergency department were reviewed. From the first to the second halves of their rotations, the rate of resident decision-making errors (3.1% [12 of 385] to 2.3% [9 of 399]) and technical errors (9.1% [35 of 395] to 7.3% [29 of 399]) decreased. Excluding decision-making and technical errors, the complication rate for patients discharged home was 3.4% (27 of 784).

CONCLUSIONS

Residents demonstrated decreased decision-making and technical error rates on overnight call while maintaining low complication rates.

Management of symptomatic os acromiale: a survey of the American shoulder and elbow surgeons

BACKGROUND

The purpose of this paper was to survey members of the American Shoulder and Elbow Surgeons (ASES) to assess their opinion on management options, help highlight important clinical factors, and elucidate surgical preferences for the treatment of a symptomatic meso-os.

METHODS

An online questionnaire was distributed to the active members of the ASES. The survey queried surgeon demographics and perioperative management preferences, and presented multiple clinical case scenarios of patients with a presumed symptomatic, unstable os acromiale.

RESULTS

There were 116 ASES members who responded to the survey, and 26% (n = 30) who stated they do not operatively manage a symptomatic os. We identified two main clusters of respondents. Cluster 1 (n = 67) (as compared to cluster 2, n = 19) was comprised of surgeons with significantly more experience treating a symptomatic os acromiale (p < 0.05). These surgeons regarded gender, age, BMI, and hand dominance as important clinical factors when deciding when to proceed to surgery. Overall, arthroscopic management of the os was preferred, but those surgeons more experienced in treating os acromiale preferred open reduction and internal fixation (ORIF) in specific clinical cases.

CONCLUSION

The survey findings reflect the current lack of consensus in the treatment of a unstable, symptomatic os acromiale. Overall, arthroscopic management was preferred by most surgeons, though ORIF was preferred in certain clinical scenarios by those more experienced with os acromiale. The overall preference for arthroscopy suggests a possible shift in the treatment paradigm for patients with symptomatic meso-acromions, but higher level studies are needed to substantiate these findings.

Orthopedics and Traumatology Residency - Working Conditions, Training, and Psychological Stress

PURPOSE OF THE STUDY The specialty of orthopedics and traumatology that is completed in the 5 years period in our country is a challenging educational process and our purpose in this study is to demonstrate through a survey training conditions of the orthopedic assistants in our country and the effects of this process on assistants. MATERIAL AND METHODS 524 (70.05%) of 748 assistants who receive specialization training in Turkey were reached. There were 20 multiple choice questions ( 1 mark each) and 3 questions (more than 1 mark each) in the survey consisting of twenty-three questions. Our study group was formed by doctors who have still worked as assistant in our country and have accepted to participate in the study. The doctors who finished assistantship with any reason and did assistantship for time less than 6 months and did not exactly fill the questionnaire form were excluded from the study. RESULTS 524 (71.97%) of 728 assistant who are in 40 (100%) of 40 provinces where assistant training given in Turkey were reached. 474 (90.45%) participants were satisfied to do orthopedic specialization. When considering working hours, it was observed that 337 (64.31%) participants had over 90 hours weekly including night shift and 521 (99.42%) participants had to work after night shift. The majority of participants (361 persons 68.89%) were receiving salaries between TL 4000-6000. When looking at the entire working group, the rate of participants who said that scientific training is weak or there is no scientific training was 427 (81.48%). CONCLUSIONS Our survey study is one of the first statistical study which investigating professional and social problems of orthopedic assistants. Some of important problems as training satisfaction, abuse by patients and/or manager, the average monthly income and psychological status assessment is emphasized. Orthopedics and Traumatology assistantship is a challenging process to cause physical and psychological problems with the hard working conditions in our Turkey. Key words:residency training, orthopedic surgery, life quality, salary.

Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

OBJECTIVES

Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome.

DESIGN AND SETTING

Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders.

PARTICIPANTS

In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures.

RESULTS

There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders.

CONCLUSIONS

There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.

[10 years German Society for Orthopedics and Trauma Surgery (DGOU): trauma surgery-quo vadis?]

On the occasion of the 10th anniversary of the foundation of the German Society for Orthopedics and Trauma Surgery (DGOU), the current General Secretary of the German Society for Trauma Surgery sees the need for a standpoint on trauma surgery in Germany. This manuscript outlines future options and perspectives for the development of trauma surgery in Germany.

Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey

There is no consensus regarding strategies to optimally treat children with a brachial plexus birth injury (BPBI). Comparison of outcome data presented by different centers is impossible due to the use of (1) many different outcome measures to evaluate results; (2) different follow-up periods after interventions; and (3) different patient ages at the time of assessment. The goal of iPluto (international PLexus oUtcome sTudy grOup) was to define a standardized dataset which should be minimally collected to evaluate upper limb function in children with BPBI. This dataset must enable comparison of the treatment results of different centers if prospectively used. Three rounds of internet surveys were used to reach consensus on the dataset. A Delphi-derived technique was applied using a nine point Likert scale. Consensus was defined as having attained a rating of 7/8/9 by > = 75% of the participants. A total of 59 participants from five continents participated in the Second and Third Rounds of the survey. Consensus was reached regarding four elements: (1) evaluation should take place at the age of 1/3/5/7 years; range of motion in degrees should be measured for (2) passive joint movement; (3) active range of motion; and (4) the Mallet score should be determined. Consensus on how to asses and report outcome for BPBI was only reached on motor items from the "Body Function and Structure" domain. Consensus regarding additional ICF domains to obtain a more elaborate set of outcome items, should be addressed in future research. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2533-2541, 2018.

Current practice of orthopaedic surgical skills training raises performance of supervised residents in total knee arthroplasty to levels equal to those of orthopaedic surgeons

AIM

To investigate whether the current, generally accepted practice of orthopaedic surgical skills training can raise the performance of supervised residents to levels equal to those of experienced orthopaedic surgeons when it comes to clinical outcomes or implant position after total knee arthroplasty.

METHODS

In a retrospective analysis of primary total knee arthroplasty outcomes (minimum follow-up of 12 months) procedures were split into two groups: supervised orthopaedic residents as first surgeon (group R), and experienced senior orthopaedic surgeons as first surgeon (group S). Outcome data that were compared 1 year postoperatively were operation times, complications, revisions, Knee Society Scores (KSS) and radiological implant positions.

RESULTS

Of 642 included procedures, 220 were assigned to group R and 422 to group S. No statistically significant differences between the two groups were found in patient demographics. Operation time differed significantly (group R: 81.3 min vs. group S: 71.3 min (p = 0.000)). No statistically significant differences were found for complications (p = 0.659), revision rate (p = 0.722), femoral angle (p = 0.871), tibial angle (p = 0.804), femoral slope (p = 0.779), tibial slope (p = 0.765) and KSS (p = 0.148).

DISCUSSION AND CONCLUSION

Supervised residents needed 10 minutes extra operation time, but they provided the same quality of care in primary total knee arthroplasty as experienced orthopaedic surgeons concerning complication rates, revisions, implant position on radiographs and KSS. The currently used training procedure in which the supervising surgeon and the resident decide if the resident is ready to be first surgeon is safe for patients.

Quality Measures in Orthopaedic Sports Medicine: A Systematic Review

PURPOSE

To report the current quality measures that are applicable to orthopaedic sports medicine physicians.

METHODS

Six databases were searched with a customized search term to identify quality measures relevant to orthopaedic sports medicine surgeons: MEDLINE/PubMed, EMBASE, the National Quality Forum (NQF) Quality Positioning System (QPS), the Agency for Healthcare Research and Quality (AHRQ) National Quality Measures Clearinghouse (NQMC), the Physician Quality Reporting System (PQRS) database, and the American Academy of Orthopaedic Surgeons (AAOS) website. Results were screened by 2 Board-certified orthopaedic surgeons with fellowship training in sports medicine and dichotomized based on sports medicine-specific or general orthopaedic (nonarthroplasty) categories. Hip and knee arthroplasty measures were excluded. Included quality measures were further categorized based on Donabedian's domains and the Center for Medicare and Medicaid (CMS) National Quality Strategy priorities.

RESULTS

A total of 1,292 quality measures were screened and 66 unique quality measures were included. A total of 47 were sports medicine-specific and 19 related to the general practice of orthopaedics for a fellowship-trained sports medicine specialist. Nineteen (29%) quality measures were collected within PQRS, with 5 of them relating to sports medicine and 14 relating to general orthopaedics. AAOS Clinical Practice Guidelines (CPGs) comprised 40 (60%) of the included measures and were all within sports medicine. Five (8%) additional measures were collected within AHRQ and 2 (3%) within NQF. Most quality measures consist of process rather than outcome or structural measures. No measures addressing concussions were identified.

CONCLUSIONS

There are many existing quality measures relating to the practice of orthopaedic sports medicine. Most quality measures are process measures described within PQRS or AAOS CPGs.

CLINICAL RELEVANCE

Knowledge of quality measures are important as they may be used to improve care, are increasingly being used to determine physician reimbursement, and can inform future quality measure development efforts.

Effect of patient safety incident review and reflection in an extended morbidity and mortality meeting

BACKGROUND

We modified the departmental mortality and morbidity (M&M) meetings to evaluate whether patient safety incident review as a part of this meeting was associated with reduced patient safety incidents.

METHOD

A pilot programme of peer review of patient safety incidents (PSI) supported by education relevant to that event and follow-on action plan was introduced as a part of an extended morbidity and mortality meeting in a university hospital orthopaedic department. The pilot programme was conducted over six months (January 2012-June 2012). This programme involved junior and senior doctors including consultants although multidisciplinary groups were invited to attend. We investigated PSI rate/1000 hospital admissions for trauma and elective surgery, which were collected prospectively and independently between Jan 2011 to June 2013. We noted if the incident was caused by a medical or a nursing error and compared PSI rates.

RESULTS

Rates of PSI (33/1000) were 7.8 times higher in trauma cases (80.2/1000) than in elective admissions (11.2/1000). There was 18% reduction in trauma and 27% reduction in planned elective admissions. The rate increased after the pilot programme finished but there was still a 7% reduction compared to the pre-pilot period. This study found a significant reduction in the PSI rate for medical error but no change in the rate of nursing error.

CONCLUSION

This continuous reflection, education and action process, where safety events are reviewed as a part of the extended morbidity and mortality meeting, is associated with reduction of patient safety incidents. We recommend that PSI reflection should be introduced in Mortality and Morbidity meetings with mandated attendance of the entire multidisciplinary health care team.