The characteristics and predictors of mortality in periprosthetic fractures around the knee

Aims

Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality.

Methods

Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality.

Results

Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation.

Conclusion

The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

Collaborative Team Training in Virtual Reality is Superior to Individual Learning For Performing Complex Open Surgery: A Randomized Controlled Trial

OBJECTIVE

To assess whether multiplayer immersive Virtual Reality (iVR) training was superior to single-player training for the acquisition of both technical and nontechnical skills in learning complex surgery.

BACKGROUND

Superior teamwork in the operating room (OR) is associated with improved technical performance and clinical outcomes. iVR can successfully train OR staff individually; however, iVR team training has yet to be investigated.

METHODS

Forty participants were randomized to individual or team iVR training. Individually trained participants practiced alongside virtual avatar counterparts, whereas teams trained live in pairs. Both groups underwent 5 iVR training sessions over 6 weeks. Subsequently, they completed a real-life assessment in which they performed anterior approach total hip arthroplasty surgery on a high-fidelity model with real equipment in a simulated OR. Teams performed together, and individually trained participants were randomly paired up. Videos were marked by 2 blinded assessors recording the 'Non-Operative Technical Skills for Surgeons, Oxford NOn-TECHnical Skills II and Scrub Practitioners' List of Intraoperative Non-Technical Skills' scores. Secondary outcomes were procedure duration and the number of technical errors.

RESULTS

Teams outperformed individually trained participants for nontechnical skills in the real-world assessment (Non-Operative Technical Skills for Surgeons: 13.1±1.5 vs 10.6±1.6, P = 0.002, Non-TECHnical Skills II score: 51.7 ± 5.5 vs 42.3 ± 5.6, P = 0.001 and Scrub Practitioners' List of Intraoperative Non-Technical Skills: 10 ± 1.2 vs 7.9 ± 1.6, P = 0.004). They completed the assessment 33% faster (28.2 minutes ± 5.5 vs 41.8 ± 8.9, P < 0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, P < 0.001).

CONCLUSIONS

Multiplayer training leads to faster surgery with fewer technical errors and the development of superior nontechnical skills.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study

INTRODUCTION

Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip.

METHODS

Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality.

RESULTS

A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality.

CONCLUSION

The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

Survivorship and risk factors for revision of metal-on-metal hip resurfacing

Aims

Metal-on-metal hip resurfacing (MoM-HR) has seen decreased usage due to safety and longevity concerns. Joint registries have highlighted the risks in females, smaller hips, and hip dysplasia. This study aimed to identify if reported risk factors are linked to revision in a long-term follow-up of MoM-HR performed by a non-designer surgeon.

Methods

A retrospective review of consecutive MoM hip arthroplasties (MoM-HRAs) using Birmingham Hip Resurfacing was conducted. Data on procedure side, indication, implant sizes and orientation, highest blood cobalt and chromium ion concentrations, and all-cause revision were collected from local and UK National Joint Registry records.

Results

A total of 243 hips (205 patients (163 male, 80 female; mean age at surgery 55.3 years (range 25.7 to 75.3)) with MoM-HRA performed between April 2003 and October 2020 were included. Mean follow-up was 11.2 years (range 0.3 to 17.8). Osteoarthritis was the most common indication (93.8%), and 13 hips (5.3%; 7M:6F) showed dysplasia (lateral centre-edge angle < 25°). Acetabular cups were implanted at a median of 45.4° abduction (interquartile range 41.9° - 48.3°) and stems neutral or valgus to the native neck-shaft angle. In all, 11 hips (4.5%; one male, ten females) in ten patients underwent revision surgery at a mean of 7.4 years (range 2.8 to 14.2), giving a cumulative survival rate of 94.8% (95% confidence interval (CI) 91.6% to 98.0%) at ten years, and 93.4% (95% CI 89.3% to 97.6%) at 17 years. For aseptic revision, male survivorship was 100% at 17 years, and 89.6% (95% CI 83.1% to 96.7%) at ten and 17 years for females. Increased metal ion levels were implicated in 50% of female revisions, with the remaining being revised for unexplained pain or avascular necrosis.

Conclusion

The Birmingham MoM-HR showed 100% survivorship in males, exceeding the National Institute for Health and Care Excellence '5% at ten years' threshold. Female sex and small component sizes are independent risk factors. Dysplasia alone is not a contraindication to resurfacing.

5 year follow up of a hydroxyapatite coated short stem femoral component for hip arthroplasty: a prospective multicentre study

Short stem, uncemented femoral implants for hip arthroplasty are bone conserving achieving stability through initial metaphyseal press-fit and biological fixation. This study aimed to evaluate the survivorship, mid-term function and health related quality of life outcomes in patients who have undergone total hip arthroplasty (THA) with a fully hydroxyapatite coated straight short stem femoral component with up to 5 years follow-up. 668 patients were recruited to a multicentre study investigating the performance of the cementless Furlong Evolution® stem for THA. 137 patients withdrew at various time points. The mean follow-up was 49 months. Clinical (Harris Hip Score (HHS), radiographic and patient-reported outcome measures-Oxford Hip Score (OHS) and EuroQol 5D (EQ-5D), were recorded pre-operatively and at 6 weeks, 6 months, 1 year, 3 year and 5 year follow ups. At 5-year follow-up, 12 patients underwent revision surgery, representing a cumulative revision rate of 1.8%. Median OHS, HHS and EQ5D scores improved significantly: OHS improved from a pre-operative median of 21 (IQR 14-26) to 47 (IQR 44-48) (p < 0.001). HHS improved from 52 (IQR 40-63) to 98 (IQR 92-100) (p < 0.001) and EQ5D improved from 70 (IQR 50-80) to 85 (IQR 75-95) (p < 0.001). This fully HA-coated straight short femoral stem implant demonstrated acceptable mid-term survivorship and delivered substantial improvements in function and quality of life after THA.

Three-Dimensional Preoperative Planning Software for Hip Resurfacing Arthroplasty

Three-dimensional planning of hip arthroplasty is associated with better visualisation of anatomical landmarks and enhanced mapping for preoperative implant sizing, which can lead to a decrease in surgical time and complications. Despite the advantages of hip resurfacing arthroplasty (HRA), it is considered a technically challenging procedure and associated with inaccurate implant placement. This study aimed to examine the validity, reliability, and usability of preoperative 3D Hip Planner software for HRA. Fifty random cases of various hip osteoarthritis severity were planned twice by two junior trainees using the 3D Hip Planner within a one-month interval. Outcome measures included femoral/cup implant size, stem-shaft angle, and cup inclination angle, and were assessed by comparing outcomes from 2D and 3D planning. An adapted unified theory of acceptance and use of technology (UTAUT) survey was used for software usability. Bland-Altman plots between 3D and 2D planning for stem-shaft and inclination angles showed mean differences of 0.7 and -0.6, respectively (r = 0.93, p < 0.001). Stem-shaft and inclination angles showed inter-rater reliability biases of around -2° and 3°, respectively. Chi-square and Pearson's correlation for femoral implant size showed a significant association between the two assessors (r = 0.91, p < 0.001). The 3D test-retest coefficient of repeatability for stem-shaft and inclination angles were around ±2° and ±3°, respectively, with a strong significant association for femoral implant size (r = 0.98, p < 0.001). Survey analyses showed that 70-90% agreed that 3D planning improved expectancy in four domains. 3D hip planner appears to be valid and reliable in preoperative HRA and shows significant potential in optimising the quality and accuracy of surgical planning.

Low dose CT-based spatial analysis (CTSA) to measure implant migration after ceramic hip resurfacing arthroplasty (HRA): A phantom study

Implant migration is a predictor of arthroplasty survivorship. It is crucial to monitor the migration of novel hip prostheses within premarket clinical investigations. RSA is the gold standard method, but requires calibrated radiographs using specialised equipment. A commercial computed tomography micromotion analysis solution is a promising alternative but is not yet available for use with monobloc ceramic implants. This study aimed to develop and validate a CT-based spatial analysis (CTSA) method for use with ceramic implants. A phantom study was undertaken to assess accuracy and precision. A ceramic hip resurfacing arthroplasty (HRA) and 20 tantalum beads were implanted into a synthetic hip model and mounted onto a 6-degree of freedom motion stage. The hip was repeatedly scanned with a low dose CT protocol, with imposed micromovements. Data were interrogated using a semiautomated technique. The effective radiation dose for each scan was estimated to be 0.25 mSv. For the head implant, precision ranged between 0.11 and 0.28 mm for translations and 0.34°-0.42° for rotations. For the cup implant, precision ranged between 0.08 and 0.11 mm and 0.19° and 0.42°. For the head, accuracy ranged between 0.04 and 0.18 mm for translations and 0.28°-0.46° for rotations. For the cup, accuracy ranged between 0.04 and 0.08 mm and 0.17° and 0.43°. This in vitro study demonstrates that low dose CTSA of a ceramic HRA is similar in accuracy to RSA. CT is ubiquitous, and this method may be an alternative to RSA to measure prosthesis migration.

1019 Collaborative Surgical Team Training in Virtual Reality Is Superior to Individual Learning: A Randomised Controlled Trial

Aim

This study aimed to assess if multiplayer virtual reality training was superior to single player training for acquisition of both technical and non-technical skills in learning complex open surgery.

Method

40 participants (20 novice surgeons and 20 novice scrub nurses) were enrolled in this study and randomised to solo or team virtual reality training learning anterior approach total hip arthroplasty. Solo participants trained with virtual avatar counterparts, whilst teams trained in pairs (surgeon and scrub nurse). Both groups underwent 5 VR training sessions over 6 weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated operating theatre. Teams performed together and solo participants were randomly paired up with a solo player of the opposite role. Videos of the assessment were marked by two blinded expert assessors. The primary outcome was team performance as graded by the NOTECHs II score. Secondary outcomes were procedure time, technical errors from an expert pre-defined protocol and acetabular component positioning.

Results

Teams outperformed solo trained participants in non-technical skills in the real-world assessment (NOTECHS-II score 50.3 ± 6.04 vs 43.90 ± 5.90, p=0.0275). They completed the assessment 28.11% faster than solos (31.22 minutes ±2.02 vs 43.43 ±2.71, p=0.01), and made close to half the number of technical errors when compared to the solo group (12.9 ± 8.3 vs 25.6 ± 6.1, p=0.001).

Conclusions

Multiplayer training appears to lead to faster surgery with fewer technical errors and the development of superior non-technical skills.

A Delphi consensus statement for digital surgery

The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term ‘digital surgery’. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and <30% unimportant. A final online meeting was held to discuss consensus statements. The definition of digital surgery as the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support, or training, to improve outcomes and reduce harm achieved 100% consensus agreement. We highlight key ethical issues concerning data, privacy, confidentiality and public trust, consent, law, litigation and liability, and commercial partnerships within digital surgery and identify barriers and research goals for future practice. Developers and users of digital surgery must not only have an awareness of the ethical issues surrounding digital applications in healthcare, but also the ethical considerations unique to digital surgery. Future research into these issues must involve all digital surgery stakeholders including patients.

The metabolic equivalent of task score : a useful metric for comparing high-functioning hip arthroplasty patients

AIMS

This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures.

METHODS

From our electronic database of 751 hip arthroplasty procedures, 221 patients were included. Patients were excluded if they had revision surgery, an alternative hip procedure, or incomplete data either preoperatively or at one-year follow-up. Included patients had a mean age of 59.4 years (SD 11.3) and 54.3% were male, incorporating 117 primary total hip and 104 hip resurfacing arthroplasty operations. Oxford Hip Score (OHS), EuroQol five-dimension questionnaire (EQ-5D), and the MET were recorded preoperatively and at one-year follow-up. The distribution was examined reporting the presence of ceiling and floor effects. Validity was assessed correlating the MET with the other scores using Spearman's rank correlation coefficient and determining responsiveness. A subgroup of 93 patients scoring 48/48 on the OHS were analyzed by age, sex, BMI, and preoperative MET using the other metrics to determine if differences could be established despite scoring identically on the OHS.

RESULTS

Postoperatively the OHS and EQ-5D demonstrate considerable negatively skewed distributions with ceiling effects of 41.6% and 53.8%, respectively. The MET was normally distributed postoperatively with no relevant ceiling effect. Weak-to-moderate significant correlations were found between the MET and the other two metrics. In the 48/48 subgroup, no differences were found comparing groups with the EQ-5D, however significantly higher mean MET scores were demonstrated for patients aged < 60 years (12.7 (SD 4.7) vs 10.6 (SD 2.4), p = 0.008), male patients (12.5 (SD 4.5) vs 10.8 (SD 2.8), p = 0.024), and those with preoperative MET scores > 6 (12.6 (SD 4.2) vs 11.0 (SD 3.3), p = 0.040).

CONCLUSION

The MET is normally distributed in patients following hip arthroplasty, recording levels of activity which are undetectable using the OHS. Cite this article: Bone Joint Res 2022;11(5):317-326.

IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit. Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

Aims

This international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients.

Methods

A multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1st March-31st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded.

Results

A total of 7090 patients were included, with a mean age of 82.2 (range 50–104) years and 4959 (69.9%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) were positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p = 0.001), residential care (OR 2.15, p < 0.001), inpatient fall (OR 2.23, p = 0.003), cancer (OR 0.63, p = 0.009), ASA grades 4 (OR 1.59, p = 0.008) or 5 (OR 8.28, p < 0.001), and longer admission (OR 1.06 for each increasing day, p < 0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p < 0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p < 0.001). Increasing age (HR 1.03, p = 0.028), male sex (HR 2.35, p < 0.001), renal disease (HR 1.53, p = 0.017), and pulmonary disease (HR 1.45, p = 0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.

Conclusion

The prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher 30-day mortality risk.

Cognitive task analysis-based training in surgery: a meta-analysis

BACKGROUND

Reduced hands-on operating experience has challenged the development of complex decision-making skills for modern surgical trainees. Cognitive task analysis- (CTA-)based training is a methodical solution to extract the intricate cognitive processes of experts and impart this information to novices. Its use has been successful in high-risk industries such as the military and aviation, though its application for learning surgery is more recent. This systematic review aims to synthesize the evidence evaluating the efficacy of CTA-based training to enable surgeons to acquire procedural skills and knowledge.

METHODS

The PRISMA guidelines were followed. Four databases, including MEDLINE, EMBASE, Web of Science and Cochrane CENTRAL, were searched from inception to February 2021. Randomized controlled trials and observational studies evaluating the training effect of CTA-based interventions on novices' procedural knowledge or technical performance were included. Meta-analyses were performed using a random-effects model.

RESULTS

The initial search yielded 2205 articles, with 12 meeting the full inclusion criteria. Seven studies used surgical trainees as study subjects, four used medical students and one study used a combination. Surgical trainees enrolled into CTA-based training groups had enhanced procedural knowledge (standardized mean difference (SMD) 1.36 (95 per cent c.i. 0.67 to 2.05), P < 0.001) and superior technical performance (SMD 2.06 (95 per cent c.i. 1.17 to 2.96), P < 0.001) in comparison with groups that used conventional training methods.

CONCLUSION

CTA-based training is an effective way to learn the cognitive skills of a surgical procedure, making it a useful adjunct to current surgical training.

1393 The Impact of Using A Virtual Reality Surgical Curriculum to Train Scrub Practitioners in Complex Orthopaedic Surgery

Background

The training scrub practitioners receive varies considerably in comparison to their surgical counterpart, although their performance is key to a proficient surgical team. For infrequent procedures that require specific and often intricate equipment such as revision total knee arthroplasty (RTKA), their training may be limited to an initial guidance session by company representatives. This study aims to evaluate the impact of using a virtual reality (VR) curriculum to train scrub practitioners in the performance of a RTKA.

Method

Ten orthopaedic scrub practitioners were enrolled into VR training across four sessions. Each VR session consisted of training where participants were guided through the assembly of equipment and steps of the surgery. In the concluding three sessions, each training session was supplemented by an assessment session in VR without guidance. The outcomes measured in VR assessment were incorrect procedural sequence, duration of surgery and efficiency of movement. The transfer of skills outside VR were assessed pre-training and post-training by the participants performance in a sequence of tasks using real equipment.

Results

All participants enhanced their surgical performance in successive assessed VR sessions reducing their operative time by 47%, assistive prompts by 75% and dominant hand motion by 28%. Improvements in VR showed effective transfer when assessed using real equipment with participants achieving superior scores post-training (11.3% versus 83.5%).

Conclusions

VR enables safe learning and provides measurable feedback of procedural steps and technical skills of complex orthopaedic surgery. VR is an effective training tool for scrub practitioners, with transfer to the real world.

905 How to prioritise patients and safely resume elective surgery during the Covid-19 pandemic

Introduction

There are now over 2.5 million NHS patients awaiting elective surgery, with the most in orthopaedics. We present an algorithm and results for safely and equitably restarting surgery at COVID-light sites.

Method

An MDT applied the COVID-19 Algorithm for Resuming Elective Surgery (CARES) on 1169 patients awaiting elective orthopaedic surgery. It assessed safety, procedural efficacy, and biopsychosocial factors, to prioritise patients. They were assigned to five categories and underwent surgery at one of three COVID-light sites (1. access to HDU/ITU/Paediatrics/specialist equipment, 2. an NHS elective surgical unit and 3. a private elective surgical unit).

Results

21 ‘Urgent’ patients received expedited care; 118 were Level 1/2; 222 were Level 3; 808 were Level 4. In 6 weeks, 355 surgeries were performed, with Urgent and Level 1/2 cases performed soonest (mean 18 days, p &lt; 0.001). 33 high-risk/complex/paediatric patients had surgery at Site 1 and the rest at Sites 2 and 3. No patients contracted COVID-19 within 2 weeks of surgery.

Conclusions

We validated a widely generalisable model to facilitate resumption of elective surgery in COVID-light sites. It enabled surgery for patients in most suffering, undergoing the most efficacious procedures and/or at highest risk of deterioration, without compromising patient-safety.

Calipered kinematic alignment technique for implanting a Medial Oxford®: A technical note

This note describes a surgical technique to kinematically align a medial Oxford® UKA. Applying kinematic alignment principles is an alternative, personalised, physiological, and potentially clinically advantageous method for implanting the medial Oxford® UKA. Further investigations are needed to better define the reproducibility and clinical impact of this new surgical technique.

V7 Project Restart’; Safe resumption of elective orthopaedic surgery following the Covid-19 pandemic

Introduction

The Covid-19 pandemic resulted in nearly 2 million patients being put on waiting lists for elective procedures in the UK. We aim to describe how the COVID-19 Algorithm for Resuming Elective Surgery (CARES) was used to allocate patients to elective theatre lists while factoring in patient safety, risk to healthcare workers and, protection of resources.

Methodology

A multidisciplinary team was employed with the task of using CARES to allocate theatre slots to 1169 patients on the waiting list. CARES was used in conjunction with an evidence-based scale for procedural urgency (Levels 1-4) to stratify patients and list them for surgery at one of three ‘COVID-light’ sites i.e. 1. With HDU/ITU access, specialist staff, and equipment, 2. An NHS short-stay surgical unit, 3. A private surgical unit. Incidence of post-operative Covid-19 infection was assessed by looking at positive Covid-19 RT-PCR or CT Chest with characteristic findings performed within 2 weeks of the surgery.

Results

118 cases were deemed to be Priority 1/2, 222 were Level 3, and 808 were Level 4. In 6 weeks, 355 surgeries were performed, with Urgent and Level 1/2 cases performed soonest (mean 18 days, p < 0.001). 33 high-risk/complex/paediatric patients had surgery at Site 1 and the rest at Sites 2 and 3. No patients contracted COVID-19 within 2 weeks of surgery.

Conclusion

CARES’ holistic approach enabled equitable and safe resumption of arthroplasty during the pandemic, by stratification and creation of COVID-light sites. It could be applied internationally and across sub-specialties.

Introduction

The Covid-19 pandemic resulted in nearly 2 million patients being put on waiting lists for elective procedures in the UK. We aim to describe how the COVID-19 Algorithm for Resuming Elective Surgery (CARES) was used to allocate patients to elective theatre lists while factoring in patient safety, risk to healthcare workers and, protection of resources.

Methodology

A multidisciplinary team was employed with the task of using CARES to allocate theatre slots to 1169 patients on the waiting list. CARES was used in conjunction with an evidence-based scale for procedural urgency (Levels 1-4) to stratify patients and list them for surgery at one of three ‘COVID-light’ sites i.e. 1. With HDU/ITU access, specialist staff, and equipment, 2. An NHS short-stay surgical unit, 3. A private surgical unit. Incidence of post-operative Covid-19 infection was assessed by looking at positive Covid-19 RT-PCR or CT Chest with characteristic findings performed within 2 weeks of the surgery.

Results

118 cases were deemed to be Priority 1/2, 222 were Level 3, and 808 were Level 4. In 6 weeks, 355 surgeries were performed, with Urgent and Level 1/2 cases performed soonest (mean 18 days, p < 0.001). 33 high-risk/complex/paediatric patients had surgery at Site 1 and the rest at Sites 2 and 3. No patients contracted COVID-19 within 2 weeks of surgery.

Conclusion

CARES’ holistic approach enabled equitable and safe resumption of arthroplasty during the pandemic, by stratification and creation of COVID-light sites. It could be applied internationally and across sub-specialties.

How to prioritize patients and redesign care to safely resume planned surgery during the COVID-19 pandemic

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

Methods

A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively.

Results

A total of 1,142 patients were included, 47 declined surgery, and 110 were deemed high-risk or requiring specialist resources. In the ten-week study period, 28 high-risk patients underwent surgery, during which 68% (13/19) of Priority 2 (P₂, surgery within one month) patients underwent surgery, and 15% (3/20) of P₃ (< three months) and 16% (11/71) of P₄ (> three months) groups. Of the 1,032 low-risk patients, 322 patients underwent surgery. Overall, 21 P₃ and P₄ patients were expedited to ‘Urgent’ based on biopsychosocial factors identified by the SPAG. During the study period, 91% (19/21) of the Urgent group, 52% (49/95) of P₂, 36% (70/196) of P₃, and 26% (184/720) of P₄ underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19.

Conclusion

Our widely generalizable model enabled the restart of planned surgery during the COVID-19 pandemic, without compromising patient safety or excluding high-risk or complex cases. Patients classified as Urgent or P₂ were most likely to undergo surgery, including those deemed high-risk. This model, which includes assessment of biopsychosocial factors alongside disease severity, can assist in equitably prioritizing the substantial list of patients now awaiting planned orthopaedic surgery worldwide.

Cite this article: Bone Jt Open 2021;2(2):134–140.

Tibial Plateau Fracture: Anatomy, Diagnosis and Management

Tibial plateau fractures are peri-articular knee fractures of the proximal tibia. The presentation is dependent on the mechanism of injury. The tibial plateau is the bony platform of the distal half of the knee joint, and is made up of a medial and lateral condyle separated by the intercondylar eminence. The presentation of tibial plateau fractures can vary greatly as a result of the bimodal mechanism of injury and patient characteristics. The patient should be assessed for life- and limb-threatening injuries in accordance with British Orthopaedic Association Standards of Trauma guidelines. Imaging is undertaken to understand configuration of the fracture, which is classified by the Schatzker classification. Definitive management of the fracture depends on the severity, ranging from conservative to surgical management. Surgery is required for more severe tibial plateau fractures to restore articular congruity, mechanical alignment, ligamentous stability and to permit early mobilisation. Medium-term functional outcome after tibial plateau fractures is generally excellent when anatomy and stability is restored. At least half of patients return to their original level of physical activity. Surgical management of tibial plateau fractures is not without complication. Risk factors include postoperative arthritis, bicondylar and comminuted fractures, meniscal removal, instability, malalignment and articular incongruity. Tibial plateau fractures account for 1% of all fractures, and typically occur either as a fragility fracture or secondary to a high-energy impact. These latter injuries are associated with extensive soft tissue injury, life- and limb-threatening complications and long-term sequelae. While outcomes are generally good, severe injuries are at higher risk of infection and post-traumatic arthritis requiring knee arthroplasty. This article considers the anatomy, diagnosis and evidence-based management strategies for tibial plateau fracture.

Reduced-dose computed tomography is the most accurate method to measure ceramic hip resurfacing cup version

BACKGROUND

A precise assessment of cup version after hip resurfacing is generally requested, especially in clinical trials or in case of complications.

AIMS

To identify which diagnostic imaging modality, between AP pelvis X-rays, the AP Pelvis CT Scout image and reduced-dose axial CT scan, is the most precise to assess cup version of an all-ceramic hip resurfacing implant in a first-in-human clinical trial.

METHODS

We retrospectively assessed the cup version of the first 20 patients who underwent an experimental all-ceramic hip resurfacing on AP pelvis X-rays (0.8 mSv of radiation), AP pelvis CT scout images (0.016 mSv) and axial CT slices performed using a reduced dose protocol (0.3 mSv). The intra-observer and inter-observer reliabilities were calculated.

RESULTS

Reduced dose Pelvis CT scan was the most precise imaging modality to detect cup version (Pearson Correlation Coefficient, PCC = 0.98, p < 0.001). The AP Pelvis CT Scout image was found to be sufficient to measure cup version within an acceptable margin of tolerance (mean difference ± 4.7° from pelvis CT scan) and highly correlated to axial pelvis CT scan measurements (PCC 0.97, p < 0.001). Analysis of cup version from AP X-rays poorly correlated with measurements from Pelvis CT (PCC 0.59, p = 0.006).

CONCLUSIONS

Due to lower radiation exposure and highest accuracy, reduced dose CT is a valid modality to measure acetabular cup version after ceramic hip resurfacing. Plain X-rays are not accurate nor precise to measure version, whereas high agreement of measurements between AP Pelvis CT Scout and axial pelvis CT scan was found.

Fully Immersive Virtual Reality for Total Hip Arthroplasty: Objective Measurement of Skills and Transfer of Visuospatial Performance After a Competency-Based Simulation Curriculum

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.

A Multicenter Randomized Controlled Trial Evaluating the Effectiveness of Cognitive Training for Anterior Approach Total Hip Arthroplasty

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.

A single-use, size-specific, nylon arthroplasty guide: a preliminary study for hip resurfacing

INTRODUCTION

In arthroplasty surgery, positioning of the components must be accurate and reproducible to avoid complications. Conventional guides are often used to align a component, but they require surgical skill and experience, and are prone to error. To this end, a single-use, size-specific, nylon guide (single-use nylon guide) has been developed for the purpose of increasing the accuracy without adding extra cost to the operation. The effectiveness of this type of guide was evaluated in using a synthetic bone study.

METHODS

A total of 66 synthetic femurs with the same osteoarthritic morphology were prepared. 3 surgeons participated in the experiments, and each surgeon created a drill hole for the femoral component by using the single-use nylon guide or a commercially-available, conventional, metal, neck-based guide (conventional guide). Anteversion, inclination, and insertion point acquired by the guide were compared between the guides, between surgeons, and to the computer-based plan.

RESULTS

Anteversion acquired by the single-use nylon guide (6.7° [4.9-11.5°]) was significantly closer to the plan (14.6°) than that acquired by the conventional guide (4.3° [2.4-8.6°]) (p = 0.03). The insertion point was also significantly closer to the plan for the single-use nylon guide (3.8 mm ± 1.6 mm) than the conventional guide (5.7 mm ± 2.4 mm) (p < 0.001). No significant difference was found for the inclination (p = 0.76).

CONCLUSION

A single-use, size-specific nylon guide was effective in acquiring a higher accuracy and precision in anteversion and insertion point than a conventional guide in this synthetic bone, hip resurfacing arthroplasty study. The use of single-use guides in other orthopaedic procedures should be explored.

Virtual reality training improves trainee performance in total hip arthroplasty: a randomized controlled trial

Aims

Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA).

Patients and Methods

A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration.

Results

VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (sd 3) vs 12 (sd 3)), were 12° more accurate in component orientation (mean error 4° (sd 6°) vs 16° (sd 17°)), and were 18% faster (mean 42 minutes (sd 7) vs 51 minutes (sd 9)).

Conclusion

Procedural knowledge and psychomotor skills for THA learned in VR were transferred to cadaveric performance. Basic preparatory materials had limited value for trainees learning a new technique. VR training advanced trainees further up the learning curve, enabling highly precise component orientation and more efficient surgery. VR could augment traditional surgical training to improve how surgeons learn complex open procedures. Cite this article: Bone Joint J 2019;101-B:1585–1592

Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review

BACKGROUND

Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI.

METHODS

This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model.

RESULTS

A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above.

CONCLUSIONS

The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hip capsule biomechanics after arthroplasty

Aims

The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional THA, and surgical approach on ligament function.

Materials and Methods

Eight paired cadaveric hip joints were skeletonized but retained the hip capsule. Capsular ROM restraint during controlled internal rotation (IR) and external rotation (ER) was measured before and after HRA, DM-THA, and conventional THA, with a posterior (right hips) and anterior capsulotomy (left hips).

Results

Hip resurfacing provided a near-native ROM with between 5° to 17° increase in IR/ER ROM compared with the native hip for the different positions tested, which was a 9% to 33% increase. DM-THA generated a 9° to 61° (18% to 121%) increase in ROM. Conventional THA generated a 52° to 100° (94% to 199%) increase in ROM. Thus, for conventional THA, the capsule function that exerts a limit on ROM is lost. It is restored to some extent by DM-THA, and almost fully restored by hip resurfacing. In positions of low flexion/extension, the posterior capsulotomy provided more normal function than the anterior, possibly because the capsule was shortened during posterior repair. However, in deep flexion positions, the anterior capsulotomy functioned better.

Conclusion

Native head-size and capsular repair preserves capsular function after arthroplasty. The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments. Cite this article: Bone Joint J 2019;101-B:426–434.

The loading patterns of a short femoral stem in total hip arthroplasty: gait analysis at increasing walking speeds and inclines

BACKGROUND

The purpose of this study was to examine the gait pattern of total hip arthroplasty (THA) patients with a new short femoral stem at different speeds and inclinations.

MATERIALS AND METHODS

A total of 40 unilateral THA patients were tested on an instrumented treadmill. They comprised two groups (shorter stemmed THA n = 20, longer stemmed THA n = 20), both which had the same surgical posterior approach. The shorter femoral stemmed patients were taken from an ongoing hip trial with minimum 12 months postop. The comparative longer THR group with similar disease and severity were taken from a gait database along with a demographically similar group of healthy controls (n = 35). All subjects were tested through their entire range of gait speeds and inclines with ground reaction forces collected. Body weight scaling was applied and a symmetry index to compare the implanted hip to the contralateral normal hip. An analysis of variance with significance set at α = 0.05 was used.

RESULTS

The experimental groups were matched demographically and implant groups for patient reported outcome measures and radiological disease. Both THA groups walked slower than controls, but symmetry at all intervals for all groups were not significantly different. Push-off loading was less favourable for both the shorter and longer stemmed THR groups (p < 0.05) depending on speed.

CONCLUSIONS

Irrespective of femoral stem length, symmetry for ground reaction forces for both THA groups were returned to a normal range when compared to controls. However individual implant performance showed inferior (p < 0.05) push-off forces and normalised step length in both THR groups when compared to controls.

LEVEL OF EVIDENCE

III.

Do patient-specific instruments (PSI) for UKA allow non-expert surgeons to achieve the same saw cut accuracy as expert surgeons?

INTRODUCTION

High-volume unicompartmental knee arthroplasty (UKA) surgeons have lower revision rates, in part due to improved intra-operative component alignment. This study set out to determine whether PSI might allow non-expert surgeons to achieve the same level of accuracy as expert surgeons.

MATERIALS AND METHODS

Thirty-four surgical trainees with no prior experience of UKA, and four high-volume UKA surgeons were asked to perform the tibial saw cuts for a medial UKA in a sawbone model using both conventional and patient-specific instrumentation (PSI) with the aim of achieving a specified pre-operative plan. Half the participants in each group started with conventional instrumentation, and half with PSI. CT scans of the 76 cut sawbones were then segmented and reliably orientated in space, before saw cut position in the sagittal, coronal and axial planes was measured, and compared to the pre-operative plan.

RESULTS

The compound error (absolute error in the coronal, sagittal and axial planes combined) for experts using conventional instruments was significantly less than that of the trainees (11.6°±4.0° v 7.7° ±2.3º, p = 0.029). PSI improved trainee accuracy to the same level as experts using conventional instruments (compound error 5.5° ±3.4º v 7.7° ±2.3º, p = 0.396) and patient-specific instruments (compound error 5.5° ±3.4º v 7.3° ±4.1º, p = 0.3). PSI did not improve the accuracy of high-volume surgeons (p = 0.3).

CONCLUSIONS

In a sawbone model, PSI allowed inexperienced surgeons to achieve more accurate saw cuts, equivalent to expert surgeons, and thus has the potential to reduce revision rates. The next test will be to determine whether these results can be replicated in a clinical trial.

Adopting and sustaining a Virtual Fracture Clinic model in the District Hospital setting - a quality improvement approach

Virtual Fracture Clinics (VFCs) are an alternative to the conventional fracture clinics, to manage certain musculoskeletal injuries. This has recently been reported as a safe, cost-effective and efficient care model. As demonstrated at vanguard sites in the United Kingdom, VFCs can enhance patient care by standardising treatment and reducing outpatient appointments. This project demonstrates how a Quality Improvement approach was applied to introduce VFCs in the District General Hospital setting. We demonstrate how undertaking Process Mapping, Driver Diagrams, and Stakeholder Analysis can assist implementation. We discuss Whole Systems Measures applicable to VFCs, to consider how robust and specific data collection can progress this care model. Three Plan-Do-Study-Act cycles led to a change in practice over a 21-month period. Our target for uptake of new patients seen in VFCs within 6 months of starting was set at 50%. It increased from 0% to 56.1% soon after introduction, and plateaued at an average of 56.4% in the six-months before the end of the study period. Careful planning, frequent monitoring, and gathering feedback from a multidisciplinary team of varying seniority, were the important factors in transitioning to, and sustaining, a successful VFC model.

Validating a global rating scale to monitor individual resident learning curves during arthroscopic knee meniscal repair

PURPOSE

To determine whether a global rating scale (GRS) with construct validity can also be used to assess the learning curve of individual orthopaedic trainees during simulated arthroscopic knee meniscal repair.

METHODS

An established arthroscopic GRS was used to evaluate the technical skill of 19 orthopaedic residents performing a standardized arthroscopic meniscal repair in a bioskills laboratory. The residents had diagnostic knee arthroscopy experience but no experience with arthroscopic meniscal repair. Residents were videotaped performing an arthroscopic meniscal repair on 12 separate occasions. Their performance was assessed by use of the GRS and motion analysis objectively measuring the time taken to complete tasks, path length of the subject's hands, and number of hand movements. One author assessed all 228 videos, whereas 2 other authors rated 34 randomly selected videos, testing the interobserver reliability of the GRS. The validity of the GRS was tested against the motion analysis.

RESULTS

Objective assessment with motion analysis defined the surgeon's learning curve, showing significant improvement by each subject over 12 episodes (P < .0001). The GRS also showed a similar learning curve with significant improvements in performance (P < .0001). The median GRS score improved from 15 of 34 (interquartile range, 14 to 17) at baseline to 22 of 34 (interquartile range, 19 to 23) in the final period. There was a moderate correlation (P < .0001, Spearman test) between the GRS and motion analysis parameters (r = -0.58 for time, r = -0.58 for path length, and r = -0.51 for hand movements). The inter-rater reliability among 3 trained assessors using the GRS was excellent (Cronbach α = 0.88).

CONCLUSIONS

When compared with motion analysis, an established arthroscopic GRS, with construct validity, also offers a moderately feasible method to monitor the learning curve of individual residents during simulated knee meniscal repair.

CLINICAL RELEVANCE

An arthroscopic GRS can be used for monitoring skill improvement during knee meniscal repair and has the potential for use as a training and assessment tool in the real operating room.

Noise levels in a burn intensive care unit

INTRODUCTION

Increased noise levels in hospitals, critical care units, and peri-operative areas have been associated with higher levels of sleep deprivation and patient stress. The World Health Organization (WHO) guidelines stipulate a limit of 35 decibels (dB(A)) equivalent continuous sound level (LEq) during the day and 30 dB(A) LEq at night in patients' rooms. To date, no quantitative studies of noise levels have been performed in burn units. The objective of this study was to quantify noise levels in a burn critical care unit to ascertain compliance with guidelines in order to minimize this potential insult.

METHODS

An A-weighted sound pressure level meter was used to measure the ambient noise levels in a burn intensive care unit. Maximum and minimum sound pressure levels were measured at 30-min intervals on 10 days over a 1 month period. Measurements were obtained during shift changes and random times during the day and night-time. Descriptive statistical analyses were performed, to calculate means and standard deviations. Noise measurements at specified times were compared using analysis of variance (ANOVA).

RESULTS

Mean dB(A) LEq values for shift changes, day, and night-time were 65.9 ± 2.8, 65.7 ± 2.6, and 60.9 ± 5.2 dB(A), respectively. There was no significant difference in dB(A)(max) or dB(A)(min) between shift changes, day or night-time (p>0.05). However, night-time minimum values were consistently lower. There was no significant difference between sound pressure level (SPL) inside and outside patients' rooms (p>0.05) at any time.

CONCLUSIONS

Irrespective of time or location, the mean dB(A) LEq in the burn unit was significantly greater than World Health Organization (WHO), National Institute for Occupational Safety and Health (NIOSH), and the Environmental Protection Agency (EPA) recommendations. Guidelines for decreasing noise exposure are necessary to reduce potential negative effects on patients, visitors, and staff.

The possible clinical predictors of fatigue in Parkinson's disease: a study of 135 patients as part of international nonmotor scale validation project

Fatigue is a common yet poorly understood and underresearched nonmotor symptom in Parkinson's disease. Although fatigue is recognized to significantly affect health-related quality of life, it remains underrecognised and empirically treated. In this paper, the prevalence of fatigue as measured by a validated visual analogue scale and the Parkinson's disease nonmotor symptoms scale (PDNMSS) was correlated with other motor and nonmotor comorbidities. In a cohort of patients from a range of disease stages, occurrence of fatigue correlated closely with more advanced Parkinson's disease, as well as with depression, anxiety, and sleep disorders, hinting at a common underlying basis.

Excessive daytime sleepiness in patients with Parkinson's disease

Excessive daytime sleepiness (EDS) is described as inappropriate and undesirable sleepiness during waking hours and is a common non-motor symptom in Parkinson's disease, affecting up to 50% of patients. EDS has a large impact on the quality of life of Parkinson's disease patients as well as of their caregivers, in some cases even more than the motor symptoms of the disease. Drug-induced EDS is a particular problem as many dopamine agonists used for the treatment of Parkinson's disease have EDS as an adverse effect. Dopaminergic treatment may also render a subset of Parkinson's disease patients at risk for sudden-onset sleep attacks that occur without warning and can be particularly hazardous if the patient is driving. This demonstrates the need for early recognition and management not only to increase health-related quality of life but also to ensure patient safety. There are many assessment tools for EDS, including the Epworth Sleepiness Scale (ESS) and the Multiple Sleep Latency Test (MSLT), although only the Parkinson's Disease Sleep Scale (PDSS) and the SCales for Outcomes in PArkinson's Disease-Sleep (SCOPA-S) are specifically validated for Parkinson's disease. Polysomnography can be used when necessary. Management comprises non-pharmacological and pharmacological approaches. Non-pharmacological approaches can be the mainstay of treatment for mild to moderate EDS. Advice on good sleep hygiene is instrumental, as pharmacological approaches have yet to provide consistent and reliable results without significant adverse effects. The efficacy of pharmacological treatment of EDS in Parkinson's disease using wakefulness-promoting drugs such as modafinil remains controversial. Further areas of research are now also focusing on adenosine A(2A) receptor antagonists, sodium oxybate and caffeine to promote wakefulness. A definitive treatment for the highly prevalent drug-induced EDS has not yet been found.

An analysis of the posterior cruciate ligament isometric position using an in vivo 3-dimensional computed tomography-based knee joint model

PURPOSE

This study aimed to review the isometric point of the posterior cruciate ligament (PCL) based on insertional locations identified in recent anatomic studies by use of a 3-dimensional knee model.

METHODS

Ten living subjects with healthy knees were evaluated. High-resolution computed tomography scans were performed at 3 positions of 0°, 90°, and 135°, and 3-dimensional knee images were constructed. Customized software was used to define tibial and femoral insertion points of the PCL, based on recently described anatomy. The femoral attachment site of the PCL was divided into 4 sectors (labeled A through D), and the tibial attachment site was divided into 6 sectors (labeled 1 through 6). Twenty-four virtual PCL bundles were created between these sectors, and their length was measured in the 3 knee flexion positions.

RESULTS

In 0° and 90° of knee flexion, the virtual bundle showing the least amount of length change (1.10 ± 0.66 mm) was at sector D-6, that is, a posteromedial bundle inserting into the most posterior femoral sector (sector D) and the most distal tibial sector (sector 6). This change was not significantly different compared with all other virtual bundles with tibial points connected to femoral sector D (P > .05). An isometric position for the PCL (length change <2 mm) could not be found in 135° of knee flexion because of lengthening of all virtual bundles.

CONCLUSIONS

Our data suggest that the femoral attachment point is more important than the tibial attachment point: any of the 6 tibial bundles attached to the most posterior femoral sector had similar isometric properties.

CLINICAL RELEVANCE

Reproducing normal tibial and femoral anatomy underpins PCL surgical reconstruction. These findings suggest that to perform an isometrically accurate PCL reconstruction, particular attention should be paid to the location of the femoral attachment site, once the tibial footprint has been established. There were no isometric points in any virtual PCL bundle in the fully flexed knee because of excessive lengthening. Therefore, to avoid lengthening of the reconstructed graft, we recommend that fixation is performed at knee flexion angles between 0° and 90° and that patients avoid high flexion during postoperative rehabilitation.

Cams and pincer impingement are distinct, not mixed: the acetabular pathomorphology of femoroacetabular impingement

BACKGROUND

Many impinging hips are said to have a mix of features of femoral cam and an overcovered acetabulum causing pincer impingement. Correction of such a mixed picture by reduction of the cam lesion and the acetabular rim is the suggested treatment.

QUESTIONS/PURPOSES

We therefore asked two questions: (1) Is the acetabulum in cam impingement easily distinguishable from the pincer acetabulum, or is there a group with features of both types of impingement? (2) Is version or depth of socket better able to distinguish cam from pincer impingement?

METHODS

We analyzed the morphologic features of the acetabulum and rim profile of 20 normal, healthy hips, 20 with cams and 20 with pincers on CT. Pelvises were digitized, orientated to the best-fit acetabular plane, and a rim profile was plotted.

RESULTS

Cam hips were shallower than normal hips, which in turn were shallower than pincer hips (84 degrees +/- 5 degrees versus 87 degrees +/- 4 degrees versus 96 degrees +/- 5 degrees, respectively). The rim planes of cam, normal, and pincer hips had similar version (23 degrees, 24 degrees, 25 degrees), but females were 4 degrees more anteverted than males.

CONCLUSIONS

We concluded cam and pincer hips are distinct pathoanatomic entities. Cam hips are slightly shallower than normal, whereas pincers are deeper.

CLINICAL RELEVANCE

Before performing surgery for cam-type femoroacetabular impingement, surgeons should consider measuring the acetabular depth. The cam acetabulum is shallower than normal and may be rendered pathologically shallow by acetabular rim resection leading to early joint failure.

Actinomycosis complicating sigmoid diverticular disease: a case report

A 63-year-old Caucasian woman was admitted to hospital as hypotensive with abdominal tenderness and vaginal discharge. Laboratory investigations showed microcytic anaemia, low albumin and high white cell count. Computerised tomography scans revealed small bowel dilatation, sigmoid diverticula, ascites and pelvic fluid. The endometrial pipelle was positive and vaginal swab was negative for actinomyces. Post mortem examination revealed widespread sigmoid diverticular disease and bowel perforation with an intense inflammation. Actinomycotic granules were noted in the diverticular inflammatory debris, pelvic abscess and lung sections. Clinical course and histomorphological findings favour the perforating sigmoid diverticular actinomycosis as an origin of the systemic infection.

Actinomycosis complicating sigmoid diverticular disease: a case report

A 63-year-old Caucasian woman was admitted to hospital as hypotensive with abdominal tenderness and vaginal discharge. Laboratory investigations showed microcytic anaemia, low albumin and high white cell count. Computerised tomography scans revealed small bowel dilatation, sigmoid diverticula, ascites and pelvic fluid. The endometrial pipelle was positive and vaginal swab was negative for actinomyces. Post mortem examination revealed widespread sigmoid diverticular disease and bowel perforation with an intense inflammation. Actinomycotic granules were noted in the diverticular inflammatory debris, pelvic abscess and lung sections. Clinical course and histomorphological findings favour the perforating sigmoid diverticular actinomycosis as an origin of the systemic infection.