How real is a virtual interview? Perspectives of orthopaedic surgery residency directors

OBJECTIVE

As a result of COVID-19 pandemic, the 2021 US residency MATCH was devoid of the traditional in-person interviews. Herein, we assess the impact of Virtual Interviews (VIs) on resident selection, from the perspectives of Orthopedic Surgery (OS) Program Directors (PDs).

MATERIALS AND METHODS

A 14-item survey was sent to PDs of ACGME-accredited OS residencies. Questions were designed to assess the pros, cons, and robustness of VIs compared to their antecedent in-person format.

RESULTS

Forty-seven PDs responded to our survey. VIs antagonized PDs' ability to assess applicants' fit to program (76.6%), commitment to specialty (64%), and interpersonal skills (68.1%). This led to heavier dependence upon applicants' portfolios (64%). Almost all respondents (97.9%) found VIs to be more cost-efficient, saving a median of $3000 in interview-related expenses. Overall, only 8.5% of PDs were willing to conduct exclusive VIs in future cycles, compared to the majority in favor of dual formats (51.5%) or exclusive in-person interviews (40.4%).

CONCLUSIONS

VIs have been an overall success, making most PDs opt for dual interview formats in future cycles. How this technology is further implemented in the future remains to be seen.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic

BACKGROUND

Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance.

OBJECTIVES

To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery.

METHODS

We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage.

RESULTS

We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation.

CONCLUSIONS

Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Cervical lymphatic malformations amenable to transhairline robotic surgical excision in children: A case series

Lymphatic malformations are rare benign malformations that predominantly occur in the head and neck region. The advent of surgical robots in head and neck surgery may provide beneficial outcomes for pediatric patients. Here, we describe our experiences with transhairline incisions for robot-assisted surgical resection of cervical lymphatic malformations in pediatric patients.In this prospective longitudinal cohort study, we recruited consecutive patients under 18 years of age who were diagnosed with congenital cervical lymphatic malformations and scheduled for transhairline approach robotic surgery at a single medical center. We documented the docking times, console times, surgical results, complications, and postoperative follow-up outcomes.The studied patients included 2 with mixed-type lymphatic malformations and 2 with macrocystic-type lymphatic malformations. In all 4 patients, the incision was hidden in the hairline; the incision length was <5 cm in 3 patients but was extended to 6 cm in 1 patient. Elevating the skin flap and securely positioning it with Yang retractor took <1 hour in all cases. The mean docking time was 5.5 minutes, and the mean console time was 1 hour and 46 minutes. All 4 surgeries were completed endoscopically with the robot. The average total drainage volume in the postoperative period was 21.75 mL. No patients required tracheotomy or nasogastric feeding tubes. Neither were adverse surgery-associated neurovascular sequelae observed. All 4 patients were successfully treated for their lymphatic malformations, primarily with robotic surgical excisions.Cervical lymphatic malformations in pediatric patients could be accessed, properly visualized, and safely resected with transhairline-approach robotic surgery. Transhairline-approach robotic surgery is an innovative method for meeting clinical needs and addressing esthetic concerns.

Extensile lateral versus sinus tarsi approach for calcaneal fractures: A meta-analysis

BACKGROUND

Calcaneal fractures are the most common tarsal bone fracture, and are often accompanied by heel pain, local swelling, tenderness, and inability to walk or stand. Surgical intervention results in better reconstruction of the calcaneal anatomy and reduces future complications; however, the optimal incision approach is still controversial. The incision is exposed better with extensile lateral approach (ELA), while the sinus tarsi approach (STA) causes fewer complications. The purpose of this meta-analysis is to compare the outcomes of STA and ELA.

MATERIALS AND METHODS

Published trials comparing ELA and STA in calcaneal fractures were included in our analysis. The quality of each study was assessed using the revised Jadad scale and the Newcastle-Ottawa scale. Two researchers (CP and BY) independently extracted data from all selected studies. Fixed- or random-effects models with mean differences and odds ratios were used to pool the continuous and dichotomous variables to determine the heterogeneity of the included studies.

RESULTS

Calcaneal height and calcaneal width had high heterogeneity. Results showed that the incidence of incision complications in STA was lower than that in ELA (P < .001). There was high heterogeneity in operative time (I2 = 97%), length of hospital stay (I2 = 98%), Böhler angle (I2 = 80%), Gissane angle (I2 = 98%), and American Orthopaedic Foot & Ankle Society scores (I2 = 73%). No source of heterogeneity was found by sensitivity analysis, subgroup analysis, or regression analysis, and the random-effects model was used. STA operative time was significantly shorter than ELA (P < .001). Length of hospital stay after STA was significantly shorter than after ELA (P = .002). There was no statistical difference in the Böhler and Gissane angles between STA and ELA. Postoperative American Orthopaedic Foot & Ankle Society scores after STA were higher than after ELA (P = .01).

CONCLUSIONS

Results show that, compared with ELA, STA is superior for treating calcaneal fractures due to anatomical reduction of the calcaneus, reduction of incision complications incidence, and shortened operative time and postoperative stay.

[How to Resume Elective Orthopaedic Surgical Procedures during the COVID-19 Pandemic?]

This document was prepared by the College of Orthopedics of the Portuguese Medical Association with the aim of developing the guidelines on the resumption of elective surgical activity in Orthopedics during the COVID-19 pandemic. It sets the criteria that allow the prioritization of surgeries according to the severity of the clinical situation, based on existing and published classifications. Moreover, it provides an organizational model for patient preparation and describes the patient pathways in the preoperative, intraoperative and postoperative periods. It also describes safety rules for elective surgery and a model for monitoring patients after discharge according to scientific evidence.

Is it safe and effective to correct congenital scoliosis associated with multiple intraspinal anomalies without preliminary neurosurgical intervention?

The aim of the study was to determine if multiple intraspinal anomalies increase the risk of scoliosis correction compared to the normal intraspinal condition or 1 or 2 intraspinal anomalies in congenital scoliosis (CS) and whether correction for multiple intraspinal anomalies need to be performed with preliminary neurosurgical intervention before scoliosis correction.A total of 318 consecutive CS patients who underwent corrective surgery without preliminary neurosurgical intervention at a single institution from 2008 to 2016 were retrospectively reviewed, with a minimum of 2 years of follow-up. The patients were divided into 3 groups according to different intraspinal conditions. In the normal group (N group; n = 196), patients did not have intraspinal anomalies. In the abnormal group (A group; n = 93), patients had 1 or 2 intraspinal anomalies. In the multiple anomaly group (M group; n = 29), patients had 3 or more intraspinal anomalies including syringomyelia, split cord malformation [SCM], tethered cord, low conus, intraspinal mass, Chiari malformation or/and arachnoid cyst. The occurrence of complications as well as perioperative and radiographic data were analyzed.The incidence rate of multiple intraspinal anomalies in CS patients was 9.1% (29/318). No significant difference was observed in the perioperative outcomes or radiographic parameters at the final follow-up. There were no significant differences among the 3 groups in the total, major or neurological complication rates (all P > .05). Two patients (1 in the N group and 1 in the A group) experienced transient neurological complications, whereas no patient experienced permanent neurological deficits during surgery or follow-up.To our knowledge, the current study reported the largest cohort of intraspinal anomalies in patients with CS that has been reported in the literature. The results of our study demonstrated that patients with congenital scoliosis associated with intraspinal anomalies, even multiple intraspinal anomalies that coexist with more complex intraspinal pathologies, may safely and effectively achieve scoliosis correction without preliminary neurological intervention. More complex intraspinal pathologies do not seem to increase the risk of neurosurgical complications during corrective surgery.

Experience of clinical screening for COVID-19 among patients undergoing elective orthopedic surgeries: an alternative proposal

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic is the largest global event in recent times, with millions of infected people and hundreds of thousands of deaths worldwide. Colombia has also been affected by the pandemic, including by the cancellation of medically necessary surgical procedures that were categorized as nonessential. The objective of this study was to show the results of the program implemented in two institutions in Bogotá, Colombia, in April 2020 to support the performance of elective essential and nonessential low- and medium-complexity orthopedic surgeries during the mitigation phase of the COVID-19 pandemic, which involved a presurgical clinical protocol without serological or molecular testing.

METHODS

This was a multicenter, observational, retrospective, descriptive study of a cohort of patients who underwent elective orthopedic surgery at two institutions in the city of Bogota, Colombia, in April 2020. We implemented a preoperative clinical protocol that did not involve serological or molecular tests; the protocol consisted of a physical examination, a survey of symptoms and contact with confirmed or suspected cases, and presurgical isolation. We recorded the types of surgeries, the patients' scores on the medically necessary, time-sensitive (MeNTs) scale, the presence of signs, symptoms, and mortality associated with COVID-19 developed after the operation.

RESULTS

A total of 179 patients underwent orthopedic surgery. The average age was 47 years (Shapiro-Wilk, P = 0.021), and the range was between 18 and 81 years. There was a female predominance (61.5%). With regard to the types of surgeries, 86 (48%) were knee operations, 42 (23.5%) were hand surgeries, 34 (19%) were shoulder surgeries, and 17 (9.5%) were foot and ankle surgeries. The average MeNTs score was 44.6 points. During the 2 weeks after surgery, four patients were suspected of having COVID-19 because they developed at least two symptoms associated with the disease. The incidence of COVID-19 in the postoperative period was 2.3%. Two (1.1%) of these four patients visited an emergency department where RT-PCR tests were performed, and they tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). No patients died or were hospitalized for symptoms of COVID-19.

CONCLUSION

Through the implementation of a presurgical clinical protocol consisting of a physical examination; a clinical survey inquiring about signs, symptoms, and epidemiological contact with suspected or confirmed cases; and presurgical isolation but not involving the performance of molecular or serological diagnostic tests, positive results were obtained with regard to the performance of low- and medium-complexity elective orthopedic surgeries in an early stage of the COVID-19 pandemic.

LEVEL OF EVIDENCE

IV.

Nonsensus in the treatment of proximal humerus fractures: uncontrolled, blinded, comparative behavioural analysis between Homo chirurgicus accidentus and Macaca sylvanus

OBJECTIVE

To investigate the inter-rater reliability of Barbary macaques compared with an expert group of surgeons for the choice of treatment and predicted outcome of proximal humerus fractures.

DESIGN

Uncontrolled, blinded, comparative behavioural analysis.

SETTING

Germany and United States.

PARTICIPANTS

10 blinded experts in the field of orthopaedic trauma surgery (Homo chirurgicus accidentus), with special focus on upper extremity surgery from Germany and the US, and five Barbary macaques (Macaca sylvanus) from a semi-free range enclosure.

MAIN OUTCOME MEASURES

The reliability of agreement between raters assessed with Fleiss' ĸ.

RESULTS

Barbary macaques seem to have inferior inter-rater reliability in comparison with experts for choice of treatment (non-surgical v surgical), but for the geriatric age group most frequently affected by proximal humeral fractures, they performed similarly to the experts in their choices of treatment and choice of surgical procedure. Agreement about predicted outcome was poor among the macaques and slight among the experts. All experts almost always predicted the outcome incorrectly and tended to underestimate it. While only 4 (4.4%) of 90 experts' predictions were correct, 13 (28.9%) of 45 macaques' predictions were correct.

CONCLUSIONS

Consensus on treatment and expected outcomes of proximal humeral fractures is lacking even beyond the human species. Although Barbary macaques tend to predict the clinical outcome more accurately, their reliability to assist surgeons in making a consistent decision is limited. Future high quality research is needed to guide surgeons' decision making on the optimal treatment of this common injury.

The Effect of Rotation on Intraoperative Fluoroscopic Evaluation of Hindfoot Alignment and How to Help Prevent Error

OBJECTIVE

Restoration of hindfoot alignment correlates with improved clinical and biomechanical outcomes after fracture care and reconstruction. Intraoperative assessment of alignment with fluoroscopy is challenging. This study was designed to determine the effect of rotation on the measurement of hindfoot alignment and to determine if any radiographic landmarks can be utilized to help surgeons identify appropriate rotation during intraoperative imaging.

METHODS

Ten unmatched cadaveric limbs that had been disarticulated at mid-tibia were used and placed supine in a radiolucent jig. Fluoroscopic images were obtained with the C-arm positioned at 45°. Images were obtained in sequential rotational adjustments from 12° of internal rotation to 12° of external rotation. The location of the fibula relative to the base of the fifth metatarsal was measured on images and recorded as an interval percentage overlap (0% to 50%, 50% to 100%, and greater than 100%). Hindfoot alignment was recorded by measuring the angle between the tibial and calcaneal axis.

RESULTS

Varus and valgus hindfoot alignment demon-strated a linear relationship to leg rotation (r2 = 0.998, p < 0.001). In these uninjured cadaveric specimens, 8° to 15° of internal rotation relative to the medial border of the foot produced a normal valgus angle (0° to 5°). Using 50% to 100% overlap of the fibula over the fifth metatarsal base as a radiographic test was a reliable indicator of predicted measurement, with 89% sensitivity and 99% specificity.

CONCLUSIONS

The measurement of hindfoot alignment changes with foot rotation. Use of the fibula overlap of the fifth metatarsal base may be a helpful tool to judge appro-priate rotation intraoperatively.

The impact of integrating electronic referral within a musculoskeletal model of care on wait time to receive orthopedic care in Ontario

An MSK model of care for hip and knee patients integrated with an electronic referral solution (eReferral) has been deployed within four subregions across Ontario. Referrals are sent from primary care offices to a central intake (CI), where the referral forms are reviewed and forwarded, if appropriate, to a rapid access clinic (RAC) where patients are assessed by an advanced practice clinician (APC). The pragmatic design of eReferral allows for a seamless flow of electronic orthopedic referrals from primary care to CI. It also enables CI to process and transcribe faxed referrals into the eReferral system for a smooth flow of data electronically to the RACs. In general, wait time is the time interval between receiving the patient's referral at CI or the surgeon's office until receiving the orthopedic surgeon's first consultation. Wait time is further broken down into wait 1 a and wait 1 b. Wait 1 a is the time between the receipt of the referral at CI until the date of the first initial assessment at the RAC. This study aimed at: a) assessing the processing time of orthopedic referrals at central intakes (CI) to be forwarded to the RAC, b) assessing the wait time (wait 1 a) of orthopedic referrals processed through the eReferral system to receive an initial assessment at the RACs. c) comparing the ability of the RACs to meet the target wait time for assessment (four weeks) by the method of referral (eReferrals vs. fax). d) evaluating patients' satisfaction with the length of time they waited to receive care at the RACs with eReferral. We used Ocean eReferral database to access MSK hip and knee referral data processed through the system. Patients whose referrals were initiated electronically through the system and opted to receive email notification of their referral status had the opportunity to take an online satisfaction survey embedded in the booked appointment notification message. There were 1,723 patients initially referred electronically for hip, and knee pain consults, while 13,780 referrals started as paper-based and transcribed into the system to be forwarded later electronically by CI to a RAC. Higher mean processing time at CI by 21.76 days for paper-based referral was detected as opposed to referrals received electronically (p<0.001). RACs took significantly less time to book appointments for referrals initiated electronically with a shorter average wait 1a of 21.42 days for eReferrals compared to paper-based referrals (p<0.001). RACs timeframe to book an appointment was significantly shorter for eReferrals versus fax referrals. A total of 393 patients completed the patient satisfaction survey with a response rate of 16%. Overall, 87.7% were satisfied with their experience with the eReferral process, and 81% agreed that they had waited a reasonable time to receive the needed care. eReferral can elicit faster processing of referrals and shorter wait time for patients, which improved patient satisfaction with the referral process.

Comparison of suture-button and screw fixation in the treatment of ankle syndesmotic injuries: Cohort study protocol

BACKGROUND

Syndesmotic injuries account for a significant number of ankle injuries. There is no consensus regarding the recommended method of treatment. The purpose of this study was to evaluate: METHODS:: This study was performed and reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology checklist. The records of 200 patients with ankle fractures who had undergone surgical treatment in our clinics between January 2014 and January 2018 were retrospectively investigated. This retrospective cohort study was approved by the institutional review board in the 2nd Hospital of Jilin University. The primary outcome measure was the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale and the Foot Function Index. Secondary outcome measures included visual analog scale score, complications, range of movement of ankle, reoperations, and radiologic outcomes. For statistical comparison of the clinical and radiologic findings between the 2 groups, we used SPSS, version 21.0 (SPSS, Chicago, IL), statistical software. P Values of < .05 were considered statistically significant.

CONCLUSION

The hypothesis was that the SB technique would achieve better functional outcomes as compared to the syndesmotic screw technique after surgery.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5793).

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.

Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines Developed by the International Consensus Group (ICM)

»As we resume elective surgical procedures, it is important to understand what practices and protocols should be altered or implemented in order to minimize the risk of pathogen transfer during the severe acute respiratory syndrome (SARS)-CoV-2 pandemic. »Each hospital and health system should consider their unique situation in terms of SARS-CoV-2 prevalence, staffing capabilities, personal protection equipment supply, and so on when determining how and when to implement these recommendations. »All patients should be screened for SARS-CoV-2 by means of a thorough history and physical examination, as well as reverse transcription-polymerase chain reaction (RT-PCR) testing whenever possible, prior to undergoing elective surgery. »Patients who are currently infected with coronavirus disease 2019 (COVID-19) should not undergo elective surgery. »These guidelines are based on the available scientific evidence, albeit scant. The recommendations have been reviewed and voted on by the expert delegates who produced this document.

Pelvic circumferential compression devices for prehospital management of suspected pelvic fractures: a rapid review and evidence summary for quality indicator evaluation

BACKGROUND

Pelvic fractures, especially when unstable, may cause significant haemorrhage. The early application of a pelvic circumferential compression device (PCCD) in patients with suspected pelvic fracture has established itself as best practice. Ambulance services conduct corresponding performance measurement. Quality indicators (QIs) are ideally based on high-quality evidence clearly demonstrating that the desirable effects outweigh the undesirable effects. In the absence of high-quality evidence, best available evidence should be combined with expert consensus.

OBJECTIVES

The aim of the present study was to identify, appraise and summarize the best available evidence regarding PCCDs for the purpose of informing an expert panel tasked to evaluate the validity of the following QI: A patient with suspected pelvic fracture has a PCCD applied.

METHODS

A rapid review of four databases was conducted to identify relevant literature published up until 9 June 2020. Systematic reviews, experimental, quasi-experimental and observational analytic studies written in English were included. One author was responsible for study selection and quality appraisal. Data extraction using a priori extraction templates was verified by a second reviewer. Study details and key findings were summarized in tables.

RESULTS

A total of 13 studies were assessed to be eligible for inclusion in this rapid review. Of these, three were systematic reviews, one was a randomized clinical trial (crossover design), two were before-after studies, and seven were retrospective cohort studies. The systematic reviews included mostly observational studies and could therefore not be considered as high-level evidence. Overall, the identified evidence is of low quality and suggests that PCCD may provide temporary pelvic ring stabilization and haemorrhage control, although a potential for adverse effects exists.

CONCLUSION

Given the low quality of the best available evidence, this evidence would need to be combined with expert consensus to evaluate the validity of a related quality indicator before its implementation.

[The killer turn in the posterior cruciate ligament reconstruction: mechanism and improvement]

OBJECTIVE

To summarize the research progress of killer turn in posterior cruciate ligament (PCL) reconstruction.

METHODS

The literature related to the killer turn in PCL reconstruction in recent years was searched and summarized.

RESULTS

The recent studies show that the killer turn is considered to be the most critical cause of graft relaxation after PCL reconstruction. In clinic, this effect can be reduced by changing the fixation mode of bone tunnel, changing the orientation of bone tunnel, squeezing screw fixation, retaining the remnant, and grinding the bone at the exit of bone tunnel. But there is still a lack of long-term follow-up.

CONCLUSION

There are still a lot of controversies on the improved strategies of the killer turn. More detailed basic researches focusing on biomechanics to further explore the mechanism of the reconstructed graft abrasion are needed.

Operational strategies of a trauma hub in early coronavirus disease 2019 pandemic

Purpose

The “Spedali Civili”, one of the largest hospitals in the Italian region most affected by SARS-CoV-2 infection, is managing a large number of traumatic injuries. The objective of this article is to share our operational protocols to deliver an appropriate hospital trauma care in the context of the COVID-19 pandemic.

Methods

We changed our work shifts, in consideration of the high number of patients; colleagues from smaller hospitals in the area joined us to increase the number of surgeons available. Thanks to the collaboration between orthopaedists, anaesthesiologists, and nurses, we created a flow chart and separate routes (in the emergency room, in the wards, and in the operating rooms) to optimize patient management. Our protocols allow us to always provide healthcare professionals with the correct personal protective equipment for the task they are performing.

Results

Our strategies proved to be practical and feasible. Having a well thought plan helped us to provide for the most robust response possible. We have not yet been able to study the effectiveness of our protocols, and our recommendations may not be applicable to all healthcare facilities. Nonetheless, sharing our early experience can help other institutions conducting and adapting such plans more quickly.

Conclusions

Having a clear strategy during the COVID-19 pandemic kept our systems resilient and effective and allowed us to provide high-quality trauma care. We offer this approach for other institutions to adopt and adapt to their local setting.

A Review of State Guidelines for Elective Orthopaedic Procedures During the COVID-19 Outbreak

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic has resulted in widespread cancellation of elective orthopaedic procedures. The guidance coming from multiple sources frequently has been difficult to assimilate as well as dynamic, with constantly changing standards. We seek to communicate the current guidelines published by each state, to discuss the impact of these guidelines on orthopaedic surgery, and to provide the general framework used to determine which procedures have been postponed at our institution.

METHODS

An internet search was used to identify published state guidelines regarding the cancellation of elective procedures, with a publication cutoff of March 24, 2020, 5:00 P.M. Eastern Daylight Time. Data collected included the number of states providing guidance to cancel elective procedures and which states provided specific guidance in determining which procedures should continue being performed as well as to orthopaedic-specific guidance.

RESULTS

Thirty states published guidance regarding the discontinuation of elective procedures, and 16 states provided a definition of "elective" procedures or specific guidance for determining which procedures should continue to be performed. Only 5 states provided guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly allowed for trauma-related procedures and 4 states provided guidance against performing arthroplasty. Ten states provided guidelines allowing for the continuation of oncological procedures.

CONCLUSIONS

Few states have published guidelines specific to orthopaedic surgery during the COVID-19 outbreak, leaving hospital systems and surgeons with the responsibility of balancing the benefits of surgery with the risks to public health.

Rupture of plantar fascia: Current standard of therapy: A systematic literature review

BACKGROUND

The aim of the present systematic literature review is to give an overview of ruptures of the plantar fascia. For this purpose, a detailed description of the patient collective is provided. However, the focus of this analysis is based on the current therapy concepts. Based on the results the authors propose a standardized therapy concept.

MATERIAL AND METHODS

A systematic literature review was performed using the PubMed database using the terms: ("rupture plantar fascia" OR "plantar fascia tear" OR "rupture plantar aponeurosis"). All articles published in the PubMed database until 07.11.2018 were included. The articles were evaluated with regard to three research question: (1) Which patients are affected by a rupture of the plantar fascia? (2) Which therapy concept was used to treat rupture of the plantar fascia? And (3) which result was achieved and how was this measured?

RESULTS

A total of 78 studies were identified, of which the full text of 17 were analysed. 12 publications were cases reports, 5 studies were retrospective analyses. Data from 124 patients could be included. The average age of patients was 39.6 years. In 63.2% (n = 12) of the studies, patients with a high level of athletic activity or even professional athletes were analyzed. 94.4% of all patients were treated conservatively. The average duration of immobilization in a rigid walker was 2.6 weeks. In the majority of cases, pain-adapted weight-bearing was allowed in the rigid walker.

CONCLUSION

There are few available studies concerning the rupture of plantar fascia. The quality of data is poor. The maximum duration of immobilization of 3 weeks in a rigid walker with pain-adapted weight-bearing appears to be the most applied therapy concept. Further studies are needed to evaluate the efficacy of the therapy and to optimize the therapy concept.

Development of a core outcome set for lower limb orthopaedic surgical interventions in ambulant children and young people with cerebral palsy: a study protocol

INTRODUCTION

Musculoskeletal deformities and gait deviations are common features in ambulatory cerebral palsy (CP). Deformity correction through lower limb orthopaedic surgery is the standard form of care aimed at improving or preserving motor function. Current research on CP care does not always take into account individual patients' expectations and needs. There is a wide range of outcome domains and outcome measures used to assess outcome from treatment. This can lead to reporting bias and make it difficult to compare and contrast studies. A core outcome set (COS) would enhance the efficiency, relevance and overall quality of CP orthopaedic surgery research. The aim of this study is to establish a standardised COS for use in evaluating lower limb orthopaedic surgery for ambulatory children and young people with CP.

METHODS/ANALYSIS

A set of outcomes domains and outcome measures will be developed as follows: (1) a qualitative evidence synthesis to identify relevant outcomes from children and young people and family perspective; (2) a scoping review to identify relevant outcomes and outcome measures; (3) qualitative research to explore the experience of key stakeholders; (4) prioritisation of outcome domains will be achieved through a two-round Delphi process with key stakeholders; (5) a final COS will be developed at a consensus meeting with representation from key stakeholder groups.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted in the UK by the Oxfordshire Research Ethics Committee B (REC reference 19/SC/0357). Informed consent will be obtained from participants taking part in the qualitative research and Delphi process. Study findings will be published in an open access journal and presented at relevant national and international conferences. Charities and associations will be engaged to promote awareness of the project COS results.

TRIAL REGISTRATION NUMBER

COMET registration: 1236.

PROSPERO REGISTRATION NUMBER

CRD42018089538.

Treatment of a high-energy transsyndesmotic ankle fracture: A case report of "logsplitter injury"

INTRODUCTION

The "logsplitter injury" is a special type of ankle fractures that results from high energy violence with combined rotational forces and axial loads. So far, the diagnose and treatment of "logsplitter injury" remain largely unsettled and related literature is rare.

PATIENT CONCERNS

An 18-year-old male fell from a fence and got his left ankle injured with severe malformation and swollen condition. No open wound was observed.

DIAGNOSIS

Logsplitter injury, ankle fracture (AO/OTA classification 44C1.1, Lauge-Hansen classification: pronation-external rotation).

INTERVENTIONS AND OUTCOMES

The patient was initially treated by internal fixation of fibular, repair of deltoid ligaments, and 1 syndesmotic screw fixation. When the X-ray applied after surgery, another 2 syndesmotic screws were performed to enhance stability. The syndesmotic screws were removed at 12-week and 16-week respectively. The patient was allowed for full weight-bearing immediately. However, the syndesmotic space was slightly increased compared to the contralateral side in CT views at 1-year follow-up, the function outcome was satisfied.

CONCLUSION

The logsplitter injury is a high-energy ankle fracture that requires both axial and rotational load. It is categorized as 44B or 44C by the AO/OTA classification. In the classification scheme of Lauge-Hansen, our case is in line with the pronation-external rotation classification. Anatomic reduction and fixation of ankle syndesmotic injuries are required to restore the biomechanics of the ankle joint so that long-term complications can be prevented. How to fixation the syndesmosis, whether to reconstruct the deltoid ligament remains in debate in the treatment of logsplitter injury, whether and when to remove the syndesmotic screws were still debated. Correct surgical intervention is successful in the treatment of "logsplitter injury", however, the optimal fixation of syndesmosis and repair of deltoid ligaments need further investigate.

Online ratings of spinal deformity surgeons: analysis of 634 surgeons

STUDY DESIGN

Observational study.

OBJECTIVE

To evaluate the online ratings of spine deformity surgeons and variables that may affect online ratings Physician review websites (PRW) continue to be an emerging trend in the US across all specialties. Previous literature with smaller sample sizes revealed that most spine surgeons are rated on at least on PRW. To date, the online ratings of spinal deformity surgeons have not been evaluated.

MATERIALS AND METHODS

A review of the 2017 Scoliosis Research Society (SRS) Fellowship directory for active fellows and candidate members yielded 634 active members. Online ratings from five PRWs were recorded and scaled from 0 to 100. Using SPSS, one-way analysis of variance was used to compare differences between multiple groups. A t test was used to compare differences between two groups. Significance was set at p < 0.05.

RESULTS

Most surgeons (98.7%) were rated on at least one PRW. Surgeons in academic or hospital practice had higher ratings than those in private practice (83.4 vs. 78.8, and 83.7 vs. 78.8, p < 0.001). Surgeons with 0-5-year experience had higher ratings than more experienced surgeons (p < 0.001). However, surgeons in practice for 0-5 years also had fewer reviews than their more experienced colleagues (p < 0.05). We found no differences in ratings based on sex, specialty, or region. The largest differences in ratings between high and poorly rated spine surgeons was in areas pertaining to the doctor-patient relationship (answering questions, time spent with the patient).

CONCLUSION

The majority (98.7%) of SRS surgeons are rated on at least one PRW. SRS surgeons in practice between 0 and 5 years have higher ratings than more experienced surgeons, but were rated by fewer patients than their more experienced counterparts. Higher ratings were associated with variables pertaining to the patient-doctor relationship.

LEVEL OF EVIDENCE

IV.

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.

Surgical Upper Extremity Infections in Immunosuppressed Patients: A Comparative Analysis With Diagnosis and Treatment Recommendations for Hand Surgeons

Background: Immunosuppression is encountered in patients with oncologic, transplant, and autoimmune disorders. The purpose of this study is to provide guidance for physicians treating surgical hand and upper extremity (UE) infections in immunosuppressed (IS) patients. Methods: We retrospectively reviewed our database of patients presenting with UE infections over 3 years. IS patients were matched randomly to non-IS patients. Patient background, infection presentation, surgical evaluation, and microbiology variables were recorded. Infection variables included mechanism, location, and type. Outcomes included inpatient length of stay (LOS) and need for repeat drainage. Results: We identified 35 IS and 35 non-IS out of 409 UE infection patients. Patients most commonly had a hematologic malignancy (34%) as their IS class, and the most frequent immunosuppressive medication was glucocorticoids (57%). IS patients were more likely to be older and less likely to have a history of drug abuse or hepatitis C virus infections. IS infections were more likely to have idiopathic mechanisms, more likely to involve deeper anatomy such as joints, bone, tendon sheath, or muscle/fascia, and less likely to present with leukocytosis. IS cultures more commonly exhibited atypical Mycoplasma or fungus. There was no difference between IS and non-IS patients regarding LOS or recurrent drainage. Conclusions: Mechanism and white blood cell count are less reliable markers of infection severity in IS patients. Physicians treating infections in IS patients should maintain a higher suspicion for deeper involved anatomy and atypical microbiology. Nonetheless, with careful inpatient management and closer surveillance, outcomes in IS patients can approach that of non-IS patients.

Changing perioperative prophylaxis during antibiotic therapy and iterative debridement for orthopedic infections?

Background

Perioperative antibiotic prophylaxis in non-infected orthopedic surgery is evident, in contrast to prophylaxis during surgery for infection. Epidemiological data are lacking for this particular situation.

Methods and findings

It is a single-center cohort on iterative surgical site infections (SSIs) in infected orthopedic patients. We included 2480 first episodes of orthopedic infections (median age 56 years and 833 immune-suppressed): implant-related infections (n = 648), osteoarticular infections (1153), and 1327 soft tissue infections. The median number of debridement was 1 (range, 1–15 interventions). Overall, 1617 infections (65%) were debrided once compared to 862 cases that were operated multiple times (35%). Upon iterative intraoperative tissue sampling, we detected pathogens in 507 cases (507/862; 59%), of which 241 (242/507; 48%) corresponded to the initial species at the first debridement. We witnessed 265 new SSIs (11% of the cohort) that were resistant to current antibiotic therapy in 174 cases (7% of the cohort). In multivariate analysis, iterative surgical debridements that were performed under current antibiotic administration were associated with new SSIs (odds ratio 1.6, 95%CI 1.2–2.2); mostly occurring after the 2^nd debridement. However, we failed to define an ideal hypothetic prophylaxis during antibiotic therapy to prevent further SSIs.

Conclusions

Selection of new pathogens resistant to ongoing antibiotic therapy occurs frequently during iterative debridement in orthopedic infections, especially after the 2^nd debridement. The new pathogens are however unpredictable. The prevention, if feasible, probably relies on surgical performance and wise indications for re-debridement instead of new maximal prophylactic antibiotic coverage in addition to current therapeutic regimens.

What Do U.K. Orthopedic Surgery Patients Think About PROMs? Evaluating the Evaluation and Explaining Missing Data

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

The Dedicated Orthopaedic Trauma Room Model: Adopting a New Standard of Care

The dedicated orthopaedic trauma room (DOTR) has emerged over the last decade as an effective approach to improving workflow while reducing the complications and costs that are associated with musculoskeletal trauma care. We surveyed the top 20 hospitals in the United States and found that 14 (70%) utilize a DOTR. Coupled with recent data on improved outcomes and patient flow, we see evidence that the availability of a DOTR has become a best practice for orthopaedic trauma care.

Effect of Training Modules on Hip Fracture Surgical Skills Simulation Performance: Early Validation of the AAOS/OTA Simulator

BACKGROUND

A preliminary validation study on a computer-based force-feedback simulation platform demonstrated the ability of the simulator to distinguish between novice and experienced users during a simulated hip-pinning procedure. The purpose of the present study was to further investigate whether the simulator and associated training modules are effective for improving user performance during simulated percutaneous hip-pinning procedures.

METHODS

With institutional review board approval, 24 medical students at our institution were randomized to "Trained" and "Untrained" groups. After a basic introduction, the Untrained group placed 3 guidewires in a valgus-impacted femoral neck fracture with use of the simulator. The Trained group completed 9 simulator-based training modules before performing the same task. Measured outcomes included an overall performance score and the distance from the pin to various ideals on the femoral neck, femoral head articular surface, and lateral cortex. Performance parameters were compared between groups with the Mann-Whitney U test.

RESULTS

The Trained group achieved a significantly higher overall score (median, 29) compared with the Untrained group (median, 6) (p < 0.01), outperformed the Untrained group in 4 specific performance metrics, and trended toward improvement over the Untrained group in 4 pin placement measures (p < 0.2).

CONCLUSIONS

Completion of novel training modules for percutaneous hip pinning on this fluoroscopic surgery simulator improves skill performance on simulator-based objective measurements and a simulated orthopaedic procedure compared with non-simulator-trained surgically inexperienced users. Improvement in the overall score and on 4 of 13 specific performance parameters implies that the training modules more effectively teach only certain motor and 3-dimensional spatial skills.

CLINICAL RELEVANCE

A valid platform such as the one described here has the potential to improve surgical education in orthopaedic trauma.

Association of Cost Savings and Surgical Quality With Single-Vendor Procurement for Spinal Implants

IMPORTANCE

Significant cost savings can be achieved from consolidating purchases of spinal implants with a single vendor. However, it is currently unknown whether sole-source contracting or vendor rationalization more broadly affects patient care.

OBJECTIVES

To describe the single-vendor procurement of spinal implants, characterize the economic benefits of sole-source contracting, and gauge whether vendor rationalization is associated with a diminished quality of care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed adult patients receiving single-level lumbar interbody fusions at a single institution from January 1, 2009, to July 31, 2017. Exclusion criteria included multilevel fusions and prior spinal fusions.

EXPOSURES

Patients were analyzed based on the number of vendors available to surgeons at the time of the patient's surgery. January 1, 2009, to December 31, 2010, was defined as the multivendor period (10 vendors); January 1, 2011, to December 31, 2014, was defined as the dual-vendor period; and January 1, 2015, to July 31, 2017, was defined as the single-vendor period.

MAIN OUTCOMES AND MEASURES

Rates of 12-month revision surgery, complications, 30-day readmissions, and postoperative patient-reported outcomes, as measured by 5-dimension European Quality of Life (EQ-5D) and Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) utilities. Propensity score weighting was performed to control for confounding. The Holm method was used to correct for multiple testing. Annual cost savings associated with the dual-vendor and single-vendor periods were also reported.

RESULTS

A total of 1373 patients (mean [SD] age, 59.2 [12.6] years; 763 [55.6%] female; 1161 [84.6%] white) were analyzed. Rates of revisions after adjusting for confounding were 3.2% (95% CI, 1.5%-6.7%) for the multivendor period, 4.5% (95% CI, 3.1%-6.5%) for the dual-vendor period, and 3.0% (95% CI, 1.7%-5.0%) for the single-vendor period. Complication rates were 5.3% (95% CI, 2.7%-10.1%) for the multivendor period, 7.2% (95% CI, 5.4%-9.6%) for the dual-vendor period, and 6.4% (95% CI, 4.6%-8.8%) for the single-vendor period. Readmission rates were 14.2% (95% CI, 9.7%-20.2%) for the multivendor period, 12.6% (95% CI, 10.1%-15.5%) for the dual-vendor period, and 9.7% (95% CI, 7.4%-12.7%) for the single-vendor period. Revisions, complications, and patient-reported outcomes were statistically equivalent across all periods. Readmissions were not statistically equivalent but not statistically different. The savings attributable to vendor rationalization were 24% for the dual-vendor and 21% for the single-vendor periods.

CONCLUSIONS AND RELEVANCE

The single-vendor procurement of spinal implants was associated with significant cost savings without evidence of an associated decline in the quality of care. Large hospital systems may consider sole-source purchasing as a viable cost reduction strategy.

A novel method to teach and assess the sterility of donning sterile gloves

Sterility is of utmost importance during surgery, particularly orthopaedic surgery. The literature suggests sterility, when compromised, is frequently contaminated at the point of donning sterile gowns and gloves. We describe a novel method to assess the compliance of sterility whilst applying surgical gloves using an ultraviolet lightbox and an ultraviolet-sensitive 'Germ paint'. We carried out an audit of 'sterility' using this method with our surgical trainees. A subsequent educational programme described methods of glove-donning. Repeat assessment yielded significantly improved results. Educating staff using this method may improve sterility in theatre. We believe this is a novel method to teach and assess sterility during glove-donning. The equipment is readily accessible within each NHS hospital. Medical and theatre staff should use this as part of training and departmental induction programmes.

State-of-the-Art Reviews: Safety in Complex Spine Surgery

The surgical correction of spinal deformities carries a high risk of perioperative morbidity. As the incidence of debilitating spinal deformities continues to increase, so too does our obligation to search for ways to enhance safety in our delivery of surgical care. Standardized work processes and other lean manufacturing methodologies have the potential to improve efficiency, safety, and hence value in our delivery of surgical care to patients with complex spine pathologies by reducing variability in our work processes. These principles can be applied to patient care from the initial preoperative assessment to long-term postoperative follow-up in the creation of comprehensive protocols that guide the management of these complex patients. Early evidence suggests that short-term outcomes can be improved by implementing packages of systems reform aimed at reducing variability in our work processes; however, contradicting evidence exists on the utility of several specific components of these systems-reform packages.

What is the quality of clinical practice guidelines for the treatment of acute lateral ankle ligament sprains in adults? A systematic review

BACKGROUND

Acute lateral ankle ligament sprains (LALS) are a common injury seen by many different clinicians. Knowledge translation advocates that clinicians use Clinical Practice Guidelines (CPGs) to aid clinical decision making and apply evidence-based treatment. The quality and consistency of recommendations from these CPGs are currently unknown. The aims of this systematic review are to find and critically appraise CPGs for the acute treatment of LALS in adults.

METHODS

Several medical databases were searched. Two authors independently applied inclusion and exclusion criteria. The content of each CPG was critically appraised independently, by three authors, using the Appraisal of Guidelines for REsearch and Evaluation (AGREE II) instrument online version called My AGREE PLUS. Data related to recommendations for the treatment of acute LALS were abstracted independently by two reviewers.

RESULTS

This study found CPGs for physicians and physical therapists (Netherlands), physical therapists, athletic trainers, physicians, and nurses (USA) and nurses (Canada and Australia). Seven CPGs underwent a full AGREE II critical appraisal. None of the CPGs scored highly in all domains. The lowest domain score was for domain 5, applicability (discussion of facilitators and barriers to application, provides advice for practical use, consideration of resource implications, and monitoring/auditing criteria) achieving an exceptionally low joint total score of 9% for all CPGs. The five most recent CPGs scored a zero for applicability. Other areas of weakness were in rigour of development and editorial independence.

CONCLUSIONS

The overall quality of the existing LALS CPGs is poor and majority are out of date. The interpretation of the evidence between the CPG development groups is clearly not consistent. Lack of consistent methodology of CPGs is a barrier to implementation.

SYSTEMATIC REVIEW

Systematic review registered with PROSPERO ( CRD42015025478 ).

A Critical Analysis of the Exercise Prescription and Return to Activity Advice That Is Provided in Patient Information Leaflets Following Lumbar Spine Surgery

Background and objectives: Lumbar spine surgery may be considered if pharmacologic, rehabilitation and interventional approaches cannot provide sufficient recovery from low back-related pain. Postoperative physiotherapy treatment in England is often accompanied by patient information leaflets, which contain important rehabilitation advice. However, in order to be an effective instrument for patients, the information provided in these leaflets must be up to date and based on the best available evidence and clinical practice. This study aims to critically analyse the current postoperative aspects of rehabilitation (exercise prescription and return to normal activity) that are provided in patient information leaflets in England as part of an evaluation of current practice following lumbar spine surgery. Materials and Methods: Patient information leaflets from English National Health Service (NHS) hospitals performing lumbar spine surgery were sourced online. A content analysis was conducted to collect data on postoperative exercise prescription and return to normal activities. Results: Thirty-two patient information leaflets on lumbar surgery were sourced (fusion, n = 11; decompression, n = 15; all lumbar procedures, n = 6). Many of the exercises prescribed within the leaflets were not based on evidence of clinical best practice and lacked a relationship to functional activity. Return to normal activity advice was also wide ranging, with considerable variation in the recommendations and definitions provided. Conclusions: This study highlights a clear variation in the recommendations of exercise prescription, dosage and returning to normal activities following lumbar spine surgery. Future work should focus on providing a consistent and patient-centred approach to recovery.

Perioperative Pain Control in Upper Extremity Surgery: Prescribing Patterns, Recent Developments, and Opioid-Sparing Treatment Strategies

Background: Perioperative pain management in hand and upper extremity surgery has become increasingly challenging following recent efforts to accelerate postoperative recovery, decrease length of stay, and maximize the number and complexity of surgical interventions provided in an ambulatory setting. This issue has been further complicated by the growing opioid epidemic in the United States and increasing insights into its detrimental effects on society. Practicing hand surgeons must acknowledge this ongoing public health crisis and adapt their clinical practices to minimize and optimize distribution of prescription opioids. Methods/Results: This review outlines current opioid prescribing patterns, recent developments, and treatment strategies designed to maintain effective perioperative analgesia in orthopedic upper extremity surgery while minimizing opioid delivery available for diversion, misuse, and abuse. Conclusions: The authors advise hand surgeons to utilize the strategies discussed in this review to assist in forming a unique, patient-specific postoperative analgesic regimen.

Preventing Inadvertent Hypothermia in Patients Undergoing Major Spinal Surgery: A Nonrandomized Controlled Study of Two Different Methods of Preoperative and Intraoperative Warming

PURPOSE

To evaluate if a Full Access Underbody (FAU) blanket used preoperatively and intraoperatively in patients undergoing major spinal surgery prevents hypothermia compared with current practice and to explore patients' experiences of comfort.

DESIGN

A nonrandomized controlled trial.

METHODS

Sixty patients were included, 30 in each group. Temperature was assessed on arrival, after connecting to the bladder catheter, and at the start and end of surgery. In the FAU group, comfort was evaluated at arrival and after 10 minutes of prewarming.

FINDINGS

The incidence of hypothermia at the start of surgery was significantly lower (relative risk [95% confidence interval], 0.28 [0.13 to 0.59]). Before prewarming, 77% felt comfortable, 20% cold, and 3% hot. After prewarming 60% felt comfortable, 37% hot, and 3% very hot.

CONCLUSIONS

Patients using the FAU blanket had a 72% lower incidence of hypothermia at the start of the operation. Attention to thermal comfort during surgery is important.

Patient Safety Room Assessing Orthopedic Surgery Interns' Abilities to Identify Patient Safety Hazards

OBJECTIVE

An important part of clinical training is learning how to identify and prevent hospital-acquired conditions or injuries. Despite this, there are few standardized methods in graduate medical education (GME) for teaching and assessing resident patient safety skills. Residents often do not report safety events, and increasing resident engagement can positively impact patient safety. In the current study, we sought to apply such a tool in gauging the capacity of orthopedic surgery interns at a large academic medical center to identify patient safety hazards and begin a discussion regarding the management of potential patient safety issues.

METHODS

A total of 27 orthopedic surgery interns at a single large academic medical center participated in the current observational study divided into two distinct groups in the summers of 2016 and 2017. A patient room was simulated with a training mannequin lying supine in a hospital bed. A mock patient chart and handoff were created in the electronic medical record (EMR) on the bedside computer. Patient safety hazards and errors of care were placed around the room and in the EMR, including several derived from the Joint Commission's National Patient Safety Goals. Each intern was given a maximum of 20 minutes to identify as many of the simulated patient safety hazards as possible. A debrief was conducted at the end of the exercise to discuss their responsibility to speak up when hazards are identified in a non-simulated patient room. For analysis, the hazards were distributed into four categories: room organization, EMR, patient care, and white board. Each intern's individual score (number of complete identifications/total number of hazards) and the group's performance as a whole in each category were calculated.

RESULTS

The mean individual score was 51.54% (26.67% to 70.00%) in group A and 40.41% (25.71% to 54.29%) in group B. In group A, room organization hazards were identified more than any other category (74.62%), followed by patient care errors (40.38%), EMR hazards (40.17%), and white board errors (38.46%). In group B, room organization was identified the most (57.74%), followed by EMR (50%), and patient care and white board hazards (28.57% each). Certain critical safety hazards were identified by a small number of interns. For example, the inadequate handoff was only identified by four interns in each group.

CONCLUSIONS

Hazards related to room cleanliness were easier to identify than hazards related to specific errors in patient care. A wide variation in the identification of critical safety issues was observed among the trainees assessed. This type of simulated educational experience provides important opportunities for resident-specific education in the realm of patient safety and health care quality.

The use of intravenous magnesium sulfate on postoperative analgesia in orthopedic surgery: A systematic review of randomized controlled trials

INTRODUCTION

The aim of this systematic review is to investigate the effects of perioperative intravenous administration of MgSO4 on postoperative pain, analgesic consumption and adverse effects in patients undergoing orthopedic surgery.

METHODS

Two investigators independently searched for articles on randomized controlled trials (RCTs) from 1998 to 2016 in Pubmed, Web of science and Google scholar. We evaluated clinical outcomes, comparing postoperative pain scores, cumulative analgesic consumption, time to first analgesia, and adverse effects between orthopedic surgery patients with and without the administration of MgSO4.

RESULTS

After screening 2350 articles, 11 RCTs (with a total sample size of 535 subjects) were included in this systematic review. Perioperative intravenous administered MgSO4 could reduce postoperative pain intensity compared with control in 6 trials (55%), but without significant difference in 5 trials (45%). With MgSO4 treatments, postoperative analgesic consumption was significantly reduced in 8 trials (73%), and without significant difference in 2 trials (18%). Two trials evaluated the time to first request of analgesic after surgery and showed prolong of 2.3 hours and 93 minutes respectively. MgSO4 group had less postoperative nausea (relative risk [RR] = 0.32, 95% confidence interval [CI] = 0.12-0.82, number needed to harm [NNH] = 8.8), vomiting (RR = 0.38, 95% CI = 0.15-0.92, NNH = 9.7), and shivering (RR = 0.31, 95% CI = 0.11-0.88, NNH = 5.2).

CONCLUSION

Perioperative intravenous administration of MgSO4 in orthopedic surgery could reduce postoperative analgesic consumption and adverse effects such as vomiting, nausea, and shivering. These trials do not provide convincing evidence of beneficial effects on postoperative pain intensity and the time to first analgesic request. More trials should be conducted for the roles of MgSO4 in pain management for orthopedic surgery. However, intravenous MgSO4 administration should be considered as a strategy to relieve postoperative pain in orthopedic surgery patients.

[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.

Percutaneous Kyphoplasty: Indications and Technique in the Treatment of Vertebral Fractures from Myeloma

Aims and background

The purpose of our research was to assess the effectiveness and safety of percutaneous kyphoplasty, the new method of treatment for pain deriving from vertebral compression fractures due to myeloma.

Methods

We treated 3 patients with pain refractory to conventional medical therapy (analgesics, bed-rest, bracing with orthopedic devices for more than 4 weeks), localized in the lumbar area, painful to the touch and in the absence of neurological signs.

Results

The method demonstrated a swift pain relief associated with an evident augmentation in the resistance and restoration of the vertebral body's physiological shape. Polymethylmethacrylate leaks were not observed in the epidural or foraminal area, nor were complications such as pulmonary embolism for involvement of the venous plexus or related to phenomenon of infections due to the procedure, or toxicity due to the polymethylmethacrylate.

Conclusions

Kyphoplasty was found to be an effective alternative, simple and safe in the treatment of vertebral collapse consequent to multiple myeloma. The same injection of polymethylmethacrylate can be done before the radiotherapy treatment, thereby synergizing its delayed analgesic action to pain, or after the failure or in the case of local recurrence.

Reporting Standards in Clinical Studies Evaluating Bone Marrow Aspirate Concentrate: A Systematic Review

PURPOSE

To perform a systematic review of clinical studies evaluating bone marrow aspirate concentrate (BMAC) in the treatment of musculoskeletal pathology to compare levels of reporting with recently published minimum standards.

METHODS

A systematic review of the clinical literature from August 2002 to August 2017 was performed. Human clinical studies published in English and involving the administration of BMAC for musculoskeletal applications were included. Studies evaluating non-concentrated preparations of bone marrow aspirate or preparations of laboratory cultured cells were excluded. Studies evaluating the treatment of dental or maxillofacial conditions were excluded. Similarly, in vitro studies, editorials, letters to the editor, and reviews were excluded. Levels of reporting were compared with previously published minimum standards agreed on through an international Delphi consensus process.

RESULTS

Of 1,580 studies identified on the initial search, 46 satisfied the criteria for inclusion. Considerable deficiencies in reporting of key variables including the details of BMAC preparation and composition were noted. Studies reported information on only 42% (range, 25%-60%) of the variables included within established minimum reporting standards. No study provided adequate information to enable the precise replication of preparation protocols and accurate characterization of the BMAC formulation delivered.

CONCLUSIONS

We found that all existing clinical studies in the literature evaluating BMAC for orthopaedic or sports medicine applications are limited by inadequate reporting of both preparation protocols and composition. Deficient reporting of the variables that may critically influence outcomes precludes interpretation, prevents other researchers from reproducing experimental conditions, and makes comparisons across studies difficult. We encourage the adoption of emerging minimum reporting standards for clinical studies evaluating the use of mesenchymal stem cells in orthopaedics.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

What Is the State of Quality Measurement in Spine Surgery?

BACKGROUND

Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery.

QUESTIONS/PURPOSES

(1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent?

METHODS

We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study.

RESULTS

Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]).

CONCLUSIONS

Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

Anemia - the Neglected Problem in Patients with Orthopedic Conditions

Anemia and the necessity of blood product transfusion in perioperative procedures is an important and frequently discussed clinical issue. Presently, a constantly growing interest in this problem is observed among clinicians who search the ways to reduce the number of blood or blood product transfusions in patients after surgical procedures, both during the preoperative period and during and after the surgery. Generally, the decision whether to start transfusion or not should follow the analysis of pros and cons, considering the beneficial effect of transfusion and the risk of undesirable effects. The most effective approach in prophylaxis and treatment of anemia among patients on the orthopedic service should combine surgical anesthetic and pharmacological procedures during the preoperative, perioperative and postoperative periods. The aim of the paper is presenting the latest knowledge of the practical determinants concerning anemia pharmacological treatment, especially considering the principles, value and therapeutic effectiveness of iron supplementation, both at orthopedic injury clinics and outpatient clinics.

Optimal low-molecular-weight heparin regimen in major orthopaedic surgery

Low-molecular-weight heparins (LMWH) are routinely used for thromboprophylaxis in major lower limb orthopaedic surgery. However the optimal LMWH regimen, offering the greatest efficacy with an acceptable risk of bleeding, has not been clearly established with regard to dose and timing of treatment initiation. We performed a meta-analysis of all available randomised trials comparing LMWH to placebo. Relative risks (RR) and corresponding 95% confidence intervals (CI) were calculated. By means of subgroup analysis, we evaluated the consistency of the results according to the timing of treatment initiation (preoperative versus postoperative) and dose of LMWH used (low doses, i.e. 4000 anti-Xa IU or below versus high doses). The possibility of a dose-effect relationship of LMWH was also evaluated by meta-regression. Thirteen studies were included (1925 patients). In four studies, LMWH treatment was started postoperatively. Daily LMWH doses ranged from 3000 anti-Xa IU to over 6000 anti-Xa IU. Compared to placebo, LMWH significantly reduced the risk of asymptomatic deep-vein thrombosis (DVT) (RR=0.51, 95% CI=[0.45-0.59], p<0.001) without significantly increasing the risk of major haemorrhage (RR=0.80 [0.36-1.79], p=0.58). We found no convincing evidence that starting prophylaxis preoperatively was associated with a significantly reduced risk of asymptomatic DVT relative to starting postoperatively. Our results showed a strong correlation between the risk of DVT and LMWH dose (meta-regression, test of slope p=0.03).These findings are tentative because the comparisons are across trials, but nevertheless suggest that the different LMWH regimens currently recommended are effective and safe.

Atypical femur fractures: a survey of current practices in orthopedic surgery

The results of a self-administered online survey demonstrate that orthopedic surgeons' management practices for AFF are variable. These data will inform the development of clinical practice guidelines.

INTRODUCTION

We aimed to determine current AFF treatment practices of orthopedic surgeons to inform clinical practice guideline development.

METHODS

A self-administered online survey was developed and sequentially posted on the Orthopaedic Trauma Association (OTA) website from July to August 2015 and the Canadian Orthopaedic Association (COA) website from December 2015 to January 2016. Level of confidence in diagnosis and treatment as well as treatment preferences between respondents who self-identified as trauma surgeons vs. non-trauma surgeons were compared.

RESULTS

A total of 172 completed surveys were obtained (OTA, N = 100, 58%; COA, N = 72, 8%). Seventy-eight percent of respondents had treated ≥1 AFF in the previous 6 months. Seventy-six percent reported feeling extremely or very confident in diagnosing AFF (trauma 84% vs. non-trauma surgeons 70%, p = 0.04), and 63% reported feeling extremely or very confident in treating AFF (trauma 82%, non-trauma surgeons 50%, p < 0.01). Preferred management for complete and symptomatic incomplete AFFs was surgical fixation with a cephalomedullary nail (CMN) by 88 and 79%, respectively, while close follow-up was preferred for asymptomatic incomplete AFFs in 72% of respondents. Trauma surgeons used the CMN more frequently than non-trauma surgeons (90 vs. 76% p = 0.03). In patients with bilateral AFFs, with one side surgically treated, 56% were extremely likely to surgically treat the contralateral side, if symptomatic. Most felt guidelines (81%) and educational resources (73%) would be valuable.

CONCLUSIONS

Current orthopedic treatment practices for AFFs are variable. The results of this survey will inform the development of practice guidelines and educational resources.