If we can't get to theatre, we can't learn to operate : a study of factors influencing core trainee access to the operating theatre in trauma and orthopaedics

This is a qualitative research study using in-depth, semi-structured interviews with CT1–ST3 trainees in trauma & orthopaedics (T&O) to characterise the factors that affect core surgical trainees’ access to the operating theatre for training. There were significant reported difficulties in accessing the operating theatre among core surgical T&O trainees in our study sample. The considerable service provision demands of the administrative and routine daily ward work, much of which offers negligible educational value in this group of trainees, is in direct conflict with the need to gain operative experience to meet the learning objectives of the curriculum. These results merit attention as the consequence of being unable to access the appropriate training environment threatens preparedness for registrar practice at ST3, and may serve to exacerbate the known morale issues, career dissatisfaction and burnout in this group

Ankle fracture internal fixation performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees : a preliminary, multicentre randomized controlled trial

Aims: Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. Methods: We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs. Results:Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym2, 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time. Conclusion: Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required

Health systems strengthening to arrest the global disability burden: Empirical development of prioritised components for a global strategy for improving musculoskeletal health

Introduction Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health. Methods Design: mixed-methods, three-phase design. Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response. Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci. Phase 3: informed by phases 1-2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions. Results Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action. Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model. Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening. Conclusion An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives

The Oxford Knee Score; Problems and Pitfalls

The Oxford Knee Score is a self-completed patient based outcome score. We audited the outcome of total knee arthroplasty at our unit using the Oxford Knee Score. The hypothesis of this study is that the OKS can be easily and accurately completed by unassisted patients. Of 856 patients who had undergone total knee arthroplasty and were given questionnaires, 769 (90%) responded. 624 (81%) of the respondents managed to complete the questionnaire. A number of the 12 items composing the questionnaire posed problems for the patients and a number of items were left blank. Item 4 (concerning walking time) was omitted in 82 (13%) of the 624 completed questionnaires. Calculation of Cronbach's alpha for internal consistency suggests that there are redundancies within the Score. Limitations in some of the items of the scale suggest the need for reconsideration and reformulation of questions and response categories. This study suggests that where detailed assessment of outcome is required, such as for outcome studies or controlled trials, the Oxford Knee Score, in its present form, is not ideal for use as a postal questionnaire

Modelling the effects of the weather on admissions to UK trauma units : a cross-sectional study

Objective To assess the relationship between daily trauma admissions and observed weather variables, using data from the Trauma Audit and Research Network of England and Wales and the UK Meteorological Office. Design A cross-sectional study. Setting Twenty-one accident and emergency departments (ED) located across England. Participants All patients arriving at one of the selected ED, with a subsequent death, inpatient stay of greater than 3 days, interhospital transfer or requiring critical care between 1 January 1996 and 31 December 2006. Main Outcome Measures Daily counts of adult and paediatric trauma admissions. Results Multivariate regression analysis indicated that there were strong seasonal trends in paediatric (χ2 likelihood ratio test p<0.001), and adult (p=0.016) trauma admissions. For adults, each rise of 5°C in the maximum daily temperature and each additional 2 h of sunshine caused increases in trauma admissions of 1.8% and 1.9%. Effects in the paediatric group were considerably larger, with similar increases in temperature and hours of sunshine causing increases in trauma admissions of 10% and 6%. Each drop of 5°C in the minimum daily temperature, eg, due to a severe night time frost, caused adult trauma admissions to increase by 3.2%. Also the presence of snow increased adult trauma admissions by 7.9%. Conclusion This is the largest study of its kind to investigate and quantify the relationship between trauma admissions and the weather. The results show clear associations that have direct application for planning and resource management in UK ED

Patient-reported outcomes after total hip and knee arthroplasty: Comparison of midterm results

The aim of this study was to compare the mid-term functional outcomes of total knee replacement (TKR) and total hip replacement (THR). A cross-sectional postal audit survey of all consecutive patients who had a primary joint replacement at one orthopaedic centre 5-8 years ago was conducted. Participants completed an Oxford hip score or Oxford knee score, which are self-report measures of functional ability. Completed questionnaires were returned from 1112 THR patients and 613 TKR patients, giving a response rate of 72%. The median Oxford knee score of 26 was significantly worse than the median Oxford hip score of 19 (p<0.001). In conclusion, TKR patients experience a significantly poorer functional outcome than THR patients 5-8 years post-operatively

Early Death Following Primary Total Hip Arthroplasty: 1,727 Procedures With Mechanical Thrombo-Prophylaxis

The aims of this study were to quantify the risk and identify the causes of early postoperative mortality after total hip arthroplasty. This would help clinicians address preventable causes of death and help in accurate counseling and consenting of patients. METHODS: We determined the death rate at 90 days in an unselected consecutive series of 1,727 primary total hip arthroplasties where patients had not routinely received chemothromboprophylaxis. RESULTS: The mortality at 90 days was 17/1,727 (1%). The 90-day mortality was 0.2% in patients under 70 years of age, 1.3% in patients between 70 and 80, and 2.5% in those over 80. 7 patients died from ischemic heart disease, 4 died following cerebrovascular events, and 2 from pulmonary embolism. 4 patients died from non-vascular causes. Of the vascular deaths, ischemic heart disease outnumbered cerebrovascular events which, in turn, outnumbered pulmonary embolism (7 vs. 4 vs. 2). INTERPRETATION: Strategies aimed at reducing deaths should address all vascular causes, not just pulmonary embolism. Our findings can be used to inform patients as to the risk of early death after total hip arthroplast

Assessing technical skill in ankle fracture surgery from the postoperative radiograph

Aims To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment. Methods An e-Delphi exercise was undertaken at a major trauma centre (n = 39) to identify relevant parameters. Feasibility was tested by two authors. Reliability and validity was tested using postoperative radiographs of ankle fracture operations performed by trainees enrolled in an educational trial (IRCTN 20431944). To determine construct validity, trainees were divided into novice (performed < ten cases at baseline) and intermediate groups (performed ≥ ten cases at baseline). To assess concurrent validity, the procedure-based assessment (PBA) was considered the gold standard. The inter-rater and intrarater reliability was tested using a randomly selected subset of 25 cases. Results Overall, 235 ankle ORIFs were performed by 24 postgraduate year three to five trainees during ten months at nine NHS hospitals in England, UK. Overall, 42 PBAs were completed. The e-Delphi panel identified five ‘final product analysis’ parameters and defined acceptability thresholds: medial clear space (MCS); medial malleolar displacement (MMD); lateral malleolar displacement (LMD); tibiofibular clear space (TFCS) (all in mm); and talocrural angle (TCA) in degrees. Face validity, content validity, and feasibility were excellent. PBA global rating scale scores in this population showed excellent construct validity as continuous (p 0.8), and inter-rater reliability was substantial for LMD, MMD, TCA, and moderate (ICC 0.61 to 0.80) for MCS and TFCS. Assessment was time efficient compared to PBA. Conclusion Assessment of technical skill in ankle fracture surgery using the first postoperative radiograph satisfies the tested Van der Vleuten’s utility criteria for effective assessment. 'Final product analysis' assessment may be useful to assess skill transfer in the simulation-based research setting