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The Journal of Bone and Joint Surgery. British volumeVol. 87-B, No. 9 AnnotationFree AccessAssessment of performance in orthopaedic trainingD. Pitts, D. I. Rowley, J. L. SherD. PittsSurgical Education Development AdvisorUniversity Department of Orthopaedics & Trauma Surgery, TORT Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.Search for more papers by this author, D. I. RowleyUniversity Department of Orthopaedics & Trauma Surgery, TORT Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.Search for more papers by this author, J. L. SherWansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK.Search for more papers by this authorPublished Online:1 Sep 2005https://doi.org/10.1302/0301-620X.87B9.16434AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail The reliable measurement of performance is a problem faced by training authorities worldwide. At a recent international orthopaedic conference, none of a group of experienced orthopaedic educators could report significant progress on this issue.The current Record of In Training Assessment (RITA) process which relies on simple assessment forms filled in by trainers and trainees is regarded widely as inadequate and lacking in objectivity. More robust evidence is needed.The Orthopaedic Competence Assessment Project (OCAP), a combined initiative of the Education Committee of the British Orthopaedic Association and the Specialist Advisory Committee (SAC) in Trauma & Orthopaedics was given the remit to improve training through a competency-based portfolio of coaching and assessment tools. These instruments had to be easily understood by a range of trainers and trainees, not time-consuming and simple to apply.OCAP recognises the need for a battery of tools to address the different aspects of performance. These have been described by Miller1 who refers to different levels of assessment which are best tested in different ways (Fig. 1). In Miller’s pyramid, ‘knowing’ and ‘knowing how’ are reliably tested in well-defined examination formats and set-piece assessments, such as clinical examinations and orals can monitor ‘shows how’. However, ‘does’ requires real-time assessment and it is to this need that OCAP has responded.Any assessment needs to be valid and reliable. Validity is well served by real clinical situations. Reliability, which is equally important, requires a tool which is practical, consistent and easy to repeat.The instruments described below follow the principles of Miller1 and Norman.2 In this article, we describe the instruments, their validation and how reliability might be ensured.OCAP instruments (Fig. 2)The package consists of two types of instrument: agenda setting/coaching, and assessment.The agenda-setting instruments of the trainer profile have been piloted and found to be acceptable in two large training programmes in the United Kingdom. The assessment instruments are also complete in terms of validity, but reliability studies are ongoing. The personal effectiveness instruments which coach and test generic skills are at an early stage of development.How OCAP works.In advance of an attachment, trainers and trainees exchange information about themselves. A trainee’s portfolio is shared with the trainer who provides a personal profile for the trainee. This profile is easily formatted from a database of ‘knowledge’ and ‘procedures’ and outlines the surgical training available in an attachment. The profile describes the procedures the trainer performs regularly and the knowledge base to underpin this activity. Both parties then meet at the start of the attachment and draw up a learning agreement of which the key objectives are: to identify the trainee’s level of knowledge and experience; to set realistic goals and expectations for the attachment; to agree the knowledge which should be acquired during the attachment and to define those aspects of the trainee’s performance to be assessed at the end of the attachment.The agreement needs regular review by both parties, including a formal review at mid-attachment. However, plans may have to change according to circumstances. For example, a target may become unrealistic due to unforeseen circumstances such as ill health or prove to be overly optimistic. At the end of the attachment, the goals need to be compared with achievement. This comparison provides evidence for the summative RITA.Figure 3 is an extract from a Procedures Profile showing a trainee’s estimate (A) of their position at start of attachment and the goal for the end of the job (G).Figure 4 is an extract from a Knowledge Map which similarly compares a trainee’s estimate of their position at the start and finish of an attachment.Performance-based assessmentsA cornerstone of OCAP is the collection of performance-based assessments. These are formal, structured assessments of clinical activity (including surgical performance). They take a holistic approach, including understanding a problem, communicating, planning, operating and ensuring clear post-operative instructions.Performance-based assessments identify and capture relevant activity, which is performed in sufficient numbers often enough to allow reliable measurement. They allow data capture through observations of a series of similar events. This is akin to the mini clinical examination and history taking skills (CEX) and simple practical procedures such as establishing an intravenous line which are based on work by Norcini et al.3 They found that snapshots of clinical activity can be used reliably provided about 15 similar but unrelated events are assessed by properly trained observers. The Royal College of Physicians expects about 40 CEX’s to be provided over the five years of Higher Medical Training (personal communication).OCAP uses a Delphi method (consensus of an expert group) of validating performance-based assessment. We identified 18 activities which were felt by a nominated group of experts to be representative of trauma and orthopaedic surgery. These include work in the wards and clinics, and commonly performed operations (Table I). Each operation is split into domains, including consent, common to pre-operative planning, preparation and surgical technique. Each domain has further components, the majority being all the performance-based assessments and all can be related to the outcomes defined in ‘Good Clinical Practice’.4 In each domain the trainee is required to demonstrate evidence of knowledge and skills (Table II).In order to validate the performance-based assessment and its domains, meetings of trainers and trainees took place in two regions of the United Kingdom. These were followed up by postal questionnaires. The overwhelming response was that the instruments are relevant, easily usable and supported the impression of the Delphic groups, confirming that the identified performance-based assessments are realistic.More recently we correlated the current performance-based assessment with the frequency of activity reported in the National Trauma and Orthopaedic Log Book.5Table III shows that in general the Delphi method of identifying commonly performed procedures is confirmed. However, there are problems ensuring that the procedures are performed often enough to permit reliable interpretation of data. For example, there was strong consensus that the application of an external fixator contains unique competencies. However, trainees seldom encounter this procedure outside a specialist attachment. As Sher et al6 point out, unless all training opportunities are used it would be difficult adequately to assess competence in many procedures.The strengths of OCAP include a consolidation sheet which not only lists procedures but also maps the domains of competency (Fig. 5). This permits a training director to record experience of core procedures and identify progress in the domains. For example, a trainee may be performing well technically but be consistently identified as a poor communicator. Such observations, especially when made by different observers, provide powerful information for appraisal.The current status of OCAPOCAP instruments have been reviewed and triangulation studies indicate they are valid. Early work shows they are reliable and further inter-observer studies are under way. Trainers and trainees have been provided with a structure based on conventional educational instruments and given a means of mapping back to core competencies. The evolving synergy with the orthopaedic log book gives strong supporting evidence of training activity.We now have a curriculum which meets the standards prescribed by national validating bodies and uses practicable language and taxonomy for trainers and trainees.Table I. List of performance-based assessments1Clinic activity in trauma and orthopaedics2Debridement of a wound3Carpal tunnel decompression4Digital and palmar fasciectomy5Diagnostic arthroscopy and simple arthroscopic procedures6Total knee replacement7First ray surgery to the foot8Total hip replacement9Lumbar discectomy10Compression hip screw for intertrochanteric fracture neck of femur11Hemiarthroplasty intracapsular fracture neck of femur12Application of limb external fixator13Operative fixation of Weber B fracture of ankle14Fixation of patella fractures by tension band wiring15Fixation olecranon fractures by tension band wiring16Intramedullary nailing for femoral or tibial shaft fractures17Tendon repair18Closed management of fracturesTable II. The core content of performance-based assessmentsIConsent C1Demonstrates sound knowledge of (contra) indications C2Demonstrates sound knowledge of complications of surgery C3Demonstrates awareness of specific problems at surgery generated by the disease being treated C4Explains the peri-operative process to the patient and/or relatives and checks understanding C5Explains likely outcome and time to recovery and checks understandingIIPre-operative planning PL1Demonstrates recognition of anatomical and pathological abnormalities and operative strategy to deal with these PL2Ability to make reasoned choice of appropriate device (if any) using appropriate investigations e.g. x-rays PL3Checks equipment and device requirements with operating room staff PL4Where applicable ensures the limb is markedIIIPre-operative preparation PR1Ensures proper and safe positioning of the patient on the operating table PR2Ensures devices e.g. diathermy and tourniquet are deployed safely PR3Arranges for and deploys supporting equipment e.g. imaging intensifiers effectively PR4Adequately prepares a sterile operating fieldIVExposure and closure E1Demonstrates knowledge of optimum skin incision E2Demonstrates respect for soft tissues including skin E3Achieves an adequate exposure and identifies all structures correctly E4Completes a sound reconstruction E5Protects the wound properly with dressings and splintsVIntra-operative technique IT1Follows a logical sequence or protocol for the procedure IT2Adheres to hospital protocols and policies IT3Anticipates and responds appropriately to variation IT4+See individual performance-based assessments for detailVIClosing the loop CL1Ensures the patient is transferred from operating table to bed CL2Construct a clear operation note, retaining the equipment documentation and checking x-rays where appropriate CL3Gives documented and sensible post-operative instructions CL4+See individual performance-based assessments for detailTable III. An example of a logbook correlationASTSSTUPTTotal exposure in years 1 to 6Total actually performed in years 1 to 6* ORIF, open reduction and internal fixation† MUA, manipulation under anaesthesiaA, assisted; STS, surgeon with trainer scrubbed; STU, surgeon with trainer present but unscrubbed; P, surgeon with trainer available but not in the operating room; T, teaching junior surgeonAll elective in Deanery X35331413719071001641All elective in Deanery X39122384247209655541Clinic activity in trauma and orthopaedics2Debridement of a wound3Hand – carpal tunnel decompression46440660504Hand Dupuytren surgery9714021125Knee arthroscopy with procedure242123381107825Knee arthroscopy9101117148385Shoulder and elbow – shoulder arthroscopy with procedure1071101995Shoulder and elbow – shoulder arthroscopy22110646Joint replacement knee51395121108567Foot and ankle – hallux valgus surgery131017132187Foot and ankle – lesser toe surgery5626019147Foot and ankle – midfoot and hindfoot surgery1351302298Joint replacement hip62384121117549Spine – discectomy72000929Spine – decompression620008210Trauma – hip fractures (intracapsular)8137598957911Trauma – hip fractures (extracapsular)3674710736012Trauma – application of external fixator55151171113Trauma – ORIF* ankle5104334564714Trauma – ORIF patella110204315Trauma – ORIF olecranon1215110816Trauma – femoral nails69381272016Trauma – tibial nails36161171317Hand – tendon repair331131211718Trauma – MUA† + Kirschner wiring3485988271Fig. 1 Miller’s pyramid.Fig. 2 Diagram of the Orthopaedic Competence Assessment Project system and tools.Fig. 3 An extract from Procedures Profile showing trainee’s estimate of their position at start (A) and goal (G) for end of attachment (1, know about; 2, seen; 3, managed with help; 4, managed; 5, confident to manage).Fig. 4 An extract from Knowledge Map showing trainee’s estimate (A) of their position at start and agreed goal (G) for end of attachment (1, knows of; 2, knows basic concepts; 3, knows generally; 4, knows specifically and broadly).Fig. 5 An example of the performance-based assessment consolidation sheetThe authors acknowledge the contribution of the members of the OCAP steering group (Tony Banks, Peter Briggs, Nick Clarke, Chris Howell, John Edge, Alan Norrish, Phil Turner, Keith Willett) and numerous trainers and trainees who continue to make invaluable contributions to the project.References1 Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65(9 Suppl):63–7. Crossref, Medline, ISI, Google Scholar2 Norman G. Examining the examination: Canadian versus US certification exam. Can Assoc Radiol J 2000;51:208–9. Medline, ISI, Google Scholar3 Norcini JJ, Blank LL, Duffy FD, Fortna Gregory S. The mini-CEX: a method for assessing clinical skills. Ann Intern Med 2003;138:476–81. Crossref, Medline, ISI, Google Scholar4 Good medical practice. Third ed, May 2001. http://www.gc-uk.org (accessed 16.6.05). Google Scholar5 National Orthopaedic and Trauma Log Book. Faculty of Health Informatics, Royal College of Surgeons of Edinburgh. Google Scholar6 Sher L, Reed M, Calvert P, Wallace A, Lamb A. Influencing the national training agent: the UK & Ireland orthopaedic eLogbook. J Bone Joint Surg [Br] 2005;87-B: 1182–6. Link, Google ScholarFiguresReferencesRelatedDetailsCited byAvaliação do desempenho dos residentes em ortopedia na prática clínica20 April 2022 | Revista Brasileira de Ortopedia, Vol. 57, No. 06Surgical portfolios: A systematic scoping reviewSurgery in Practice and Science, Vol. 10Assessing Operative Skill in the Competency-based Education Era8 October 2021 | Annals of Surgery, Vol. 275, No. 4Proficiency and Competency Assessment in Surgical Training6 May 2022The usefulness of work-based assessments in higher surgical training: A systematic reviewInternational Journal of Surgery, Vol. 94Challenges faced by orthopaedic trainees during the Covid-19 pandemic – An Irish perspectiveThe Surgeon, Vol. 19, No. 5Procedure-based assessments: the past, the present and the future26 July 2019 | Postgraduate Medical Journal, Vol. 96, No. 1131Analysis of Tools Used in Assessing Technical Skills and Operative Competence in Trauma and Orthopaedic Surgical Training1 June 2020 | JBJS Reviews, Vol. 8, No. 6Video-Based Assessment in Surgical Education: A Scoping ReviewJournal of Surgical Education, Vol. 76, No. 6Development and Evaluation of a New Formative Assessment of Surgical PerformanceJournal of Surgical Education, Vol. 75, No. 5Orthopaedic Education in Other Countries26 July 2017Orthopaedic Resident Assessment: Measuring Skills in Both Knowledge and Technical Skills26 July 2017Desarrollo de plan de entrenamiento con simulación de artroscopía para residentes de ortopediaActa Ortopédica Mexicana, Vol. 32, No. 5Existing and Future Educational Needs in Graduate and Postgraduate EducationThe Journal of Sexual Medicine, Vol. 14, No. 4Resident education in orthopaedic trauma the future role of competency-based medical educationM. T. Nousiainen, S. A. McQueen, J. Hall, W. Kraemer, P. Ferguson, J. L. Marsh, R. R. Reznick, M. R. Reed, R. Sonnadara1 October 2016 | The Bone & Joint Journal, Vol. 98-B, No. 10Operative Experience vs. Competence: A Curriculum Concordance and Learning Curve AnalysisJournal of Surgical Education, Vol. 73, No. 4Learning Curves in Arthroplasty in Orthopedic TraineesJournal of Surgical Education, Vol. 73, No. 4A Comprehensive, High-Quality Orthopedic Intern Surgical Skills ProgramJournal of Surgical Education, Vol. 73, No. 4Examining the barriers to meaningful assessment and feedback in medical trainingThe American Journal of Surgery, Vol. 211, No. 2Assessing Arthroscopic Skills Using Wireless Elbow-Worn Motion SensorsJournal of Bone and Joint Surgery, Vol. 97, No. 13Procedure-based assessments in trauma and orthopaedic training – The trainees’ perspective4 September 2014 | Medical Teacher, Vol. 37, No. 5The validity and reliability of workplacebased assessments in surgical trainingThe Bulletin of the Royal College of Surgeons of England, Vol. 97, No. 3Advances in arthroscopy—indications and therapeutic applications28 October 2014 | Nature Reviews Rheumatology, Vol. 11, No. 2Accuracy and awareness of lag screw placement when using the dynamic hip screw for fracture fixation1 September 2014 | Trauma, Vol. 17, No. 1Opinions of UK Orthopaedic Trainees Regarding Training, Assessment and the Trainee FeeThe Bulletin of the Royal College of Surgeons of England, Vol. 96, No. 10Orthopaedic Education in the United KingdomClinical Orthopaedics & Related Research, Vol. 472, No. 6Role of Simulation in Arthroscopy TrainingSimulation in Healthcare: The Journal of the Society for Simulation in Healthcare, Vol. 9, No. 2A Novel Approach to Assessing Technical Competence of Colorectal Surgery ResidentsAnnals of Surgery, Vol. 258, No. 6Reflections on current methods for evaluating skills during joint replacement surgery A scoping reviewR. Sonnadara, S. McQueen, P. Mironova, O. Safir, M. Nousiainen, P. Ferguson, B. Alman, W. Kraemer, R. Reznick1 November 2013 | The Bone & Joint Journal, Vol. 95-B, No. 11Workplace-based assessment in surgical training: experiences from the Intercollegiate Surgical Curriculum Programme8 May 2013 | ANZ Journal of Surgery, Vol. 83, No. 6The United Kingdom and Ireland Trauma & Orthopaedic eLogbook—An evidence base for enhancing trainingThe Surgeon, Vol. 10, No. 5Making sense of work-based assessment: ask the right questions, in the right way, about the right things, of the right people13 December 2011 | Medical Education, Vol. 46, No. 1Evaluation of procedure-based assessment for assessing trainees' skills in the operating theatre24 November 2010 | British Journal of Surgery, Vol. 98, No. 3Assessing the Surgeonʼs Technical Skills: Analysis of the Available ToolsAcademic Medicine, Vol. 85, No. 5Orthopaedic Surgery: Current Trends and Recent InnovationsCompetencies for a Canadian orthopaedic surgery core curriculumV. M. R. Wadey, P. Dev, R. Buckley, D. Walker, D. Hedden1 December 2009 | The Journal of Bone and Joint Surgery. British volume, Vol. 91-B, No. 12Orthopaedic training experience in the UK and Ireland: An analysis using the elogbookThe Surgeon, Vol. 7, No. 4Workplace-based assessment: assessing technical skill throughout the continuum of surgical trainingANZ Journal of Surgery, Vol. 79, No. 3Trauma experience in the UK and Ireland: Analysis of orthopaedic training using the FHI eLogbookInjury, Vol. 39, No. 8Validation of orthopaedic bench models for trauma surgeryJ. J. H. Leong, D. R. Leff, A. Das, R. Aggarwal, P. Reilly, H. D. E. Atkinson, R. J. Emery, A. W. Darzi1 July 2008 | The Journal of Bone and Joint Surgery. British volume, Vol. 90-B, No. 7Training a Competent SurgeonClinics in Podiatric Medicine and Surgery, Vol. 24, No. 1 Vol. 87-B, No. 9 Metrics History Published online 1 September 2005 Published in print 1 September 2005 InformationCopyright © 2005, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

Health care institutions are searching for system-wide approaches to reduce costs while maintaining quality and improving patient outcomes. Hospital length of stay (LOS) and readmission rate (RR) are variables that significantly impact health care costs. This investigation aimed to determine if there was a difference in the LOS and the RR for pediatric orthopedic patients admitted overnight or during the weekend. We analyzed 243 admissions for pediatric orthopedic surgery cases between September 2016 and August 2018 at a single-specialty orthopedic hospital. We categorized admissions into elective surgeries, infectious etiologies, and trauma and accidents. We compared the time and day of the week of admission to the average LOS and RR. The mean LOS of the entire cohort was 2.93 days. The mean LOS for trauma admissions was 1.90 days, the mean LOS for elective surgeries was 3.34 days, and the mean LOS for infections was 4.11 (p = 0.00009). The mean LOS for patients admitted on a weekday was 3.00 days; the mean LOS for patients admitted on the weekend was 2.33 days (p = 0.28). The mean LOS for patients admitted between 6:00 AM and 6:00 PM was 3.12 days, and the mean LOS for patients admitted between 6:00 PM and 6:00 AM was 2.66 days (p = 0.22). The mean LOS for patients admitted during regular operating hours was 3.12 days, and the mean LOS for patients admitted during off-hours was 2.67 days (p = 0.22). The mean RR for trauma admissions was 0.0%, the mean RR for elective surgeries was 4.5%, and the mean for infections was 3.7% (p = 0.1073). The mean RR for patients admitted on a weekday was 3.2%, and the mean RR for patients admitted on the weekend was 0.0% (p = 0.37). The mean RR for patients admitted between 6:00 AM and 6:00 PM was 4.2%, and the mean RR for patients admitted between 6:00 PM and 6:00 AM was 1.0% (p = 0.15). The mean RR for patients admitted during regular operating hours was 4.2%, and the mean RR for patients admitted during off-hours was 1.0% (p = 0.14). This study showed no relationship between the day or time of admission and the LOS or RR for pediatric orthopedic admissions. Our results support the institutional goal of maintaining operations overnight and on weekends while not compromising patient outcomes.

Children and adolescents are vulnerable to the ongoing opioid overdose epidemic in the United States. To minimize pediatric patients' exposure to opioids, efforts are underway to reduce opioid prescriptions after closed reduction and percutaneous pinning (CRPP) for supracondylar humerus fractures. Standardized pain management protocols preferentially using opioid-free analgesics are reported to be effective in managing postoperative pain and limiting the utilization of opioids. This study compares retrospective data collected before and after the implementation of a standardized postoperative pain management protocol at a large academic children's hospital. The primary aim of this study was to compare opioid prescription patterns during the 2 periods. The secondary aim of the study was to determine the effect of the protocol on minimizing prescription errors. This Institutional Review Board-approved study was a retrospective review of pediatric patients who underwent CRPP for supracondylar humerus fractures between January 2019 and December 2021. A control cohort of patients treated before the implementation of a department-approved pain management protocol was compared with a cohort of patients treated after the implementation of a standardized postoperative pain management protocol. We compared the number of opioid prescriptions provided to patients before and after the implementation of the protocol. Descriptive statistics and chi-square analyses were used to evaluate prescribing patterns. After the implementation of the standardized pain medication control protocol, we observed a successful decrease in pediatric patients receiving postoperative opioids from 49.6% to 13.6% and in opioid prescribing errors from 38.6% to 12.5%. In addition, there was reduced variability in the type of narcotics prescribed. After the protocol's implementation, the most common combination of medication prescribed for postoperative pain control was acetaminophen and ibuprofen (69.5%). The chi-square test demonstrated no significant association between postoperative opioid prescription and fracture classification or length of stay. Opioid prescription patterns for postoperative pain management after CRPP for supracondylar humerus fractures were highly variable before the introduction of a standardized pain management protocol. The introduction of the standardized guideline effectively decreased the number of opioids prescribed at discharge, resulted in fewer opioid prescribing errors, and reduced variability in prescribing patterns among providers. Level IV-retrospective case series.

The coronavirus disease (COVID)-19 pandemic led to shutdowns of organized sporting activity. Prolonged periods of inactivity lead to deconditioning and may increase one's risk for injury. The purpose of this study was to quantify the incidence of anterior cruciate ligament (ACL) injuries requiring reconstruction during the peripandemic period. The electronic medical record of a single university teaching hospital was queried for current procedural terminology codes for ACL reconstructions (ACLR; 29,888) from January 2017 to December 2022. Date of injury was collected from clinic notes if it could be estimated within 2 weeks. The years 2017-2019 were used as a proxy for "pre-COVID," the year 2020 for "COVID," and the years 2021-2022 for "post-COVID." In total, 2178 patients had an ACL injury and underwent reconstruction from 2017 to 2022. Date of injury could be estimated for 1,617 patients (51.3% male, average age 30.9 &#xb1; 11.0 years). There was a decrease in the number of ACL surgeries observed during the COVID era, followed by a post-COVID rebound. The proportion of female patients who underwent ACLR increased from the pre-COVID to the post-COVID period (42.7% vs. 49.4%, P < .001). The proportion of patients with American Society of Anesthesiologists (ASA) score 2 increased from the COVID to the post-COVID period in relation to the proportion of patients with ASA score 1 (P = .007). ACLRs decreased at our institution during the COVID-19 pandemic, followed by an increase in ACLRs from 2021 to 2022. The proportion of female patients and patients with higher ASA scores increased in the post-COVID era.

Dual mobility acetabular systems for total hip arthroplasty (THA) have been shown to have decreased dislocation rates and reduced revision rates, but there is controversy over the potential release of sufficient levels of metal ions into the blood to cause adverse local tissue reactions. However, there is a lack of long-term studies analyzing these levels of cobalt and chromium. Therefore, the purpose of this study was to investigate the levels these metal ions at a minimum 5-year follow-up after dual mobility implantation. Specifically, we analyzed: 1. overall blood and urine cobalt levels; 2. overall blood and urine chromium levels; 3. cobalt levels stratified by length of follow-up and various implant-related metrics (i.e., offset, cup size, stem, and neck angle); as well as 4. chromium levels stratified by length of follow-up and these various implant-related metrics. A total of 41 patients who underwent THA with modular dual mobility acetabular systems between January 1, 2011, and December 31, 2016, were identified and followed for a mean time of 6 years (range: 5 to 10 years). All patients had well-functioning hips (Harris Hip Scores greater than 90 points (range: 90 to 100 points) and had no evidence of impending radiographic failure or progressive radiolucencies. Cobalt and chromium serum and plasma, blood, as well as urine levels were obtained at final followup. Additional parameters analyzed included: head material and size, stem offset, cup size, as well as stem-neck angle. Concentrations of cobalt were low as the mean blood and urine levels for all patients were 0.6 &#xb1; 0.5 &#x3bc;g/L (normal < 1.8 &#x3bc;g/L) and 0.8 &#xb1; 0.8 &#x3bc;g/L (normal < 2.8 &#x3bc;g/L), respectively. Only one patient had a minimally elevated blood cobalt level by 0.1 &#x3bc;g/L. These levels were not substantially different when subgroup analyses were performed for ceramic and cobalt-chrome heads. The mean chromium levels in blood and urine were also found to be low for all patients as values were 0.8 &#xb1; 0.2 &#x3bc;g/L (normal: < 1.2 &#x3bc;g/L) and 1.2 &#xb1; 0.5 ng/milliliter (normal: < 2 ng/L), respectively. Similarly, only one patient had a very slightly elevated blood chromium level of 1.3 &#x3bc;g/L. Additionally, analyses of ceramic or cobalt-chrome heads separately did not demonstrate differences in blood or urine levels. Blood cobalt or chromium concentrations had minimal changes with longer lengths of follow-ups, and with different stem offsets, cup sizes, stems, or neck angles. Dual mobility acetabular systems when combined with the two stems studied produced low levels of blood as well as urine cobalt and chromium levels at a minimum follow-up of 5 years (mean: 6 years; range: 5 to 10 years). These results remained below the threshold of normal and clinically insignificant regardless of length of follow-up, head material, or various implant measurements. To the best of our knowledge, this is the first study to demonstrate low levels of metal ions at longer than 4-year follow-up. These data may be of importance to surgeons deciding on the appropriate implants to use for their high-risk patients.

Wide-awake local anesthesia no tourniquet (WALANT) surgery offers a unique clinical and economic approach to delivering high-quality upper extremity care.Purpose:This article explores the evoluation, techniques, clinical efficancy, financial advantages, and future directions of WALANT as it establishes is growing role in value-based orthopedic care. In doing so, it outlines the value proposition of WALANT for patients, providers, and the hospital system. The authors conducted a comprehensive PubMed search to identify studies evaluating the clinical and economic outcomes of WALANT surgery in upper extremity procedures. Eligible studies included prospective and retrospective research, as well as case studies and case series, comparing WALANT with traditional anesthesia. The studies examined focused on metrics such as functional outcomes, patient satisfaction, and cost savings for the patient and the hospital system. Current literature shows that hand and upper extremity surgery performed under WALANT yields similar functional outcomes and even demonstrates equal or higher patient satisfaction compared with traditional anesthesia. Regarding cost savings, WALANT's minimalist approach to procedures can lead to significant waste reduction and notable financial benefits for the patient, the provider, the hospital, and the wider healthcare system. WALANT surgery offers a compelling value proposition for the patient, the provider, and the healthcare system at large. Through efficient use of resources focused on minimizing waste and optimizing patient experience and outcomes, WALANT offers an opportunity for value-based surgical care. Further research into more sophisticated clinical uses and large-scale cost-savings analyses is necessary for WALANT procedures to be further validated and more broadly adopted. Level V.Key Words: wide-awake surgery, WALANT, upper extremity surgery, hand surgery.

Research surrounding the biomechanics and video analysis of anterior cruciate ligament (ACL) injuries at the professional level has emerged in recent years as a tool to screen athletes for potential biomechanical deficits. The purpose of this study was to analyze and discuss the most common mechanism, body position, and activity at the time of ACL injury among NBA players. Anterior cruciate ligament injuries over 10 consecutive NBA seasons (2009-2010 to 2019-2020) were reviewed from publicly available sources. A 10-question survey was developed and utilized to analyze each video clip. These questions were divided into three categories: 1. contact mechanism, 2. activity at the time of injury, and 3. position of the involved lower extremity at the time of injury. Two reviewers analyzed the videos individually, and differing answers were resolved via consensus review, with a senior author arbitrating in the case of any discrepancies. Overall, 23 ACL ruptures were included. The most common injury mechanism was indirect contact with another player without knee contact (56.5%), and no patients had an ACL rupture as a result of direct knee contact with another player. The most common action at the time of injury was pivoting (47%), and the most common basketball action was dribbling (43.5%). Additionally, the vast majority of patients were injured while on offense (91.3%). The most common knee positions were early flexion (73.9%) and abduction (95.7%). The most common foot positions were abduction relative to the knee (82.6%), in eversion (73.9%), and dorsiflexion (56.5%). The most common hip position was early flexion (87%), and all hips were abducted (100%). Our study found that the majority of ACL ruptures occurred during offensive play and over half were secondary to contact with an opposing player (but without a direct blow to the injured knee), indicating that such perturbations may alter the kinematics of the players' movement. Additionally, a large majority of ACL injuries occurred while the hip was abducted with the knee in abduction relative to the hip and while the knee was in early flexion from 0&#xb0; to 45&#xb0;.

Given the progressive spread of medical misinformation, access to understandable educational content from trusted sources has become increasingly more crucial for patients. Online patient education materials, particularly from specialty organizations, have been criticized for being too complex for the average reader. It is advised that this information be at or below the 6th-grade reading level. This study is a 9-year follow-up to an analysis conducted in 2013 which evaluated the overall readability of educational articles from the American Academy of Orthopaedic Surgeons (AAOS) and American Society for Surgery of the Hand (ASSH) websites related to shoulder and elbow conditions. In the current investigation, 74 shoulder and elbow articles were assessed using the same methodology, which included analyzing the number of years since their last update, word count, percentage of passive sentences, Flesch Reading Ease score, Flesch-Kincaid grade level, Simple Measure of Gobbledygook (SMOG) grade, and New Dale-Chall grade level. No articles from either site were at or below the recommended 6th-grade reading level. Those from the AAOS were longer than those from the ASSH (P < .001). The articles had a mean Flesch Reading Ease score of 53.8 vs. 58 (P = .01), Flesch-Kincaid grade level of 9.6 vs. 9.4, SMOG grade of 8.9 vs. 8.6, and New Dale-Chall grade of 10.5 vs. 10.1 for the AAOS and ASSH sites, respectively. Although no significant differences in the readability measures were noted between the 2013 and current AAOS articles, the current ASSH content had a significantly higher Flesch Reading Ease score (P = .01) and significantly lower Flesch-Kincaid (P = .04), SMOG (P = .03), and New Dale-Chall (P = .03) grade levels, than their 2013 counterparts. Although improvements have been made in the shoulder and elbow articles from the ASSH, there remains a need to further improve the readability of AAOS and ASSH online materials to better ensure adequate patient education.

Intra-articular (IA) injections of plateletrich plasma (PRP) have been increasingly used in the nonoperative treatment of knee osteoarthritis (OA) but have considerable heterogeneity in both formulation and clinical results. Alpha-2-macroglobulin (A2M) is a large plasma protein found in PRP that inhibits cartilage-degrading enzymes and could be an efficacious OA treatment independently. The purpose of this study was to compare the short-term clinical efficacy of IA injection of A2M-rich PRP concentrate to conventionally prepared PRP and corticosteroids in the management of symptomatic knee OA. This double-blinded, randomized, controlled clinical trial was conducted at a single medical center with enrollment from June 2018 to May 2019. Subjects with symptomatic Kellgren-Lawrence (KL) grade 2 or 3 knee OA were randomized to IA injection with A2M, PRP, or methylprednisolone (MP) and followed for 12 weeks post-injection. Knee pain and function were assessed at pre-treatment baseline and at 6-week and 12-week followup with patient-reported outcome (PRO) surveys including the visual analog scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and Tegner score. Seventy-five subjects were enrolled in the trial, of whom 68 (90.7%) completed the 12-week follow-up. The majority of subjects (73%) were female with a mean age of 59 years (range: 37 to 75 years). There were no significant differences in age (p = 0.30), sex (p = 0.44), or KL grade (p = 0.73) between treatment groups. By 12 weeks postinjection, the A2M group showed significant improvement in VAS, WOMAC, KOOS, and Tegner (p < 0.05), the PRP group showed no significant improvement in any PROs (p > 0.05), and the MP group showed significant improvement in Lysholm only (p = 0.01). However, the changes in PRO scores between baseline and 12-week follow-up did not significantly differ between the three groups (p > 0.05). Alpha-2-macroglobulin IA injection shows comparable efficacy to PRP and corticosteroids in the treatment of mild-to-moderate knee OA. Alpha-2-macroglobulin treatment resulted in modest improvement in knee pain and function at 6-week follow-up, albeit inconsistently across PRO measures and to a similar degree as PRP and corticosteroids. Given its non-superior short-term efficacy compared to established IA injections, as well as its increased cost of preparation, A2M may not be a justifiable option for routine treatment of knee OA.

Medicare's Bundled Payments for Care Initiative is a risk-sharing, value-based alternative payment model. As such, Medicare providers are financially responsible for poor outcomes, potentially disincentivizing operating on high-risk individuals, including obese patients and smokers. We sought to describe the change in these modifiable risk factors among Medicare, Medicaid, and commercially insured patients in the 6-year period after implementation of Bundled Payments for Care Initiative. We analyzed a consecutive series of 11,790 patients who underwent total hip arthroplasty between January 1, 2013, and August 31, 2019. We categorized patients based on smoking status (current, former, or never) and body mass index (BMI; obese if BMI was >30 kg/m2, morbidly obese if BMI was >40 kg/m2, and superobese if BMI was >50 kg/m2). Correlations between each year's proportion of patients in each smoking category and obesity category were evaluated. We included 11,582 patients with complete demographic and insurance information. There was a statistically significant decrease in the proportion of Medicare patients who were active smokers (7.91% in 2013, 5.99% in 2019, Pearson correlation coefficient = -0.759, P = .048). When looking at patients with BMI >40 kg/m2, commercially insured patients significantly increased (3.64% in 2013, 6.65% in 2019, Pearson correlation coefficient = 0.860, P = .013). Our study also demonstrated a significantly higher rate of active smokers among Medicaid patients compared with other insurance groups (P = .001), which is consistent with the general population. Our results demonstrated that the proportion of Medicare-insured patients who were active smokers decreased significantly over the study period. In addition, the proportion of obese commercially insured patients increased, but the proportion of obese Medicare patients did not. These findings suggest the possibility that surgeons may be disincentivized to operate on both obese patients and those who are actively smoking who are enrolled in risk-sharing, value-based programs. Notably, we found a potential trickle-down effect to Medicare patients with our smoking cessation program. The same was not observed for patients with Medicaid or Commercial insurance or for weight reduction before surgery for any insurance group. A possible explanation is that obesity is not as modifiable as smoking and increased efforts to address obesity in the arthritis population are needed. III, retrospective observational analysis.

The purpose of this study was to describe our experience using superiorly applied low-profile locking plates for the operative fixation of displaced midshaft clavicle fractures (MCFs). This was a retrospective analysis performed at an academic institution. Eighty-three patients who presented with displaced, shortened MCFs were treated operatively by a single surgeon at our institution over a 10-year period. All patients received a precontoured low-profile locking plate applied in the superior position. A displaced midshaft clavicle fracture was fixed operatively using a precountered low-profile 2.7/3.5 mm locking plate applied in the superior position. Data were analyzed to evaluate time to union, final shoulder range of motion, incidence of hardware removal, and rate of postoperative complications. The cohort was 66.2% male with an average age at initial injury of 36.5 &#xb1; 14.1 years. At a mean of 3.6 &#xb1; 1.9 months, 99% of patients had united their fracture. At an average of 7.37-month follow-up, mean range of motion was 174&#xb0; forward elevation, 173&#xb0; abduction, 82&#xb0; external rotation, and internal rotation to T7. Using the short musculoskeletal functional assessment (SMFA), the mean functional outcome index score was 4.12, bothersome index was 1.94, activity index was 1.55, emotion index was 2.51, arm and hand index was 1.14, mobility index was 0.68, and total index was 1.56. Ninety-two percent of patients had retained their hardware. There was 1 incidence of each of the following complications: infection, nonunion, hardware failure, and deep vein thrombosis. Superior clavicle plating using precontoured low-profile locking plates is an acceptable treatment modality for displaced MCF. This method yields excellent results regarding time to union, shoulder range of motion, incidence of hardware removal, and the rate of postoperative complications. Patients considering operative fixation of displaced MCF should be counseled accordingly.

The COVID-19 pandemic led to increased sedentary behavior and body mass index during 2020, which may decondition musculotendinous units and lead to increased risk for injury. As patients return to pre-COVID levels of activity, we hypothesize that there will be a resultant rebound increase in tendon ruptures. III, descriptive epidemiology study. The electronic medical record was queried for current procedural terminology codes for tendon ruptures (Achilles, patella, quadriceps, hamstring, distal biceps, triceps, and pectoralis major) from January 2017 to December 2021 at a single academic urban center. Data were reviewed to ensure only acute tendon rupture repairs were included. The years 2017-2019 were used as a proxy for pre-COVID rates, 2020 as a proxy for the COVID quarantine, and 2021 as a proxy for "post-COVID" activity. Univariate analysis was performed for comparative data. A total of 1,879 patients (82.8% male, mean age 47.8 years) who sustained tendon injuries and underwent surgical repair were identified. There were 589 (31.3%) Achilles tendon repairs, 181 (9.6%) patella tendon repairs, 414 (22.0%) quadriceps tendon repairs, 100 (5.3%) hamstring tendon repairs, 397 (21.1%) distal biceps repairs, 105 (5.6%) triceps repairs, and 93 (4.9%) pectoralis tendon repairs. The total number of tendon injuries per year was 2017-357 (19.0%), 2018-380 (20.2%), 2019-380 (20.2%), 2020-308 (16.4%), and 2021-454 (24.2%). The rates in 2017, 2018, and 2019 were within 1% of each other, but there were a 3.8% decrease in rate of tendon injuries from 2019 to 2020 and a 7.8% increase in rate of tendon injuries from 2020 to 2021. When analyzed by quarter, a linear regression model demonstrated a statistically significant increase in case counts over the period from Q2 2020 to Q2 2021 (&#x3b2; = 21.20; 95% confidence interval = 13.62-28.78, P-value < .01). A "COVID rebound" of tendon rupture repairs in 2021 from a prolonged period of inactivity during 2020 occurred at a single academic center. As patients return to pre-COVID levels of activity that may be unsuitable to their deconditioned state, healthcare providers should counsel patients appropriately on return to activity or sport following long periods of induced inactivity.

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Symptomatic idiopathic ulnar nerve instability (IUNI) in the elbow is an uncommon condition characterized by symptoms of ulnar neuritis resulting from frictional injury to the ulnar nerve from repetitive subluxation out of the cubital tunnel. This study reports the 1-year clinical outcomes after treatment of IUNI with anterior transposition of the ulnar nerve. This is a retrospective case study of five patients. Ulnar nerve instability was diagnosed clinically based on the presence of ulnar neuritis symptoms in combination with a positive "ulnar nerve push past" test. Electromyography (EMG) was performed on all patients. After failure of nonsurgical treatment, five patients underwent anterior subcutaneous transposition of the ulnar nerve at the elbow. Clinical outcome scores and time to resolution of symptoms were recorded at a minimum follow-up of 12 months. The mean age of the patients at the time of surgery was 37.8 years (range: 18 to 57 years). The mean duration of symptoms prior to surgery was 15.7 &#xb1; 4.9 months. All five patients reported neuritis symptoms in the distribution of ulnar nerve in the hand and had ulnar nerve instability in the cubital tunnel on clinical examination. All patients were symptom free within 6 months after anterior transposition of the ulnar nerve.

As orthopedic surgeons navigate the complexities of selecting their first positions, or established surgeons seek changes in employment, understanding the evolving financial and structural landscape of surgical practices is crucial. The rising influence of private equity (PE) in health care has added another dimension to this decision, as investment firms increasingly acquire stakes in practices to drive consolidation and profitability. Between 2015 and 2022, PE transactions in health care surged dramatically, reflecting the growing trend of practice consolidation in response to declining reimbursements, rising operational costs, and regulatory burdens. PE firms use leveraged buyouts to acquire and restructure practices, often forming management services organizations to streamline operations. Although PE partnerships offer benefits, including access to capital and corporate expertise, they also raise concerns about reduced autonomy, increased procedural volumes, and potential impacts on care quality and costs. This article provides an overview of PE's role in orthopedic practices, including its history, investment strategies, and the anatomy of typical deals. It explores the implications of PE partnerships on financial and clinical outcomes and highlights the importance of physicians staying informed about these developments. By understanding the benefits and risks, orthopedic surgeons can make more informed decisions in the context of a rapidly changing health care environment.

The objective of this study was to survey a cross-section of US female orthopaedic surgeons evaluating their education and attitudes on radiation safety and adherence to safety recommendations. An online survey was distributed to female orthopaedic surgery faculty through the Forum, a society for women in orthopaedic surgery, and through internal institutional education networks (residency and fellowship programs). The first component of the survey gathered demographic information including practice setting, US state, and years in practice. The second component was a 10-question knowledge assessment. The third component captured personal experiences among respondents including satisfaction with radiation safety training, radiation safety practices, and level of concern regarding exposure risk. Responses from 66 participants from differing geographic locations were collected using Research Electronic Data Capture. Sixty-six female orthopaedic surgeons from 21 states completed the survey. Regular dosimeter usage was reported by 24.2% of respondents, and 36.4% of respondents reported always having well-fitted radiation protective equipment provided. The majority (56.1%) stated that they worry about the risks of radiation to their health. Regarding their radiation safety training, 60.6% of respondents rated their training as unsatisfactory or extremely unsatisfactory, and 90.9% of respondents stated that they think training efforts for radiation safety can improve. Female orthopaedic surgeons demonstrated an inadequate knowledge of adherence to radiation safety protocols and the majority expressed concern with long-term radiation exposure, particularly regarding health and pregnancy risk. To enhance radiation safety awareness and adherence among female orthopaedic surgeons, strategies should be tailored to this demographic, fostering confidence in their knowledge of radiation exposure and bolstering safety measures.

The purpose of our study was to identify force plate-derived balance metrics that were predictive of multimodal return-to-sport test findings in a sample of anterior cruciate ligament reconstruction patients. We conducted a cross-sectional study of anterior cruciate ligament reconstruction patients who were at least 6 months postoperative. Subjects completed our multimodal Institutional RTS testing battery which included testing of hip and knee range of motion (ROM), isokinetic quadriceps strength, and core trunk muscle strength (Bunkie test), as well as balance testing on a force plate. Balance metrics predictive of Institutional RTS test findings for the involved leg were identified using multivariable regression with stepwise selection. Model significance was assessed at &#x3b1; = 0.002. Sixteen subjects (7M, 9F) were enrolled in our study with a median age of 29 years (range 20-47). Multivariate multiscale entropy (MMSExyz) of the involved leg was predictive of knee flexion active ROM (P = .02) and Bunkie stabilizing test score (P = .03), MMSExyz of the uninvolved leg was predictive of Bunkie lateral and medial test scores (P = .02 and P = .02), and interlimb symmetry of MMSExyz was predictive of triple jump test score (P = .007). Interlimb symmetry of the COPx shift balance metric was predictive of hip internal rotation active and passive ROM (P = .008 and P = .03) and step-down test score (P = .004). Force plate-based balance testing metrics are predictive of some return-to-sport test findings including knee flexion ROM and Bunkie test scores, but further analysis is needed to identify balance metrics predictive of quadriceps isokinetic testing and muscle flexibility testing results.

Nordic combined (NC) and ski jumping (SJ) athletes have a high prevalence of chronic hip pathology, which may lead to altered knee and ankle biomechanics. The purpose of this study was to determine the relationship among athlete-reported lower extremity outcomes in a proximal-to-distal sequence. cross-sectional study, Level IV. Elite SJ and NC athletes who competed at the national and international levels were prospectively recruited to complete a survey eliciting information about their Hip Disability and Osteoarthritis Outcome Score (HOOS), International Knee Demographic Committee (IKDC) score, and Foot and Ankle Outcome Score (FAOS). Univariate linear regressions modeling IKDC scores and FAOS subscores were performed for each of the following independent variables: age, sex, body mass index, Nordic event (NC or SJ), HOOS subscore, and FAOS subscore or IKDC score, respectively. A total of 22 athletes were included in the study. HOOS symptoms subscores were significantly lower (worse) among SJ athletes compared with NC athletes (P = .002). HOOS quality of life subscores were lower for female athletes compared with male athletes (54 &#xb1; 21, 73 &#xb1; 4.0; P = .029) in the entire cohort. An increase in the HOOS pain subscore (0.54 &#xb1; 0.20, P = .016) and HOOS sports subscore (0.40 &#xb1; 0.17, P = .042) was associated with a significant increase in the IKDC score. An increase in the HOOS symptoms subscore (0.63 &#xb1; 0.21, P = .011) was associated with a significant increase in the FAOS symptoms subscore. Elite NC and SJ athletes are at high risk of hip pain, which increases their risk of developing knee and ankle pain as well. These findings strongly suggest that training targeted at hip strength and conditioning may optimize knee and ankle outcomes in elite NC and SJ athletes. The results of this study may help guide physicians, allied health personnel, and coaches to alter lower extremity training regimens to decrease the risk of injury.

The purpose of this study was to evaluate changes in perioperative tranexamic acid (TXA) utilization among patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), based on patient demographics and comorbidities, including those at higher and lower risk of venous thromboembolism (VTE). Patients who underwent THA or TKA between 2012 and 2021 were identified using the TriNetX electronic health record database. Perioperative TXA use was evaluated among patients stratified according to risk of VTE. Utilization rates were analyzed using compound annual growth rates (CAGRs) and linear regression analysis. From 2012 to 2021, TXA use increased by 406% (CAGR: +17.66%; P < 0.001) for THA and 459% for TKA (CAGR: +18.86%; P < 0.001). Among patients with at least 1 factor placing them at high risk of VTE, TXA use increased by 1277% for THA (CAGR: +30.0%; P < 0.001) and by 966% for TKA (CAGR: +26.7%; P < 0.001). During the final study year (2021), surgeons overall used TXA in 67.8% of THA cases and 62.5% of TKA cases. In the high-risk group, TXA use was lowest among patients with a history of myocardial infarction (THA, 48.7%; TKA, 51.4%), cerebrovascular accident (THA, 51.0% and TKA, 50.6%), bleeding or clotting disorder (THA, 57.4% and TKA, 57.1%), or previous VTE (THA, 57.3%; TKA, 53.6%). Despite the rapid growth in TXA utilization over the past decade in THA and TKA, patients at high risk of VTE and ischemia are still less likely to receive perioperative TXA.