Orthopedic Doctors Research Articles

2329 A quality improvement project to improve bone health plan in trauma and orthopaedic discharge summaries

Abstract Introduction In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group (NOGG) intravenous zoledronate is the first line treatment option following a hip fracture. Aims We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner (GP), Fracture liaison service and patient. Results We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient’s admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September, 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%. Conclusion Despite the intervention, the bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture. Next step Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle. References National Osteoporosis Guideline Group.UK (NOGG),2021.

MedCapsNet: A modified Densenet201 model integrated with capsule network for heel disease detection and classification

Conditions affecting the heel bone, such as heel spurs and sever's disease, pose significant challenges to patients' daily activities. While orthopedic and traumatology doctors rely on foot X-rays for diagnosis, there is a need for more AI-based detection and classification of these conditions. Therefore, this study addresses this need by proposing MedcapsNet, a novel hybrid capsule model combining modified DenseNet201 with a capsule network, designed to accurately detect and classify heel bone diseases utilizing lateral heel x-ray foot images. We conducted a comprehensive series of experiments on the proposed hybrid architecture with several datasets, including the Heel dataset, Breast BreaKHis v1, HAM10000 skin cancer dataset, and Jun Cheng Brain MRI dataset. The first experiment evaluates the proposed model for heel diseases, while the other experiments evaluate the model on a range of medical datasets to demonstrate its performance over existing studies. On the heel dataset, MedCapsNet achieves an accuracy of 96.38%, AUC of 98.35% without data augmentation, cross-validation accuracy of 95.69%, and AUC of 98.87%. The proposed model, despite employing a fixed architecture and hyperparameters, outperformed other models across four distinct datasets, including MRI, X-ray, and microscopic images with various diseases. This is notable because different types of medical image datasets typically require different architectures and hyperparameters to achieve optimal performance.

Primary Arthrodesis with Retrograde Hindfoot Nail for Elderly Patients with Tibia Pilon Fractures and Psychiatric Illness.

Management of tibial pilon fracture in elderly patients with psychiatric illness remains challenging for orthopedic doctors because of patients' poor bone quality and inability for self-care. This study aimed to ascertain the viability and reliability of primary arthrodesis by using retrograde hindfoot nail for these difficult cases. We retrospectively reviewed eight elderly consecutive patients (age older than 65 years) with tibial pilon fractures and psychiatric illness from January of 2012 to December of 2019 in our institute. Primary tibiotalocalcaneal arthrodesis with retrograde hindfoot nail was used as a definitive procedure. The bone union time, wound complication rate, ankle alignment, necessity for narcotic agents, and ambulation status were evaluated. The average length of follow-up was 22.25 months (range, 15-36 months). Additional bone grafting surgery was performed for one patient because of fusion-site nonunion 6 months postoperatively. Another patient required debridement and removal of posterior calcaneal screw because of implant prominence and local infection. Osseous union with angular deformity less than 10° was achieved in all patients finally. The average bone union time was 6.6 months (range, 4-12 months). In terms of walking ability, six patients were capable of outdoor ambulation (classes 2 and 3). Two patients required oral pain medication at the final visit. The current study involved only a small number of patients, and two of the eight cases encountered undesired complications (one local infection and one bone nonunion); however, we believe that our method may serve as a valuable alternative for the treatment of tibial pilon fractures in elderly patients with psychiatric illness, considering the specificity of this fragile population.

More dietary advice may be needed to support healthy body composition for children with cerebral palsy in Aotearoa New Zealand

The available literature on the nutritional status of children with cerebral palsy (CP) worldwide has identified high rates of malnutrition, specifically undernutrition(1). However, there is a current lack of clear CP-specific dietary guidelines for children with CP across all functional levels. Standard reference tools such as estimated energy requirement (EER) and recommended dietary intake (RDI) may overestimate requirements in children with CP, especially those with reduced mobility and activity levels. Furthermore, for children with severe CP, body composition data indicates higher risks of obesity and obesity-related conditions(2). There can be a wide range of functional abilities, classifiable with tools such as the Gross Motor Function Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The majority of nutrition-related CP literature focuses on children requiring assistance for feeding (EDACS IV-V) with little information available for children with higher levels of functional independence. The aim of this study was to determine whether children with CP had received any prior dietary guidance for healthy body composition and to summarise the type of advice received. Children aged 5-12 years and their whānau were invited to participate in a study where a purpose-developed questionnaire captured their history of receiving tailored dietary recommendations for CP. Body composition was assessed via whole-body dual-energy X-ray absorptiometry scan. Nine participants (6 males, median age: 10y, n = 2 Māori), across GMFCS levels I-IV and EDACS levels I-III took part in the study. Out of 9 children, 5 (55%) indicated that their child had never received dietary advice, 3 of whom were classified as obese or overweight based on growth chart percentiles using their measures of body fat percentage, 1 was classified as underweight and 1 was within the healthy ranges. Of the 4 who had previously received advice, its nature was reported as in support of weight gain (n = 3), and weight loss (n = 1). All 4 received dietary advice from a dietitian and 1 reported some additional advice from a pediatrician and/or orthopedic doctor. Two of the children who had received dietary advice fell within a healthy body fat percentage based on the growth chart percentiles at the time of the study, while the other two were classified as overweight or obese. The results indicate the importance of developing clear dietary guidance for children with CP which may differ from that for typically developing children, particularly depending upon CP subtype diagnosis and functional level, in order to support healthy body composition.

RECITAL: a non-inferiority randomised control trial evaluating a virtual fracture clinic compared with in-person care for people with simple fractures (study protocol)

IntroductionMost simple undisplaced fractures can be managed without surgery by immobilising the limb with a splint, prescribing medication for pain, and providing advice and early rehabilitation. Recent systematic reviews based...

Doctors Versus YOLO: Comparison Between YOLO Algorithm, Orthopedic and Traumatology Resident Doctors and General Practitioners on Detection of Proximal Femoral Fractures on X-ray Images with Multi Methods

In the 1950s, the concept of artificial intelligence emerged, suggesting that machines could possess the ability to think and learn. In the 21st century, with advancements in GPUs and CPUs, deep learning has become an integral part of human life. Proximal femoral fractures are known to be one of the leading causes of mortality and injuries among the elderly population. This study aims to detect proximal femoral fractures in X-ray images and compare the success of using the YOLOv4 algorithm and provide decision support system within the diagnosis. To retrain the algorithm, more than 500 patients’ X-ray images were examined. Through data augmentation techniques, the initial set of 410 patients’ femur proximal fracture X-ray images was expanded to 820 images. After retraining the YOLO algorithm, two different groups were included for comparing the algorithm’s performance: orthopedic specialists and general practitioners. The results from these three groups were evaluated using specific criteria. The YOLOv4 model demonstrated an accuracy of 90.33%. In comparison, orthopedic and traumatology resident doctors achieved an accuracy of 91.42%, while the general practitioner group achieved an accuracy of 81.30%.

Treatment preferences and current practices regarding open tibial shaft fractures.

The purpose of this study was to reveal the treatment preferences and current practices regarding open tibial shaft fracture (OTSF). Online surveys of treatment preferences and current practice of OTSF were conducted by orthopedic trauma doctors from various medical institutions in Zhejiang Province. The survey contains three modules. The first module is the basic information of the participants, the second module is the treatment patterns for Gustilo-Anderson type I-II (GA I/II), and the third module is the treatment patterns for Gustilo-Anderson type IIIA (GA IIIA). Furthermore, each treatment pattern was divided into four aspects, including antibiotic prophylaxis, irrigation and debridement, fracture stabilization, and wound management. A total of 132 orthopedic trauma doctors from 41 hospitals in Zhejiang province, participated the online surveys. In GA I-IIIA OTSF, more than three-quarters of participants considered <3 h as the appropriate timing of antibiotic administration after trauma. In fact, only 41.67% of participants administered antibiotics within 3 h after trauma. 90.91 and 86.36% of participants thought debridement within 6 h was reasonable for GA I/II and GA IIIA OTSF, respectively. However, in reality only about half of patients received debridement within 6 h on average. The most common reason for delayed debridement was patients' transport delay. 87.88 and 97.3% of participants preferred secondary internal fixation following external fixation for GA I/II and GA IIIA OTSF, respectively. Additionally, over half of participants preferred use of locking plate for treating GA I-IIIA OTSF. The most common reasons for choosing delayed internal fixation for GA I-IIIA OTSF were infection risk and damage control. 78.79 and 65.91% supported immediate internal fixation after removing the external fixation for GA I-IIIA OTSF, respectively. Regarding wound closure, 86.36 and 63.64% of participants reported primary closure for GA I/II and GA IIIA OTSF, respectively. Over three fourths of participants agreed that preoperative and postoperative multiple wound cultures should be performed to predict infection for GA I-IIIA OTSF. The study first presents the current preference and practice regarding management of GA I-IIIA OTSF in Zhejiang. Majority of surgeons in our study preferred secondary internal fixation following external fixation for GA I-IIIA OTSF and over half of surgeons preferred use of locking plate for treating GA I-IIIA OTSF. This study may provide a reference for trauma orthopedic surgeons in the treatment of GA I-IIIA OTSF.

Suspected Cauda Equina Syndrome: Can the Presence of an Orthopaedic Doctor in the Emergency Department Reduce Waiting Times for MRI Scans and Inpatient Stays?

Introduction Cauda equina syndrome (CES) is a very rare but devastating surgical emergency that can lead to permanent bowel, bladder or sexual dysfunction and lower limb paralysis. Although it is a clinical syndrome, an MRI scan is a critical diagnostic investigation for these patients and should be done as soon as possible. Our hospital is a district general hospital with no spinal services on site. There is a protocol in place for the management of these patients locally with MRI scanning during daytime hours. However, if the patient presents after 8 pm, they are discussed with the tertiary spinal centre, which then advises if the patient requires transfer overnight for urgent scanning.Considering an MRI scan is a critical diagnostic step for these patients,we introduced a role for an orthopaedic doctor in the Emergency Department (ED) to assess all of these patientsbefore collecting data for the second cycle. The aim of this audit was to see the effect of having an orthopaedic doctor in the ED for the assessment of these patients and its impact on waiting times and admission rates. Methods A closed-loop audit cycle was done looking into all referrals to trauma and orthopaedics with acute back pain and suspected CES in a district general hospital with no spinal services on site. The first cycle was between September 30, 2020, and May 31, 2021, and included 93 patients in total. Following this, a role for an orthopaedic doctor in ED was introduced from December 1, 2021, to January 31, 2022, for assessment of these patients. Data was then collected retrospectively for all patients referred during this period (n=36). Data was extracted from all relevant clinical systems including electronic patient record (EPR), Patient Pass (Patient Pass Ltd, Greater Manchester, England), which is the system used to digitally communicate with regional spinal services, and PACS (picture archiving and communication systems). The data was collated on a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, Washinton, United States) and analysed. Results Data were collected for a total of 36 patients in the second cycle following the introduction of an orthopaedic doctor in the ED. The age of patients referred was 30-89 yearswith a mean age of 51; 44.4% were male (n=16) and 55.5% female (n=20). All the patients who were referred received their MRI scan and report within 24 hours of presentation to the ED. In the first cycle of the audit, the mean waiting time for an MRI scan had been 12.5 hours, which was reduced to eight hours following the introduction of an orthopaedic doctor in the ED during daytime hours. This was stratified further according to the time patients presented to the hospital. From 8 am to 4 pm, the mean waiting time for an MRI scan was 9.5 hours pre-intervention and 5.5 hours after. From 4 pm to 12 am, the mean waiting timewas 18 hours before and 13 hours after, and from 12 am to 8 am, the waiting time for scans improved from 8.5 hours to 6.5 hours. The number of patients discharged on the same day greatly improved from 29% (n=27) in the initial study to 58% (n=21). This decreased unnecessary inpatient stays from 71% (n=66) to 42% (n=15). Conclusion This study showed that an orthopaedic doctor in the ED for the acute assessment of patients referred with possible CES is an effective way of improving their management. This decreases waiting times for MRI scans and therefore allows the patient to be managed more efficiently.

COMPARISON OF VISUAL ESTIMATIONS OF DISTAL RADIUS FRACTURE RADIOLOGICAL PARAMETERS BETWEEN DIFFERENT LEVELS OF ORTHOPAEDIC DOCTORS

Distal radius fractures are common in South Africa. Accurate, decisive radiographic parameter interpretation is key in appropriate management. Digital radiographic facilities are rare in the public setting and goniometer usage is known to be low, thus, visual estimates are the primary form of radiographic assessment. Previous research associated orthopaedic experience with accuracy of distal radius fracture parameter estimation but, oftentimes, doctors treating orthopaedic patients are not experienced in orthopaedics.A cross-sectional questionnaire including four distal radius fracture radiographs administered to 149 orthopaedic doctors at three Johannesburg teaching hospitals. Participants grouped into ranks of: consultants (n=36), registrars (n=41), medical officers (n=20) and interns (n=52). Participants visually estimated values of distal radius fracture parameters, stated whether they would accept the position of the fractures and stated their percentage of routine usage of goniometers in real practice.The registrar group was most accurate in visually estimating radial height, whilst the interns were least accurate (p=0.0237). The consultant, registrar and medical officer groups were equally accurate in estimating radial inclination whilst the intern group was the least accurate (p&lt;0.0001). The consultant and registrar group were equally accurate at estimating volar tilt, whilst the medical officer and intern groups were least accurate (p&lt;0.0001). The Gwet's AC agreement was 0.1612 (p=0.047) for acceptance of position of the first radiograph, 0.8768 (p&lt;0.0001) for the second, 0.8884 (p&lt;0.0001) for the third and 0.8064 (p&lt;0.0001) for the fourth. All groups showed no difference in goniometer usage, using them largely 0–25% of practice (p=0.1937).The study found that accuracy in visual estimations of distal radius fracture parameters was linked to orthopaedic experience but not linked to routine practice goniometer usage, which was minimal across all groups. Inter-rater agreement on acceptability of fracture position is potentially dependent on severity of deviation from acceptable parameters.

An Audit on the Pre-operative Fasting Time of Trauma-List Orthopaedic Patients at a District General Hospital in Chichester, United Kingdom.

Pre-operative fasting of patients awaiting non-emergency surgeries has been a common practice to minimise the risk of vomiting and aspiration at the time of induction of anaesthesia. Current standard guidelines recommend that this fasting time be limited to two hours for clear fluids and six hours for solids and semi-solids, as prolonged fasting has been shown to be harmful to the patient. A descriptive cross-sectional study of the fasting times of all adult trauma orthopaedic patients who were operated on under anaesthesia between June 1 and 30,2023. Fifty patients who met the inclusion criteria were included in the study. The minimum and maximum fasting times observed for solids and semi-solids were 9 and 24 hours, respectively. The mean fasting time for solids and semi-solids was 15.8 hours. The minimum and maximum fasting times observed for clear fluids were 2 and 20 hours, respectively. The mean fasting time for clear fluids was 10.5 hours. Elderly patients accounted for a significant portion of the patients, with 64% (n=32) being above the age of 70 years. A significant disparity was noted between the current fasting practices and the recommended standards set out by the Royal College of Nursing, the Association of Anaesthetists of Great Britain and Ireland, the European Society of Anaesthesiology, and the American Society of Anaesthesiologists. The knowledge of pre-operative fasting among the orthopaedic team doctors and the ward nursing staff was found to be inadequate.

Exploring the displacement characteristics of Garden III femoral neck fractures and the reliability, validity, and value of the anteroposterior Garden Index in assessing displacement severity

BackgroundFemoral neck fractures represent a significant public health concern, particularly in the elderly population. A thorough understanding and assessment of these fractures are deemed essential for optimal treatment and management. Displacement characteristics of Garden III femoral neck fractures were explored in this study, and the reliability, validity, and clinical utility of the anteroposterior Garden Index in evaluating displacement severity were investigated.MethodsPatients diagnosed with Garden III femoral neck fractures were included in this study. The anteroposterior Garden Index was computed from X-ray images by three experienced orthopedic doctors. Additionally, the contact area of the fracture endpoint and displacement of the femoral neck were evaluated using 128-slice 3D CT scans. Inter-observer and retest reliability of the Garden Index measurements were assessed, along with its correlation with CT measurements.ResultsIn this study, a total of 110 patients with Garden III femoral neck fractures were analyzed, showcasing an almost equal gender distribution and an age range spanning from 20 to 88 years. An average Garden Index of 135° (± 16°) was observed. The intra-observer repeatability of the Garden Index was found to exceed 90%. A significant positive correlation was identified between the Garden Index and the contact surface area of the fracture endpoint (r = 0.82, P < 0.001), while a significant negative correlation was noted with the upward displacement of the femoral neck (r = − 0.79, P < 0.001).ConclusionsThe anteroposterior Garden Index has been demonstrated to have promising potential as a reliable and valid tool for assessing the displacement severity of Garden III femoral neck fractures. Nonetheless, further research is needed to elucidate its relationship with other fracture characteristics and to enhance its criterion and construct validity.

Chronic shoulder injury related to vaccine administration following coronavirus disease 2019 vaccination: a case report

BackgroundShoulder injury related to vaccine administration, defined as shoulder pain and limited range of motion occurring after administration in the upper arm, has been previously reported. The symptom resolved completely after treatment with oral nonsteroidal anti-inflammatory drugs or an intraarticular steroid injection, however there have been few reports of long-term symptoms following coronavirus disease 2019 vaccination. This case report describes a healthy, middle-aged, healthcare worker who developed post-vaccination subacromial–subdeltoid bursitis that lasted for more than 6 months after Pfizer–BioNTech coronavirus disease 2019 vaccination.Case presentationA 55-year-old Japanese woman with no significant medical history was vaccinated in the standard site, with the needle direction perpendicular to the skin. Within a few hours after the second vaccination, severe shoulder pain and limited range of motion appeared. Although shoulder range of motion improved, her shoulder pain did not improved for several months, and she consulted an orthopedic doctor 5 months later. Radiographs of her left shoulder did not provide helpful diagnostic information. High intensity in the subacromial–subdeltoid space was seen on short TI inversion recovery of magnetic resonance imaging, showing subacromial–subdeltoid bursitis. She was diagnosed with a shoulder injury related to vaccine administration. The patient was started on an oral anti-inflammatory drug, and the left subacromial space was injected with 2.5 mg of betamethasone with 3 ml of 1% lidocaine without epinephrine every 2 weeks. One month after starting this treatment, since her shoulder pain had not improved, the oral anti-inflammatory drug was switched to tramadol hydrochloride acetaminophen. However, 3 months after switching medication, the shoulder pain continued, and she worked so as to have minimal impact on her shoulder.ConclusionA case of subacromial–subdeltoid bursitis following a second dose of the Pfizer–BioNTech coronavirus disease 2019 vaccine that lasted many months is reported. Injection technique is a modifiable risk factor, the adverse effects of which could potentially be mitigated with appropriate and relevant training of healthcare providers. To prevent this type of case, the appropriate landmark, needle length, and direction should be confirmed.

916 Introducing a New Guideline for the Fifth Metatarsal Fracture (5th MTF)

Abstract Background The 5th MTF is a common injury occurring in the long bone joining the ankle to the toes. This injury can be categorised into two main sub-sections, namely green zone fractures (GZF) and red zone fractures (RZF) which are treated differently. Moreover, patients suffering from uncomplicated GZF are to be discharged directly from emergency department (ED), whereas the complex cases require a review from orthopaedic doctors. Due to time-restraint in ED, some fractures might be misdiagnosed/referred directly to fracture clinics unnecessarily. Aim Increase ED-led management and discharge of patients suffering from GZF Method A QI was introduced to implement a new guideline and update the patient information leaflet in the emergency department at ELHT. For each set of baseline data, an intervention was suggested to achieve the goal of this project and ensure a safe discharge of patients from ED. Results During a four-week study period, 20 patients presented to ED with an uncomplicated green zone fracture, 40% of which were discharged directly from ED. This demonstrates an improvement of 12.7% from a baseline of 27.3%. In addition, 80% of these patients were managed with a walker boot, as mentioned in the new guideline. In total, only three fracture clinic appointments were booked, due to complications, as opposed to twenty appointments. This resulted in a saving of £1.835,4. Conclusions The new guideline has led to an improvement of 50% in patient care. The new management plan benefits patients and improves the efficacy of the ED as well as fracture clinics.

295 Education and Training to Improve Compliance to the BOAST Guidelines on Assessing and Documenting Peripheral Nerve Status and Injury

Abstract Introduction Peripheral nerve injuries affect 2-3% of trauma patients, with potentially high morbidity, and associations with litigation. BOAST guidelines were introduced in December 2021 outlining standards in assessing and documenting neurovascular status in trauma patients. Key elements included nerve-specific documentation and assessments pre- and post-interventions such as manipulation. Aim This project assessed departmental performance against the BOAST standards, then presented the results to both orthopaedic and emergency departments, as well as setting up teaching sessions to orthopaedic junior doctors in the assessment of neurovascular status and updating awareness on the guidelines. Method 50 patient records were analysed retrospectively for the first arm, and 50 records prospectively for the second arm. Acute trauma presentations with a risk of peripheral nerve injury met the inclusion criteria. Intervention included practical senior-led teaching on clinically assessing neurovascular status, and the importance of detailed documentation, as well as when to repeat the examination. Results Results were improved drastically from initial audit against standards to post-intervention audit; documentation improved from 70% to 95% (n = 50 for both arms), with appropriate detail in documentation improving from 11% to 49%. Conclusions Neurovascular status is critical to be documented in detail, both pre and post-interventions. By using BOAST guidance as a standard, the initial inadequacies of the departmental practice were highlighted, and significantly improved through active teaching, distribution of the guidelines, raising the standards, clinical assessment, and documentation, thus improving patient care, and robustness of legal documentation.

973 Plastering Skills and Experience Among Junior Orthopaedic Doctors

Abstract Aim The conservative management of fractures with the use of plasters is an essential skill and still forms the bulk of the orthopaedic surgeon’s workload. There is currently concern that junior orthopaedic doctors are receiving limited training in plastering and effectively becoming deskilled. The aim of this study is to provide an insight of the skills and experience of junior orthopaedic doctors in our trust. Method An electronic study was conducted in our trust in December 2022. Results Only 10% of the respondents had a plaster room induction, and only 40% had attended a plastering course. Half of the respondents had no official plastering training. The majority of junior orthopaedic doctors (80%) stated that during their on call most plasters were applied by A&amp;E nurses and doctors. Only one third of junior T&amp;O doctors were very confident applying a simple Colles’ plaster or a below knee backslab, while one third was not competent at all. All respondents agreed that plastering is a useful and essential skill to acquire for doctors working in T&amp;O or considering a career in orthopaedics. Conclusions Application of a correct plaster cast is an essential part of orthopaedic management. It is worrying that junior doctors working in orthopaedics have little to no experience in plaster application and training is limited. All doctors agreed that plastering was a useful skill and should be taught as part of orthopaedic training.

792 Assessing the Frequency of Daily Patient Reviews in a Local Orthopaedic Department

Abstract Aim To investigate the frequency at which patients admitted under a local orthopaedic department are having daily reviews by various teams, and to assess the level of clinical seniority that saw these patients. Method Patients primarily under the care of the orthopaedic department were assessed over a 10-day period in two different time frames across November 2022. These included all male and female inpatients presenting with any condition. Data was collected manually by going through the patient notes and the most senior orthopaedic doctor who saw the patient on that day was recorded as the main reviewer. Results 73 patients with an average age of 76.0 years were included. Overall, patients were seen by orthopaedics on 58.4% of the days they were in hospital. 21.2% of these were done with a consultant present, 10.4% by a registrar, 17.6% by a senior house officer, and a foundation doctor in 9.2% of occasions. Outcomes were worse over the weekends, where 56.8% of inpatients did not get reviewed at all. There were also considerable differences between the various teams, reviewing their patients from 32.9% to 69.1% of the time. Conclusions Patients should ideally be reviewed daily as not only does it affect patient flow but also ensures vulnerable individuals are getting the timely care that they need. This pilot study showed a considerable lack in the number of daily reviews, with some patients not being seen for several days. Therefore, better organisation and accountability of the workforce is required to reach higher standards of care.

The Influence of Risk Factors in the Early Detection of Developmental Dysplasia of the Hip in a Country with Limited Material Resources.

Developmental dysplasia of the hip (DDH) is a condition that includes a wide spectrum of anomalies ranging from simple instability with ligamentous hyperlaxity to the complete displacement of the femoral head outside the abnormally developed cotyloid cavity. Early detection and initiation of treatment allow "restitutio ad integrum" healing, which has raised the medical community's interest in early diagnosis. However, in countries with limited material resources, where echographic screening is not performed, efforts are being made to increase the sensitivity of clinical screening. Thus, the concept of "hip at risk" is taking shape worldwide. This is the normal clinical hip, but associated with one or more risk factors. We conducted a retrospective study for the period 2010-2015 with patients who presented in the ambulatory clinic of the St. John Children's Clinical Hospital, Galati. The study included 560 patients, who were all examined clinically and sonographically, according to the Graf method, by a senior orthopedic doctor with competence in hip sonography. The data obtained from the anamnesis, clinical examination, and ultrasound examination were recorded in the DDH file. The goal of the statistical analysis of the group of patients was to find a correlation between DDH and the risk factors used in the clinical detection of this pathology. In the studied group, four risk factors were identified that have an increased association with DDH: female sex, pelvic presentation, limitation of coxo-femoral abduction, and congenital clubfoot; thus, the conclusion of the study is that patients who have at least one of the listed risk factors should be examined sonographically as quickly as possible. The early ultrasound examination will allow the identification of the disease and the initiation of treatment.

Awareness and Attitude among Physicians Regarding Bisphosphonaterelated Osteonecrosis of the Jaw (BRONJ): A Cross-sectional Study.

An invasive dental procedure is considered one of the risk factors for osteonecrosis of the jaw, especially among patients on bisphosphonates. This study aimed to determine the awareness and perceptions of medical practitioners regarding bisphosphonate-related osteonecrosis of the jaw (BRONJ), and their attitude towards dental referrals of such patients. This cross-sectional questionnaire-based study was conducted among medical practitioners in and around Mysore city, Karnataka, India, who commonly prescribe bisphosphonates. The sample included orthopaedic doctors, physicians, endocrinologists, and oncologists, divided based on the duration of practice and speciality. Data on the type of practice, awareness of BRONJ, referral to a dentist before/during therapy, and patient education about adverse effects, were collected and analyzed. A p-value ≤0.05 was considered statistically significant. Among 58 practitioners, 84.5% (49) were aware of the association between bisphosphonates and BRONJ, while 56.9% (33/58) believed dental procedure to be a risk factor, and 55.2% (32/58) did not recommend screening of the oral cavity by a dentist before initiation of bisphosphonate therapy. A majority (65.5%) of them educated their patients about adverse effects. Mean knowledge scores varied with specialization (post-graduation vs. super specialization = 1.43 vs. 2; p = 0.01) but not with the duration of practice (<= 10 years vs. >10 years= 1.57 vs. 1.4; p= 0.24). The practitioners in our study were oblivious to dental procedures' role in the osteonecrosis of the jaw, highlighting the need for continuing education programs regarding BRONJ for medical and dental professionals. Clinicians updated regarding evidence-based practices and working cooperatively in teams may reduce the incidence of medication-related osteonecrosis of the jaw.

Impact of postmenopausal osteoporosis on the lives of Omani women and the use of cultural and religious practises to relieve pain: A hermeneutic phenomenological study.

Osteoporosis is a significant clinical and public health concern worldwide. Despite the impact of this condition on women's lives, most studies have focused on its clinical manifestations, drug efficacy, and medical treatment. Furthermore, most studies have been conducted in the West. This study aimed to uncover the personal experiences of postmenopausal Omani women living with osteoporosis. In this interpretive phenomenological study, a purposive sample of 15 postmenopausal Omani women with osteoporosis was recruited from primary and secondary care facilities in Muscat, Oman. Semi-structured one-to-one interviews were conducted via Zoom and telephone because of coronavirus disease 2019 restrictions. The interviews were audio-recorded, and the Ajjawi and Higgs framework was used to analyse the data thematically. The following key themes were constructed from the interviews: the impact of osteoporosis on religious practices, cultural and social life, and financial status, and the benefits derived from religious and cultural practices and rituals, including Muslim prayer, recitation of Quranic verses, and herbal remedies to cope with osteoporosis-related pain and suffering. Osteoporosis and fragility fractures have a significant impact on the religious, cultural, and financial lives of postmenopausal Omani women with osteoporosis. Muslim prayers, recitation of Quranic verses, and herbal remedies are coping strategies for pain in this population. Postmenopausal Omani women with osteoporosis participated in this study through interviews and contributed their lived experiences. Orthopaedic doctors helped recruit patients with postmenopausal osteoporosis.

Enhancing Radiation Safety Culture: Investigating the Mediating Role of Awareness Among Orthopedic Doctors and Operation Theatre Assistants.

The increasing use of minimally invasive orthopedic procedures has led to a greater reliance on fluoroscopy, resulting in elevated radiation exposure for surgeons. This study aimed to evaluate the knowledge, awareness, and daily practices of orthopedic surgeons regarding radiation safety in an academic hospital. Understanding radiation safety is crucial to minimize patient exposure and prevent adverse effects on surgeons. This cross-sectional study was conducted at the Department of Orthopedics of different tertiary care hospitals in Rawalpindi, Pakistan. Data were collected prospectively for two years, and a total of 505 participants, including residents, consultants, and operation theatre assistants, completed a questionnaire. The questionnaire was validated by experts and covered information on fluoroscopy usage, frequency of surgeries, awareness of radiation safety, and protective measures. Ethical approval was obtained, and data were analyzed using SPSS version 26.0. The majority of participants were male (74.1%), and the sample included various ranks of orthopedic surgeons. Only 56.2% of participants were aware of the usage of fluoroscopy, and 40.2% had read some research on the topic. While 44.6% used lead aprons for radiation protection, the usage of other protective measures and dosimeters was limited. The mediation analysis showed an insignificant indirect association between the rank of orthopedic surgeons, number of surgeries performed, and fluoroscopy usage as a mediator. Awareness and reading research on fluoroscopy were significantly associated with radiation protection. The knowledge, awareness, and daily practices of orthopedic surgeons regarding radiation safety in fluoroscopy use need improvement. The findings emphasize the importance of implementing training programs, providing radiation protection devices, and ensuring compliance with safety guidelines.