Orthopaedic Surgeons Research Articles

Trends of trauma team physicians toward patients with bleeding in Saudi Arabia: a cross-sectional study

ABSTRACT Objectives Trauma poses a significant health burden in Saudi Arabia, with high rates of morbidity and mortality rates. We evaluated the trends among trauma team (TT) physicians in Saudi Arabia regarding their awareness and referral practices for percutaneous endovascular arterial embolization (EAE) in bleeding patients. Methods A 13-question survey developed by consultants from various specialties assessed the knowledge of TT physicians regarding decision-making and appropriate approaches for managing traumatic bleeding. The surveys were administered in person to 135 TT physicians. Results Among them, 38.52% had five or more years of independent practice, and 87.41% routinely encountered patients with bleeding patients. Physicians who routinely treated patients with bleeding patients exhibited higher median scores, in line with current management standards (p = 0.634). Tertiary care physicians and academic- and military-affiliated physicians exhibited higher median scores (p = <0.001 and p < 0.006, respectively). Amongst TT physicians, 47.41% preferred EAE for unstable pelvic ring fractures with active bleeding, while 68.15% favored splenectomy for unstable patients with grade V splenic injuries. For traumatic aortic injuries, 67.42% considered TEVAR/EVAR safer options. Notably, 84.44% viewed an INR > 3 as a contraindication for EAE in hemodynamically stable patients. General surgeons scored the highest in management decision-making, followed by neurosurgeons (p = 0.001). Orthopedics, emergency medicine, intensive care (ICU), and anesthesia specialists exhibited similarly high median scores for appropriate management approaches (p = 0.003). Overall, general surgeons, orthopedic surgeons, and ICU specialists exhibited the highest median correct responses, adhering to the current standard of practice (p = 0.001). Conclusions To address the potentially life-threatening condition of traumatic bleeding, raising awareness of the appropriate management and referral patterns for EAE is crucial.

Hip fixation nail (HFN): Amulticentric prospective analysis of 189 cases of trochanteric and proximal femur fractures with a follow up of one year and more

: Encouraging results of final outcome with radiological and clinical function were observed in initial successful pilot study of Hip fixation nail in 43 cases studied in January 2020 to May 2022. This study was done individually by the author Dr Shashikant B Ganjale, who innovated this HFN. Now a Multicentric study was done by group of orthopaedic colleagues residing in different geographical areas. The cases were operated and followed up by studying the radiological, clinical results and functional outcomes were assessed individually and reported. The results were analysed by taking average of all findings of multicentric study and a final clinical results were observed and documented.: To have a multicentric study and assess the radiological and clinical functional outcomes of trochanteric and proximal femur fractures using Hip Fixation Nail operated at different geographical areas by different orthopaedic surgeons and have an unbiased prospective analysis and its mean results using Kyle’s criteria.: A small group of orthopaedic surgeons residing in different places studied individually by treating all intertrochanteric and peritrochanteric fractures along with few subtrochanteric fractures using HFN and long HFN .Trochanteric Buttress plate was also used along with HFN or Long HFN in Lateral wall fractures of proximal femur as per case.: The individual reports of final radiological, clinical and functional outcomes were documented and were grouped in common pool for analysis. An average of all results were documented and were found to be excellent and very much satisfactory using Kyle’s criteria.: The results of Hip Fixation Nail in treating stable and unstable trochanteric pertrochanteric and long HFN in subtrochanteric fractures of femur are promising and excellent.

Validation of CLASS MRI for personalized ACL footprints identification

AbstractPurposeIn modern anterior cruciate ligament (ACL) surgery, the focus is usually on anatomical reconstruction to restore the natural kinematics of the knee. The individual optimal positioning of the ACL footprints (FPs) in primary surgery is still controversial and, especially in revision surgery, difficult to realize surgically. In this regard, a new MRI‐based sequence, the Compressed Lateral and anteroposterior Anatomic Systematic Sequence (CLASS) with marked femoral and tibial FPs as a template, could help. The purpose of this study was to (1) validate the reliability and reproducibility of the localization of femoral and tibial FPs of ACL in the generation of CLASS and (2) compare the identification of ACL FPs by CLASS with previously described methods.MethodsMagnetic resonance imaging (MRI) of uninjured knees from a predominantly young cohort is used to apply the CLASS algorithm. ACL FPs were subsequently identified by a board‐certified radiologist and an orthopaedic knee surgeon. Intraobserver reliability and interobserver reproducibility were assessed. Measurements of the ACL FPs according to established methods were performed and compared with the results from the literature.ResultsIdentification of ACL FPs and generation of CLASS images resulted in ‘almost perfect’ reliability and reproducibility. Most measurements also showed ‘almost perfect’ consistency. Statistical analysis showed significant variations between the deep‐shallow and high‐low positions when compared to the published literature.ConclusionsThe CLASS MRI sequence is a reliable and reproducible method for identifying ACL FPs. The observed variability in the location of the ACL FP underlines the importance of a patient‐specific surgical approach.Level of EvidenceLevel II.

Optimizing Surgery for Idiopathic Scoliosis: Does a Dual Approach Help Young Surgeons?

Introduction Inidiopathic scoliosissurgery, studies have shown two attending surgeons have better curve correction, pain, and recovery time. There is conflicting evidence on operative time, blood loss, infection rate, and hospital length of stay. Limited literature examines the impact of surgeon experience on the dual approach. The purpose of this study was to evaluate the performance of two young orthopedic attendings compared to a senior-level attending in idiopathic scoliosis surgery. Methods We examined adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion by a single or dual-attending approach. We performed a 1:1 propensity score match with the variables of age at surgery, sex, body mass index, Cobb angle, and number of levels fused. Peri- and postoperative outcomes were analyzed. Results There were 24 patients in each cohort. Patients having surgery by dual attendings had a shorter mean operative time overall (232 vs. 327 minutes, p<0.001) and per levels fused (19 vs. 26 minutes per level, p<0.001). Dual attendings had better percent curve correction (70% vs. 56%, p=0.001) and smaller overall final postoperative curve magnitude (17° vs. 25°, p<0.001). Estimated blood loss (421 vs. 989 mL, p=0.023) and cell saver volume transfused (59 vs. 178 mL, p<0.001) were lower in dual attending cases. Dual attending patients had a shorter length of stay (3 vs. 4 days, p<0.001). There were no differences in Hemovac blood loss, transfusion requirements, need for intensive care, or complications. Over time, the young dual attendings improved in hospital length of stay (R: -0.617, p=0.001) and hemovac blood loss (R: -0.474, p=0.019). Conclusion A dual attending approach in idiopathic scoliosis surgery may result in shorter operative time, greater curve correction, reduced operative blood loss, and shortened hospital length of stay. No differences were identified in postoperative blood loss or transfusion requirement, need for intensive care, or overall complication rate. Within the limitations of this study, we conclude that dual attending surgery in idiopathic scoliosis is safe and effective when conducted by two young orthopedic surgeons, with results that are similar to that of a more experienced senior surgeon.

CHALLENGES AND OPPORTUNITIES IN ORTHOPEDICS: DO EXPERIENCES OF MALE AND FEMALE SURGEONS DIFFER VASTLY?

Objective: Although women comprise nearly half of medical school graduates globally, female orthopedic surgeons in many countries including Turkey represent less than 10% of all orthopedists. However, the number of female orthopedic residents is increasing in Turkey. This cross-sectional study aims to assess and compare the experiences of female orthopedic surgeons in Turkey with their male counterparts, focusing on workplace challenges and surgical inclinations. Methods:A survey was conducted among 110 age-matched orthopedic surgeons (54 women, 56 men). Of the 81 female orthopedic surgeons in Turkey, 54 participated in the study. The doctors’ demographics, career satisfaction, experiences of mobbing, surgical interests, and dynamics with colleagues were examined. Results:The study included residents and specialists with a mean age of 35.08±8.94 years. The largest pre-residency prejudice for women was mobbing, while for men, it was long working hours(p=0.001). Most significant challenge for both genders halfway through residency was long working hours(p=0.453). Women reported higher career satisfaction(67.4%) compared to men(58.9%). No significant difference was found between genders in the incidence of experiencing mobbing at least once in their professional lives(p=0.714). Conclusion:Mobbing is a significant issue, particularly for women in surgery, though long working hours affect both genders the most. Women however were subjected to more prejudice by coworkers, pointing out the importance of gender equity in the workplace.

Possibilities of transposition of the extensores carpi tendons in the treatment of the rheumatoid hand

With the advent of more effective conservative methods of treating rheumatoid arthritis (RA), patients with severe hand deformities are being treated less and less by orthopaedic surgeons. However, when significant changes occur in the hand joints, surgery is the only method to restore their function. The previously widespread arthrodesis procedures are gradually giving way to modern soft tissue joint-preserving surgeries that prevent the development of severe deformities and preserve hand function.Objective: to compare the functional outcomes of extensor carpi ulnaris and extensor carpi radialis longus transposition surgery (ECU+ECRL) and wrist joint arthrodesis in patients with RA.Material and methods. The study included 58 patients with a confirmed diagnosis of RA. Most patients (93%) were women with a disease duration of 4 to 6 years, the mean age was 46.3±14.6 years. All patients were seropositive for rheumatoid factors, most had radiological stages III and IV of RA according to Steinbrocker, radiological stage IV according to Larsen. Most of the patients had moderate disease activity. From 2021 to 2023, 21 patients underwent ECU + ECRL surgery and 37 patients underwent arthrodesis of the wrist joint. The groups were comparable in terms of key clinical characteristics. The average follow-up time after surgery was 6 months.Results and discussion. The mean DASH score in the transposition group (ECU + ECRL) was 38.3±10.12, while in the arthrodesis group it was 47.45±16.92 (p &lt;0.05). In the late postoperative period (after 6 months), all patients showed a positive dynamics according to the visual analogue scale, which was comparable in both groups: in the ECU + ECRL group – 2.66±1.49 cm, in the arthrodesis group – 3.0±1.6 cm. The range of motion of the wrist was significantly greater in the ECU + ECRL group than in the arthrodesis group (p &lt;0.05). At the follow-up examination in the postoperative period, a significant improvement in quality of life according to the EQ-5D was found in both the ECU+ECRL group (0.686) and the arthrodesis group (0.625), p&lt;0.05.Conclusion. X-shaped extensor tendon plastic surgery for wrist joint stabilization should be considered a promising technique that can reduce pain and improve patients' functional status and quality of life.

No need for hip precautions after total hip arthroplasty with posterior approach: A systematic review and meta-analysis.

Nowadays, total hip arthroplasty (THA) is one of the most successful procedures in the field of orthopedics and trauma. The posterior approach has historically been associated with a higher rate of hip dislocation. To reduce the rate of hip dislocation in the posterior approach, most orthopedic surgeons would recommend hip precautions (HP) for their patients postoperatively based on previous theories. However, recent randomized controlled trials have shown no significant difference in hip dislocation rates with or without HP, in contrast to previous theories. Based on these, this study conducted a meta-analysis of these randomized controlled trials to try to get qualitative conclusions. Randomized controlled trials of HP after THA up to July 28, 2023, were searched in 3 databases, PubMed, Embase, and the Cochrane Library. Data extraction and literature quality assessment were performed by 2 independent authors and extracted hip dislocation, hip disability and Osteoarthritis Outcome Score, joint replacement (HOOS JR) scores over 6 weeks, and time to discontinuation of mobility aids. Stata software and Revman software were used to perform this meta-analysis. Following screening, 3 papers with a total of 1215 participants were included in the analysis. This meta-analysis showed that there was no statistically significant difference in hip dislocation rates with or without HP after THA undergoing the posterior approach and that the without HP group instead showed better outcomes in terms of HOOS JR scores and time to discontinuation of mobility aids. THA with a posterior approach does not require hip precautions.

Relative Citation Ratio Among Pediatric Orthopaedic Surgeons: Examining the Factors Associated With Higher Scores.

Academic scholarship is often valued by clinicians, peers, and intuitions. Quantifying the effect of research publications is challenging. Various metrics have been used to assess this. This study aimed to examine the relatively new research metric, relative citation ratio (RCR), introduced by the National Institutes of Health, for pediatric orthopaedic surgeons to establish the benchmarking of research effect within the field and understand the distribution and basis for the use of this metric among pediatric orthopaedic surgeons. The RCR indices were assessed for members of the Pediatric Orthopaedic Society of North America using the iCite online web service. The mean RCR (mRCR, the yearly average RCR) and weighted RCR (wRCR, the cumulative RCR score) were assessed for each member. This information was used to perform univariate and two multivariate ordinary least squares regressions for the two metrics. Independent variables were physician sex, years since receiving national provider identifier, MD versus DO degree, whether the physician had a PhD, and geographic region of practice (Northeast, Southeast, Midwest, West, and Southwest). A total of 770 pediatric orthopaedic physicians were identified. The median [interquartile range] wRCR was 15.6 [4.9 to 54.2], and median mRCR was 1.4 [1.0 to 1.9]. Multivariable squares regression for wRCR showed an independently increased wRCR associated with male sex (39.11), PhD (23.32), years since receiving national provider identifier (4.51), and northeast region (48.44). However, these trends were not notable for mRCR where only southeast region was notable. Although each has its caveats, both mRCR and wRCR have a place in evaluating an author's publication history and other research metrics. Furthermore, it is important to know the overall research metrics within a field to allow for inter- and intraspecialty comparisons. Understanding RCR is helpful because it allows for new comparisons within and across fields and career lengths.

Two-Year Clinical Outcomes of Patients Undergoing Synthetic Cartilage Arthroplasty for First Metatarsophalangeal Osteoarthritis.

Background Severe osteoarthritis (OA) of the first metatarsophalangeal joint (MTPJ) is usually treated by arthrodesis, which results in a loss of mobility in the joint.Cartiva (Stryker Corporation, Kalamazoo, USA) is a synthetic cartilage implant (SCI) designed to repair osteochondral defects in thetreatment of the first MTP OA. Treatment using the Cartiva SCI should relieve symptoms of OA whilst sparing motion in the first MTPJ and may provide a superior alternative to arthrodesis. Objectives The objective of this article is to assess the clinical outcomes of a novel SCI, Cartiva, for arthroplasty in the management of the first MTPJarthritis. Study design and methods We retrospectively reviewed 64 patients who had received a total of67 Cartiva implants between May 2016 and June 2020. The average age of these patients at the time of surgery was 54.3 years with a range from 19 to 77 years. Forty-fiveof the 67 implants were used in females and 22 were used in males. Radiological Grade 2 OA was present in 46 cases with Grade 3 in 21 (Hattrup and Johnson classification). Validated patient-reported outcomes measures (PROMs) were used to assess the functional efficacy of the implants. All cases were performed by a single surgeon. The PROMs data was collected via follow-up phone calls with the patients who were asked questions fromthe American Academy of Orthopaedic Surgeons' Foot and Ankle Measure (AAOS-FAM), the EQ-5D-3L survey and the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ). All data collected was anonymised to preserve confidentiality and local hospital ethics committee approval was sought. All statistical analysis was done using Microsoft Excel (Microsoft® Corp., Redmond, WA) and StatisticalPackage for the Social Sciences (IBMSPSSStatisticsforWindows,IBMCorp., Version 23.0, Armonk,NY). Results There was a significant improvement in all PROMs at three years, and one patient developed an implant-related infection. The average scores for the EQ-5D-3L survey significantly improved from 0.69 to 0.85 post-operative (post-op) (p<0.05). The mean MOXFQ scores improved from 42.5 to 15.4 post-op (p<0.05). The radiologic evaluation demonstrated satisfactory implant positioning in all cases at the last follow-up. Conclusions The data shows significant improvements between pre-op and post-op scores. The implication of this is that synthetic cartilage arthroplasty provides a viable alternative to arthrodesis in the treatment of OA affecting the first MTPJ. However, more studies may need to be done focusing on larger sample sizes and patients should be observed over a longer term, including a formal multi-centred clinical trial.

Advancements in sacroiliac joint reduction for enhancing lumbosacral pain relief and achieving balanced gait: A literature review.

This article provides a comprehensive review of recent research advancements in sacroiliac joint reduction therapy for addressing lumbosacral pain and gait balance issues, delving into its application efficacy, future outlook, and existing challenges. Current literatures were searched on sacroiliac joint reduction therapy, lumbosacral pain and gait balance disorders using the databases PubMed and Cochrane. There were no restrictions when conducting the literature search with regard to publication date, study language, or study type. Research indicates notable enhancements in various gait parameters, including stride length, gait speed, and cycle uniformity, among patients undergoing sacroiliac joint reduction therapy. These improvements translate into augmented walking stability and a reduced risk of falls. Despite its clinical efficacy, this therapeutic modality encounters several challenges in practical implementation. One major hurdle is the absence of standardized international diagnostic criteria for sacroiliac joint dysfunction, hindering the widespread adoption and standardization of this treatment approach. Further clinical investigations and longitudinal data are imperative to ascertain the long-term efficacy and potential risks associated with this therapy. Future research avenues should prioritize the development of precise diagnostic tools and standardized treatment protocols to enhance the efficacy and safety of sacroiliac joint reduction therapy. Moreover, interdisciplinary collaboration is paramount, leveraging the expertise of physical therapists, rehabilitation specialists, and spine surgeons to offer comprehensive treatment solutions. Sacroiliac joint reduction therapy emerges as a compelling therapeutic option for individuals grappling with lumbosacral pain and gait instability, showcasing significant clinical potential and promising future prospects.

Orthopedic Surgeons at Greater Risk of Malpractice Claims for Treatment of Primary Malignant Bone and Soft Tissue Tumors Compared With Metastatic Bone Disease.

The aim of this study was to examine cases of malpractice litigation in primary sarcoma and metastatic bone disease inorthopedic oncology, to identify the areas in which orthopedic surgeons may be guilty of negligence, and to make them aware of this. A comprehensive examination was conducted on all closed medical malpractice cases involving bone and soft tissue malignant tumors from 2014 to 2024. Patient demographics, histopathological diagnosis, and malpractice claims made in a variety of specialties were recorded. The inclusion and exclusion criteria of the study resulted in the inclusion of 70 cases of primary bone and soft tissue sarcoma and 36 cases of metastatic bone disease. A total of 47 primary tumors were bone sarcoma and 23 were soft tissue sarcoma. A total of 11 patients with primary sarcoma were accepted for malpractice claims, representing 16% of all cases within this category. Nevertheless, no evidence of malpractice was identified among the patients with metastatic bone disease (p = 0.012). Orthopedists (44 of 85 defendants), pathologists (14 of 85 defendants), and radiologists (7 of 85 defendants) were the most common defendants in primary sarcoma malpractice cases. Surgeons other than orthopedists (21 of 49 defendants), medical oncologists (4 of 49 defendants), and radiation oncologists (4 of 49 defendants) were the most common defendants in metastatic bone disease malpractice cases. Analysis of our cases suggests that malpractice claims are more likely filed against orthopedic surgeons for the treatment of primary malignant bone and soft tissue tumors than for metastatic bone disease.

Surgeon Age, Years in Practice, and Location of Training Are Associated With Patient Satisfaction.

Patient satisfaction is associated with communication-related measures, empathy, and meeting expectations. However, it is not clear what surgeon characteristics are associated with patient satisfaction. As such, the purpose of this study was to investigate the surgeon sociodemographic, training, and practice parameters that may be associated with patient satisfaction. A retrospective study of patient satisfaction scores was conducted from 7,856 patients who rated 62 orthopaedic surgeons in 2021 within a single hospital system. Three questions from the National Research Corporation survey were used to assess patient satisfaction. Bivariate analyses and multiple linear regression analyses were performed. For chi-square analyses, patient satisfaction scores were recoded into either above the mean or below/equal to the mean score. Overall, 57 male (91.9%) and five female orthopaedic surgeons (8.1%) participated. Mean age was 49.3 ± 9.9 years. Median years in practice was 14 years (range, 1 to 38 years). More years in practice was associated with lower patient satisfaction scores for careful listening (P = 0.048), likelihood to recommend the provider (P = 0.021), and total score (P = 0.029). Older surgeon age was associated with lower total scores (P = 0.039). Surgeons with 30 or more years of practice were more likely to be recommended (P = 0.030). Surgeons who trained in the Northeast for fellowship and/or residency were more likely to be recommended. Older surgeon age and training in the Northeast were associated with higher patient satisfaction. Older surgeon age and fellowship and/or residency training in the Northeast were associated with higher patient satisfaction, whereas 30 or more years of practice was associated with lower patient satisfaction. In bivariate analysis, female surgeons and foot and ankle training were associated with higher patient satisfaction, whereas spine surgeons had lower patient satisfaction scores. These findings suggest that patient-centered communication, patient-surgeon concordance, and appropriate help may improve patient satisfaction. Level IV.

Surgical treatment of neonatal brachial plexus palsy: A cohort study using the Pediatric Health Information System (PHIS) database.

This study aims to explore demographic disparities, regional and institutional variations, surgical timing, narcotic use, and management trends in neonatal brachial plexus palsy (NBPP) patients due to limited published literature. We conducted a retrospective cohort study using the Pediatric Health Information System (PHIS) database of NBPP patients who underwent surgery within the first 2years of life. Patients were stratified into two groups based on age at surgery: ≤ 8months and > 8months. A total of 788 patients were identified, with a mean surgical age of 8.1months. Black patients were disproportionately affected (29%), over twice their national birth rate (14%). Narcotic use was more common in younger patients (63% vs. 53%, p = 0.003), as well as in those treated in the West (71%, p = 0.001) and Northeast (73%, p = 0.004), and by plastic (74%, p < 0.0001) or orthopedic surgeons (69%, p = 0.002). Patients prescribed narcotics had longer hospital stays (1.7 vs. 1.2days, p < 0.0001) and higher complication rates (7.9% vs. 3.1%, p = 0.009). Narcotic use decreased significantly over the study period (p = 0.002). Short-term outcomes, including complication and readmission rates, were similar across the three primary surgical specialties (plastic, orthopedic, and neurosurgery). High-volume centers had lower complication rates (1.5% vs. 5.4%, p = 0.002) and ICU admissions (5.8% vs. 18%, p < 0.0001) compared to medium-volume centers. While narcotic use was associated with longer stays and complications, short-term outcomes were consistent across specialties. Standardized care protocols may help improve patient outcomes.

Optimizing management strategies for malunion and nonunion of Hoffa fractures: a detailed case series with a proposed treatment algorithm.

This study aims to refine management strategies for malunion and nonunion of Hoffa fractures, as these rare complications present significant clinical challenges. We conducted a case series involving seven patients with Hoffa fracture complications, including four cases of malunion and three cases of nonunion. Each patient underwent individualized surgical treatment, depending on the nature of their complication. Treatment strategies varied from intra-articular osteotomies for malunions to revision surgery or total knee arthroplasty for nonunions. Postoperative outcomes were monitored, with follow-up ranging from 1 to 15years (mean follow-up time was 6.7years). In all malunion cases, intra-articular osteotomies restored the articular surface, leading to improved function and bone healing. In nonunion cases, two patients with non-reconstructible nonunions underwent total knee arthroplasty, while one patient achieved union with surgical revision. Overall, six out of seven patients showed significant functional improvements post-surgery, although some experienced mild residual pain or deformities. The management of malunion and nonunion in Hoffa fractures remains challenging, but the individualized strategy based on fracture type and patient-specific factors leads to favourable outcomes. The proposed treatment algorithm provides a useful framework for orthopaedic trauma surgeons in addressing these complications, with emphasis on stable fixation, early intervention, and personalized surgical planning.

A novel augmented reality-based simulator for enhancing orthopedic surgical training.

Total Hip Arthroplasty (THA) is a well-established and common orthopedic surgery. Due to the complexity involved in THA, orthopedic surgeons require rigorous training. However, the current gold standard, the tutor-guided and -evaluated apprenticeship model is time-consuming, costly, and poses risks to patients. There is a pressing need for additional training resources to enhance the efficiency and safety of the training process. In this work, we present a novel Augmented Reality (AR)-based simulator designed for THA that helps enable a new self-paced training and learning paradigm without the need for instructors. The simulator reduces the need for instructors by integrating an AR guidance module and an automated performance evaluation module. Three types of AR guidance were developed: Overlay, Virtual Twin, and Sectional Views. A feasibility study was conducted with five resident surgeons and two senior surgeons to compare these guidance methods quantitatively and qualitatively. The automated performance evaluation module was assessed against manual performance evaluation using Bland-Altman analysis with limits of agreement (LoA) and Mann-Whitney U tests. The quantitative feasibility results indicate the efficacy of the developed AR guidance, characterized by mean transitional and rotational deviation errors below 3 mm and 3 degrees. Based on the qualitative results, we provide recommendations for efficient AR guidance designs. The Bland-Altman analysis results (0.22±1.32mm with LoA -2.37 to 2.81 mm for distance deviation, 0.94±2.41 degrees with LoA -3.78 to 5.66 degrees for yaw deviation, -0.34±1.30 degrees with LoA -2.90 to 2.22 degrees for pitch deviation) and p-values of Mann-Whitney U tests (0.64 for distance deviation, 0.12 for yaw deviation, 0.11 for pitch deviation) indicate no statistically significant differences between the automated and manual performance evaluation at a significance level of 0.05. This work shows the potential of AR-based simulators in introducing a novel, data-driven approach to open surgery training in orthopedics, enabling surgeons to individually assess and improve their progress.

Breaking the Mould: Comparing 3D-Printed and Composite Bone Models in Orthopaedic Training.

Background and aim Synthetic composite bone models (reinforced solid foam) have become the standardised material used in practical orthopaedic education. However, with discussions regarding whether composite foam truly replicates human bone, there has been a drive to explore other available models. Three-dimensional (3D) printing has risen in both popularity and availability, providing a new option in the creation of anatomically accurate bone models. We designed a pilot study to assess whether a new formulation of synthetic bone provides the same tactile feedback that is essential for training purposes. Method Orthopaedic trainees of various grades across two London hospital trusts were invited to participate in a distal radius fixation workshop. As part of the workshop, trainees were asked to complete the following three tasks on the two different models: Kirschner-wire driving, pilot hole drillingand screw insertion. Participants were blinded in this trialand not informed which model was made via 3D printing or the conventional composite bone. Following completion, participants provided feedback on tactile feedback for each task on each model. Results Twenty-three orthopaedic trainees participated in the workshop, with overall majority agreement in all clinical skills that the 3D-printed model provided better tactile feedback. Three-dimensional models were rated superior in K-wire driving (mean score 7.39 vs 4.82; p<0.001) and pilot hole drilling (7.87 vs 4.96; p<0.001), with no significant difference in screw insertion. Qualitative feedback from testers noted a more anatomical representation of the 3D-printed bone, in addition to an overall better representation of the corticomedullary junction. Conclusion Overall, 3D printed models provide a new high-fidelity and sustainable option when seeking bone models for modern-day orthopaedic training. At present composite bone remains the standard for workshops. However, with the growing availability of 3D-printing models, and as supported by this study, they crucially provide the medium for future orthopaedic surgeons to learn and gain confidence.

Risk Factors for de Novo Postoperative Urinary Retention in Posterior Lumbar Spine Surgery.

Retrospective cohort study. De novo postoperative urinary retention (POUR) after lumbar posterior decompression surgery for lumbar spinal canal stenosis (LSCS) is a statistically known but uncommon complication for both patients and spine surgeons. The aim of this study is to review clinical data and imaging findings and identify preoperative predictors of de novo POUR. The subjects were 738 surgically treated patients with LSCS, without preoperative bladder dysfunction or perioperative complications. Univariate and multivariate analyses using propensity score matching were performed to identify prognostic factors for POUR lasting for at least 1week after postoperative urinary catheter removal. POUR occurred in 23 patients (3.1%). The median recovery time was 41days and only 12 patients (52.2%) showed improvement within 3months. Patients with POUR were significantly older, and the lumbar Cobb angle, location of compressed dura mater (ventral or dorsal), and type of cauda equina redundancy (curve-type) were identified as independent prognostic factors. POUR had no association with sex, comorbidities, surgical procedures, number of decompressed segments, or degree of dura mater compression. This study suggests that older age and curve-type stenosis with ventral or dorsal compression of the dura mater are risk factors for development of de novo POUR. Such preoperative imaging findings may indicate a higher risk of intraoperative thermal and nerve injuries, and possible uneven cauda equina flow improvement after decompression.

Optimization of high speed bone drilling with automated osteonecrosis avoidance using an ANN-GA hybrid method

ABSTRACT Efficient high-speed bone drilling with an automated osteonecrosis avoidance strategy is a very fascinating task to the orthopaedic surgeons. Several drilling parameters such as drill diameter, speed, and feed rate can affect the performance of drilling in terms of generated temperature and thrust force. This research is conducted using a high-speed mini CNC machine to investigate bone drilling parameters’ impact on the outputs. Here, a piece of swine bone has been used for testing material and an automated cooling system based on proportional controller (P) was developed to prevent osteonecrosis. Further, a hybrid Artificial Neural Network-Genetic Algorithm (ANN-GA) model has been proposed based on the different experimental findings. ANN predicts output variables, and GA determines the optimal input drilling parameters by minimizing the ANN model of temperature and force. The simulation results revealed that drill diameter of 1.838 mm, speed of 17,880 rpm, and feed rate of 9.973 mm/min minimized the output temperature generated on swine bone. Similarly, diameter of 1.5 mm, speed of 16,582 rpm, and 10 mm/min feed rate helped to minimize the generated force during drilling. The proposed model has been validated by conducting new experiments based on these obtained optimal parameters.

Death of the P Value? Bayesian Statistics for Orthopaedic Surgeons.

Statistical interpretation is foundational to evidence-based medicine. Frequentist (P value testing) and Bayesian statistics are two major approaches for hypothesis testing. Studies analyzed with Bayesian methods are increasingly common with a 4-fold increase in the past 10 years. The Bayesian approach can align with clinical decision making by interpreting smaller differences that are not limited by P values and misleading claims of "trends toward significance." Both methods follow a workflow that includes sampling, hypothesis testing, interpretation, and iteration. Frequentist methodology is familiar and common. However, the limitations are the misunderstanding, misuse, and deceptively simple utility of interpreting dichotomous P values. Bayesian approaches are relatively less common and provide an alternative approach to trial design and data interpretation. Marginal differences elucidated by Bayesian methods may be perceived as less decisive than a P value that may reject a null hypothesis. The purposes of this review are to introduce Bayesian principles and Bayes theorem, define how pretest probability and known information may inform diagnostic testing using an example from prosthetic joint infection, contrast Bayesian and frequentist approaches using an example from the VANCO orthopaedic prospective trial, and describe the criteria for critically reviewing Bayesian studies.

Osteoporosis screening using X-ray assessment and osteoporosis self-assessment tool for Asians in hip surgery patients.

As many patients with osteoporosis remain undiagnosed, we aimed to develop a simple method to efficiently screen for osteoporosis using a combination of anteroposterior hip X-ray assessment and the Osteoporosis Self-Assessment Tool for Asians (OSTA), which is calculated as (body weight - age) × 0.2. One hundred Japanese women (age: 73 ± 11 years, body weight: 54.4 ± 11.1 kg) who underwent hip surgery, anteroposterior hip X-ray, and DXA were included. Based on the DXA results of the total proximal femur, 35 cases were diagnosed with osteoporosis. Fifteen orthopaedic surgeons visually inspected the hip X-ray images and scored the suspicion of osteoporosis on a scale of 1-4 (1: very unlikely, 4: very suspicious), which is referred to as "pred-score." In addition, OSTA was calculated as a continuous variable (OSTA score). Osteoporosis was screened using the pred-score and OSTA score, and both scores were analyzed using the receiver operating characteristic curves. The area under the curves (AUCs) of the pred-score and OSTA score were 0.626-0.875 and 0.817 across surgeons, respectively. When both scores were used, the AUC for screening osteoporosis ranged from 0.821 to 0.915 across surgeons. Significant improvement from AUCs calculated with the pred-score or OSTA score was found in 11 surgeons (73.3%). The combination of X-ray assessment and OSTA can be used to screen for osteoporosis and has the potential to be used as a new simple screening tool in daily clinical practice.