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Orthopaedics Current Awareness

Newsletter

August 2015

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Contents Your Friendly Local Librarian… ................................................................................................................ 2

New Activity in Up-to-Date ..................................................................................................................... 4

Current Awareness Database Articles related to Orthopaedics ............................................................. 6

Medical................................................................................................................................................ 6

Patient care and management.......................................................................................................... 17

Other ................................................................................................................................................. 22

Journal Tables of Contents .................................................................................................................... 26

Journal of Bone and Joint Surgery; Vol. 97, iss. 4, February 2015 ................................................... 26

Journal of Orthopaedic Trauma; Vol. 29, iss. 4, April 2015 .............................................................. 26

Injury ; Vol. 46, iss. 4, April 2015 ....................................................................................................... 26

Strategies in Trauma and Limb Construction ; Vol. 9, iss. 3, November 2014 .................................. 26

Clinical Orthopaedics and Related Research; Vol. 473, iss. 3, March 2015 ...................................... 26

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New Activity in Up-to-Date

Prevention of venous thromboembolic disease in surgical patients

Authors: Menaka Pai, MD, FRCPC: James D Douketis, MD, FRCPC, FACP, FCCP Section Editors: Lawrence LK Leung, MD; Jess Mandel, MD Deputy Editor: Geraldine Finlay, MD

Literature review current through: Jul 2015. | This topic last updated: Jul 30, 2015.

INTRODUCTION — Using the 2003 nationwide inpatient sample from the Health Care Cost and

Utilization Project in the United States, there were over 38 million discharges in 2003. Twenty

percent of those were surgical inpatients and, using the ACCP Guidelines for risk stratification, it was

estimated that 15 percent, 24 percent, and 17 percent were at moderate, high, or very high risk for

venous thromboembolism (VTE, which includes deep vein thrombosis and pulmonary embolism).

Despite significant advances in the prevention and treatment of VTE, pulmonary embolism remains

the most common preventable cause of hospital death, responsible for approximately 150,000 to

200,000 deaths per year in the United States. Thus, it is vital that efforts continue to be made to find

the safest and most effective means of preventing and managing VTE.

Practical approaches to the prevention of VTE in surgical patients will be reviewed here. Prevention

of VTE in medical patients is presented separately.

Detailed discussions about specific pharmacologic agents employed for VTE prevention are

presented separately.

Antimicrobial prophylaxis for prevention of surgical site infection in adults Authors: Deverick J Anderson, MD, MPH; Daniel J Sexton, MD Section Editor: Anthony Harris, MD, MPH Deputy Editor: Elinor L Baron, MD, DTMH

Literature review current through: Jul 2015. | This topic last updated: Aug 01, 2014.

INTRODUCTION — Surgical site infections (SSIs) are a common cause of healthcare-associated

infection. The United States Centers for Disease Control and Prevention (CDC) has developed criteria

that define surgical site infection as infection related to an operative procedure that occurs at or

near the surgical incision within 30 days of the procedure or within 90 days if prosthetic material is

implanted at surgery. SSIs are often localized to the incision site but can also extend into deeper

adjacent structures.

Among surgical patients, SSIs are the most common nosocomial infection, accounting for 38 percent

of nosocomial infections. It is estimated that SSIs develop in 2 to 5 percent of the more than 30

million patients undergoing surgical procedures each year (ie, 1 in 24 patients who undergo

inpatient surgery in the United States has a postoperative SSI)

Antimicrobial prophylaxis for prevention of SSI will be reviewed here. Issues related to epidemiology

and adjunctive measures for prevention of SSI are discussed separately.

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Current Awareness Database Articles related to

Orthopaedics

Below is a selection of articles related to orthopaedics recently added to the healthcare databases,

grouped in the following categories:

Medical

Patient care and management

Other

If you would like any of the following articles in full text, or if you would like a more focused

search on your own topic, then get in touch: library@uhbristol.nhs.uk

Medical

Title: Pediatric Orthopedic Injuries Following an Earthquake: Experience in an Acute-Phase Field Hospital. Citation: Journal of trauma nursing : the official journal of the Society of Trauma Nurses, Jul 2015, vol. 22, no. 4, p. 223-228 Author(s): Bar-On, Elhanan, Lebel, Ehud, Blumberg, Nehemia, Sagi, Rami, Kreiss, Yitshak, Israel Defense Forces Medical Corps, Petah Tikva, Israel Abstract: Following the 2010 earthquake in Haiti, the Israel Defense Forces Medical Corps deployed a field hospital in Port au Prince. The purpose of this study was to characterize the injuries sustained by the pediatric population treated in the hospital and examine the implications for planning deployment in future similar disasters. Medical records of children treated in the hospital were reviewed and compared with medical records of the adult population. A total of 1,111 patients were treated in the hospital. Thirty-seven percent were aged 0 to 18 years. Earthquake-related injuries were the cause of admission in 47% of children and 66% of adults. Forty-seven percent of children with traumatic injuries sustained fractures. Seventy-two percent were in the lower limbs, 19% were in the upper limbs, and 9% were in the axial skeleton, with the femur being the most common long bone fractured compared with the tibia in adults. There were four functional operating theaters, and treatment guidelines were adjusted to the rapidly changing situation. Soft tissue injuries were treated by aggressive debridement. Fractures were stabilized by external fixation or casting. Amputation was performed only for nonviable limbs or life-threatening sepsis. Children were more likely than adults to undergo surgery (44% vs. 29% of trauma patients). To maximize hospital surge capacity, minor procedures were performed in the wards under sedation, and patients were discharged after an average of 1.4 days, with subsequent follow-up in the clinic. Children constitute a high percentage of patients in a developing country. The epidemiology of pediatric injuries following an earthquake differs significantly

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from that encountered in everyday practice and compared with that in adults. Children sustain a significantly higher percentage of femoral fractures and are more likely to require surgery. The shift to nontraumatic reasons for admission occurred earlier in the pediatric population than in adults. Organizations providing post-earthquake relief are usually geared toward adult populations and will require supplementation of both manpower and equipment specifically suited for treatment of pediatric patients. Early deployment teams should be adequately staffed with adult and pediatric orthopedists. (J Trauma Acute Care Surg. 2013;74: 617-621.

Title: Open proximal & distal fractures of tibia treated with Naseer Awais External Fixator with T-clamp. Citation: JPMA. The Journal of the Pakistan Medical Association, Jul 2015, vol. 65, no. 7, p. 727-732 Author(s): Makhdoom, Asadullah, Maheshwari, Lachman Das, Laghari, Muhammad Ayoub, Tahir, Syed Muhammad, Ali, Syed Muhammad, Siddiqui, Khaleeque Ahmed Abstract: To compare the outcome of the open proximal and distal fractures of tibia treated by Nasser Awais External Fixtator with T-clamp. The descriptive case series was conducted from August 2009 to July 2012 at Department of Orthopaedic Surgery & Traumatology, Liaquat University of Medical & Health Sciences, Jamshoro, and comprised in-patients of open proximal and distal fractures of tibia who were divided into two equal groups: group A had distal and group B had proximal patients. All patients had extra-articular open fractures Gustilo I, II, IIIA and IIIB of proximal and distal end of tibia between 15 and 60 years of age who had arrived within 8 hours of the injury. Below-knee plaster cast was applied for 02 to 03 weeks after the removal of Nasser Awais External Fixtator and all patients were followed up for 12 months. SPSS 17 was used for statistical analysis. Overall, there were 30 patients; 15(50%) in each of the two groups. The mean age in group A was 28.9±9.43 years and 34.3±14.60 years in group B. There were 11(73.3%) males and 4(26.7%) females in group A, and 15(100%) males in-group B. Mean fracture union time in group A was 17.20±2.93 weeks (range: 11-23 weeks) and in group B it was 23.53±2.44 weeks (range: 19-28 weeks). Ankle joint stiffness occurred in 2(6.7%) cases that were in group A, and knee joint stiffness was seen in 2(6.7%) cases and they were in group B. Nasser Awais External Fixator with T-Clamp was a safe technique and promoted the union with a low complication rate with less union time in distal tibial fracture compared to proximal fracture.

Title: Orthopaedic Surgeons as Clinical Leaders in the National Health Service, United Kingdom (NHS UK): Can the World Learn From Us? Citation: Journal of the College of Physicians and Surgeons--Pakistan : JCPSP, Jul 2015, vol. 25, no. 7, p. 531-533 Author(s): Javed, Mustafa, Moulder, Elizabeth, Mohsen, Amr Abstract: This article outlines some of the key concepts in leadership (both styles and theories) to provide a platform for further learning and to help the modern day orthopaedic

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surgeons to apply these concepts to their current practice. It is focused on two major aspects: management of medical organizations and effective twenty-first century care by surgeons through proper leadership guide and aimed in improving patient care outcomes. Practicing proper leadership skills based on evidence resulted in effective management of organization. Thus achieving patient's satisfaction.

Title: The Influence of Microsurgical Training on the Practice of Hand Surgeons. Citation: Journal of reconstructive microsurgery, Jul 2015, vol. 31, no. 6, p. 442-449 Author(s): Christensen, Thomas J, Anding, William, Shin, Alexander Y, Bishop, Allen T, Moran, Steven L Abstract: Background The study aims to determine the effect of formal training on the long-term practice of microsurgery. Methods Hand surgeons completing a 1-year hand fellowship and a 5-day microsurgery rat-model training course from a single institution over a 15-year period (1996-2011) were surveyed. Patency rates (at 24 hours), additional days spent in the laboratory, and training (orthopedic [OS] vs. plastic surgery [PS]) were correlated with the questionnaire responses regarding microsurgical confidence and practice spectrum. Results Data were obtained for 100% (61/61) of former fellows. PSs were 4.7 and 7.6 times more likely to perform replants and free flaps than OSs, respectively. Training patency rates and days in the laboratory were fair predictors of current practice of free flaps and replants. Conclusion PSs are more likely to perform replants and free flaps than OSs. Successful completion of a microsurgical skills course can be used as a predictor of those who will ultimately practice microsurgery. Broader application of microsurgical skills labs may be a technique to increase the practice of microsurgery among all hand surgeons. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Title: Prevention training of wrong-site spine surgery. Citation: Journal of surgical education, Jul 2015, vol. 72, no. 4, p. 680-684 Author(s): Mesfin, Addisu, Canham, Colin, Okafor, Louis Abstract: Wrong-site surgery (WSS) is considered a sentinel event by the Joint Commission. The education of spine surgery fellows on WSS is unknown. Our objective was to evaluate North American spine surgery fellows' education, awareness, and experience with WSS. Observational survey study. Spine surgery fellows in North America. From April 2013 to July 2013 and in July 2014 anonymous questionnaires were sent to 156 spine surgery fellows participating in 75 programs. Demographic information (fellowship location and Accreditation Council for Graduate Medical Education accreditation of the fellowship) were collected. We also collected data on the following: if didactics on WSS are offered during fellowship, spine surgery fellows' experience with WSS, WSS prevention methods used during fellowship, and whether spine surgery fellows are interested in didactics or webinars on the prevention of WSS. Of 152 spine surgery fellows, 46 (30.3%) completed the questionnaires. Among them, 39 (84.6%) were orthopedic surgeons and 7 (15.4%) were neurosurgeons. Most were in non-Accreditation Council for Graduate Medical Education-

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accredited programs (70%) and were in training in the Midwest (37%), the South (30.4%), the Northeast (15.2%), and the West (15.2%). Furthermore, 30.4% had experienced WSS. Only 15 fellows (33%) had formal didactics on WSS during their fellowship. Most spine surgery fellows (61%, p = 0.03) were interested in a formal didactics on the prevention of WSS during their fellowship curriculum. Most (58.7%) were also interested in a Webinar on the prevention of WSS. We found of the 14 fellows that experienced WSS, 11 (79%) were significantly interested in formal didactics on WSS compared with those who had not experienced WSS (14/32, 44%; p < 0.02). This is the first study evaluating spine surgery fellowship education on WSS. Among the spine surgery fellows, 30% had already experienced WSS and only 33% had formal fellowship didactics on WSS. Owing to the significant patient care and medicolegal ramifications from WSS, spine surgery fellowships should consider adding WSS prevention didactics to their curriculum.

Title: A novel approach for needs assessment to build global orthopedic surgical capacity in a low-income country. Citation: Journal of surgical education, Jul 2015, vol. 72, no. 4, p. e2. Author(s): Bhashyam, Abhiram R, Fils, Jacky, Lowell, Jim, Meara, John G, Dyer, George S M Abstract: Visiting surgical teams are a vital aspect of capacity-building continuing medical education (CME) in low-income countries like Haiti. Imperfect understanding of the genuine needs of local surgeons limit CME initiatives. Previous paper-based needs assessment efforts have been unsuccessful because of low response rates. We explored using an electronic audience response system (ARS) during a Haitian CME conference to improve the response rates and better assess needs. Data were prospectively collected using an ARS from 78 conference participants (57 Haitian and 21 foreign) about current and desired knowledge of 7 topic and 8 skill areas using a 5-point Likert scale presented in English and in French. The response rates using ARS vs a similar paper survey were compared using a 2-sample test of proportions. The current and desired knowledge levels were compared using paired t tests. Analysis of variance and post hoc unpaired t tests were used to compare between demographic groups. The response rates were significantly greater for ARS vs a paper survey (87.7 vs 63.2%, p = 0.002). The 4 areas of least self-confidence for Haitians were pelvic and articular injury, joint dislocation, and osteomyelitis. The 4 skills of least self-confidence for Haitians were arthroscopy, open reduction and internal fixation-plate, external fixation, and fasciotomy. Haitians desired improvements in knowledge and management of articular, diaphyseal, and pelvic injury, joint dislocation, and osteomyelitis to a greater extent than foreigners (p < 0.05). Participants who previously attended the conference on open fractures felt more knowledgeable about open fractures as a topic (p < 0.05), but not in its management. We are the first to show that an ARS improves response rates to allow for better characterization of surgeon needs in the developing world. We also demonstrate the importance of skill building paired with topic area teaching. Lastly, we show how a CME conference is an effective tool to build surgical capacity and increase confidence level.

Title: The Association of the H-Index and Academic Rank Among Full-Time Academic Hand Surgeons Affiliated With Fellowship Programs.

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Citation: The Journal of hand surgery, Jul 2015, vol. 40, no. 7, p. 1434-1441 Author(s): Lopez, Joseph, Susarla, Srinivas M, Swanson, Edward W, Calotta, Nicholas, Lifchez, Scott D Abstract: To evaluate the association between the Hirsch index (a measure of publications and citations) and academic rank among hand surgeons. This was a cross-sectional study of full-time academic hand surgeons within Accreditation Council for Graduate Medical Education-approved hand surgery fellowship programs in the United States and Canada. The study variables were classified as bibliometric (h-index, I-10 index, total number of publications, total number of citations, maximum number of citations for a single work) and demographics (gender, training factors). The outcome was academic rank (instructor, assistant professor, associate professor, professor, endowed professor). Descriptive, bivariate, and multiple regression statistics were computed. The sample was composed of 366 full-time academic hand surgeons; 86% were male and 98% had formal hand surgery fellowship training. The mean time since completion of surgical training was 17 ± 11 years. The distribution of primary faculty appointments was orthopedic surgery (70%) and plastic surgery (30%). Two hundred fifty surgeons (68%) were members of the American Society for Surgery of the Hand. The mean h-index was 10.2 ± 9.9 and was strongly correlated with academic rank. Gender was not associated with academic rank. Distribution of academic ranks was as follows: instructor (4%), assistant professor (28%), associate professor (40%), professor (22%), and endowed professor (5%). The h-index, years since completion of training, and American Society for Surgery of the Hand membership were associated with academic rank. The h-index had a high sensitivity and specificity for predicting academic rank. The h-index is a reliable tool for quantitatively assessing research productivity and should be considered for use in academic hand surgery. When evaluating candidates for academic promotion in hand surgery, the h-index is a potentially valuable tool for assessing research productivity and impact.

Title: Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study. Citation: The Journal of orthopaedic and sports physical therapy, Jul 2015, vol. 45, no. 7, p. 503-511 Author(s): Thomas, Lucy C, Rivett, Darren A, Attia, John R, Levi, Christopher Abstract: Study Design Cross-sectional case-control study. Objectives To identify risk factors and clinical presentation of individuals with cervical arterial dissection. Background Cervical arterial dissection is a common cause of stroke in young people and has in rare cases been associated with cervical manipulative therapy. The mechanism is considered to involve pre-existing arterial susceptibility and a precipitating event, such as minor trauma. Identification of individuals at risk or early recognition of a dissection in progress could help expedite medical intervention and avoid inappropriate treatment. Methods Participants were individuals 55 years of age or younger from the Hunter region of New South Wales, Australia with radiologically confirmed vertebral or internal carotid artery dissection and an age- and

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sex-matched comparison group. Participants were interviewed about risk factors, preceding events, and clinical features of their stroke. Physical examination of joint mobility and soft tissue compliance was undertaken. Results Twenty-four participants with cervical arterial dissection and 21 matched comparisons with ischemic stroke but not dissection were included in the study. Seventeen (71%) of the 24 participants with dissection reported a recent history of minor mechanical neck trauma or strain, with 4 of these 17 reporting recent neck manipulative therapy treatment. Cardiovascular risk factors were uncommon, with the exception of diagnosed migraine. Among the participants with dissection, 67% reported transient ischemic features in the month prior to their admission for dissection. Conclusion Recent minor mechanical trauma or strain to the head or neck appears to be associated with cervical arterial dissection. General cardiovascular risk factors, with the exception of migraine, were not important risk factors for dissection in this cohort. Preceding transient neurological symptoms appear to occur commonly and may assist in the identification of this serious pathology. Level of Evidence Prognosis, level 4. J Orthop Sports Phys Ther 2015;45(7):503-511. Epub 21 May 2015. doi:10.2519/jospt.2015.5877.

Title: Outcomes of Foot and Ankle Surgery in Diabetic Patients Who Have Undergone Solid Organ Transplantation. Citation: The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, Jul 2015, vol. 54, no. 4, p. 577-581 Author(s): Zou, Richard H, Wukich, Dane K Abstract: Foot and ankle problems are highly prevalent in patients with diabetes mellitus (DM). Increased rates of surgical site infections and noninfectious complications, such as malunion, delayed union, nonunion, and hardware failure, have also been more commonly observed in diabetic patients who undergo foot and ankle surgery. DM is a substantial contributor of perioperative morbidity in patients with solid organ transplantation. To the best of our knowledge, postoperative foot and ankle complications have not been studied in a cohort of diabetic patients who previously underwent solid organ transplantation. The aim of the present study was to evaluate the outcomes of foot and ankle surgery in a cohort of diabetic transplant patients and to compare these outcomes with those of diabetic patients without a history of transplantation. We compared the rates of infectious and noninfectious complications after foot and ankle surgery in 28 diabetic transplant patients and 56 diabetic patients without previous transplantation and calculated the odds ratios (OR) for significant findings. The diabetic transplant patients who underwent foot and ankle surgery in the present cohort were not at an increased risk of overall complications (OR 0.83, 95% confidence interval [CI] 0.33 to 2.08, p = .67), infectious complications (OR 0.54, 95% CI 0.09 to 3.09, p = .49), or noninfectious complications (OR 1.14, 95% CI 0.41 to 3.15, p = .81). Four transplant patients (14.3%) died of non-orthopedic surgery-related events during the follow-up period; however, no deaths occurred in the control group. Diabetic patients with previous solid organ transplantation were not at an increased risk of developing postoperative complications after foot and ankle surgery, despite being immunocompromised. The transplant patients had a greater mortality rate, but their premature death was unrelated to their foot and ankle surgery. Surgeons treating transplant patients can recommend foot and ankle surgery when indicated. However, owing

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to the increased mortality rate and comorbidities associated with this high-risk group, we recommend preoperative clearance from the transplant team and medical consultations before performing surgery.

Title: Association between Interruptions in Chemical Prophylaxis and VTE Formation. Citation: The American surgeon, Jul 2015, vol. 81, no. 7, p. 732-737 Author(s): Ramanathan, Rajesh, Gu, Zirui, Limkemann, Ashley J, Chandrasekhar, Shillika, Rensing, Edna, Mays, Cathy, Duane, Therese M Abstract: Venous thromboembolisms (VTE) are considered preventable events with appropriate mechanical or chemical prophylaxis. However, chemical prophylaxis is frequently delayed or interrupted during hospitalization. We investigated the impact of delayed initiation and interruption of chemical prophylaxis on VTE rates. The incidence of VTE at an urban academic medical center was measured in patients hospitalized for >2 days between November 2013 and May 2014. Patients receiving prophylaxis were grouped as complete (started within 24 hours of admission and no interruptions), delayed (started >24 hours and no interruptions), and interrupted (interruption for >24 hours with or without delay). There were 9961 hospital admissions and 33 VTE (3.3 per 1000 admissions). 25.2 per cent had complete, 16.4 per cent had delayed, and 11.8 per cent had interrupted prophylaxis. 36.8 per cent received no prophylaxis. Interrupted prophylaxis was associated with more VTE than complete (10.2 vs 2.0 per 1000, P < 0.01) and 5.2 greater odds. Admission to a surgical service and prolonged hospital stay were independently associated with increased likelihood of VTE. There was a lower likelihood of getting complete prophylaxis among patients admitted to orthopedic, transplant, cardiac, plastic, and vascular surgery. Surgical patients are at higher risk for VTE and interruptions in VTE prophylaxis significantly increase the risk of VTE.

Title: Surgical Site Infection Reduction Program: Challenges and Opportunities. Citation: Journal of pediatric orthopedics, Jul 2015, vol. 35, no. 5 Suppl 1, p. S51. Author(s): Shea, Kevin G, Styhl, Alexandra C, King, Howard A, Hammons, Jerrie, Clapp, Melissa Abstract: Surgical site infections (SSIs) make up about 23% of hospital-acquired infections and may cost up to 10 billion dollars annually in direct medical expenses. St. Luke's Health System of Boise, Idaho implemented a committee to reduce its incidence of SSIs, focusing on the orthopaedic and neurosurgical departments. After identifying risk factors associated with patient medical comorbidities, operating room practices, and type of procedure, Project Zero recommended changes. The implementation of a preoperative clinic and protocol management of environmental and procedural factors reduced the hospitals rate by 50%. Project Zero continues to research best practices for clean room management and preventative care, striving to reach the overall goal of zero infections.

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Title: Time to death in a prospective cohort of 252 patients treated for fracture of the proximal femur in a major hospital in Portugal. Citation: Cadernos de saúde pública, Jul 2015, vol. 31, no. 7, p. 1528-1538 Author(s): Campos, Sónia, Alves, Sandra Maria Ferreira, Carvalho, Marilia Sá, Neves, Nuno, Trigo-Cabral, Abel, Pina, Maria Fátima Abstract: The objectives were to analyze one-year survival and mortality predictors in patients with fracture of the proximal femur (low/moderate trauma). A prospective cohort was formed by inviting all patients hospitalized in the Orthopedic Ward of the second largest hospital in Portugal (May 2008-April 2009). Survival was assessed at 3, 6, 9, and 12 months after fracture and related to demographic factors, lifestyle, and clinical history, as well as to data from medical records (fracture type, surgery date, surgical treatment, and preoperative risk). Of the 340 patients hospitalized, 252 were included (78.9% women). Mortality at 3, 6, 9, and 12 months was 21.2%, 25%, 28.8%, and 34.6% for men and 7.8%, 13.5%, 19.2%, and 21.4% for women, respectively. Predictors of death were male gender (HR = 2.54; 95%CI: 1.40-4.58), ASA score III/IV vs. I/II (HR = 1.95; 95%CI: 1.10-3.47), age (HR = 1.06; 95%CI: 1.03-1.10), and delay in days to surgery (HR = 1.07; 95%CI: 1.03-1.12). Factors related to death were mainly related to patients' characteristics at admission.

Title: Network Meta-analysis: Users' Guide for Surgeons: Part I - Credibility. Citation: Clinical orthopaedics and related research, Jul 2015, vol. 473, no. 7, p. 2166-2171 Author(s): Foote, Clary J, Chaudhry, Harman, Bhandari, Mohit, Thabane, Lehana, Furukawa, Toshi A, Petrisor, Brad, Guyatt, Gordon Abstract: Conventional meta-analyses quantify the relative effectiveness of two interventions based on direct (that is, head-to-head) evidence typically derived from randomized controlled trials (RCTs). For many medical conditions, however, multiple treatment options exist and not all have been compared directly. This issue limits the utility of traditional synthetic techniques such as meta-analyses, since these approaches can only pool and compare evidence across interventions that have been compared directly by source studies. Network meta-analyses (NMA) use direct and indirect comparisons to quantify the relative effectiveness of three or more treatment options. Interpreting the methodologic quality and results of NMAs may be challenging, as they use complex methods that may be unfamiliar to surgeons; yet for these surgeons to use these studies in their practices, they need to be able to determine whether they can trust the results of NMAs. The first judgment of trust requires an assessment of the credibility of the NMA methodology; the second judgment of trust requires a determination of certainty in effect sizes and directions. In this Users' Guide for Surgeons, Part I, we show the application of evaluation criteria for determining the credibility of a NMA through an example pertinent to clinical orthopaedics. In the subsequent article (Part II), we help readers evaluate the level of certainty NMAs can provide in terms of treatment effect sizes and directions.

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Title: Recommendation for modifying current cytotoxicity testing standards for biodegradable magnesium-based materials. Citation: Acta biomaterialia, Jul 2015, vol. 21, p. 237-249 Author(s): Wang, Jiali, Witte, Frank, Xi, Tingfei, Zheng, Yufeng, Yang, Ke, Yang, Yuansheng, Zhao, Dewei, Meng, Jian, Li, Yangde, Li, Weirong, Chan, Kaiming, Qin, Ling Abstract: As one of the most promising medical metal implants, magnesium (Mg) or its alloys have shown significant advantages over other candidates attributed to not only their excellent biodegradability and suitable mechanical properties but also their osteopromotive effects for bone applications. Prior to approval mandated by the governmental regulatory body, the access to the medical market for Mg-based implants requires a series of testing for assurance of their safety and efficacy via preclinical evaluations and clinical tests including phase 1 and 2 evaluations, and phase 3 of multi-center randomized double blind and placebo-controlled clinical trials. However, as the most widely used protocols for biosafety evaluation of medical devices, current ISO 10993 standards should be carefully reevaluated when directly applying them to predict potential health risks of degradable Mg based biomaterials via cytotoxicity tests due to the huge gap between in vitro and in vivo conditions. Therefore, instead of a direct adoption, modification of current ISO standards for in vitro cytotoxicity test is desirable and justified. The differences in sensitivities of cells to in vitro and in vivo Mg ions and the capability of in vivo circulation system to dilute local degradation products were fully considered to propose modification of current ISO standards. This paper recommended a minimal 6 times to a maximal 10 times dilution of extracts for in vitro cytotoxicity test specified in ISO 10993 part 5 for pure Mg developed as potential orthopedic implants based on literature review and our specifically designed in vitro and in vivo tests presented in the study. Our work may contribute to the progress of biodegradable metals involved translational work.

Title: Opioids in hip fracture patients: An analysis of mortality and post hospital opioid use. Citation: Injury, Jul 2015, vol. 46, no. 7, p. 1341-1345 Author(s): Lindestrand, Anna Gaki, Christiansen, Marie Louise Schougaard, Jantzen, Christopher, van der Mark, Susanne, Andersen, Stig Ejdrup Abstract: The aim of this study was to investigate the use of opioids among hip fracture patients, and the potential relation between perioperative prescription of opioids, mortality and chronic opioid use. The purpose of this study was to investigate the use of opioids among hip fracture patients postoperatively and 90- and 180 days after discharge. The study also analysed predictors of early death at 30-, 90 and 365 days after discharge. We present data from the Orthopaedic Department at Bispebjerg University Hospital from 30 May 2010 and 31 March 2011 on 416 consecutively admitted hip fracture patients. Three patients died before surgery and were excluded from the analyses. Data were collected through medical records, hospital and national databases. Medication use was analysed before admission, at 3 and 6 months. Mortality data were analysed at 30 days, 6 months and 1 year. 24% were

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opioid users at admission, of whom 13% had an active malignant disease and 20% had been diagnosed with osteoporosis. 95% received opioids during admission, and 81% received a prescription for opioids at discharge. This fraction decreased to 36% at 3 months and 30% at 6 months. 2.9% of previous opioid naïve patients remained users at 6 months. Opioid use prior to admission and a pre-existing diagnosis of osteoporosis were the most significant factors associated with continued use at 3 and 6 months. The 30-day mortality was 10% and 1-year mortality was 27%. Mortality was associated with high age, ASA score>2, active cancer, high creatinine and leucocytosis. We found no association between opioids and mortality. The results of our study indicate no general reason to refrain from prescribing opioids to hip fracture patients based on a fear of potential abuse or increased mortality. C

Title: Scoliosis in Children With Aicardi Syndrome. Citation: Journal of pediatric orthopedics, Jul 2015, vol. 35, no. 5, p. e38. (2015 Jul-Aug) Author(s): Grigoriou, Emmanouil, DeSabato, Jessica Jo, Colo, Dino, Dormans, John P Abstract: Aicardi syndrome (ACS) is a rare neurodevelopmental disorder that was classically characterized by the triad of agenesis of corpus callosum, infantile spasms, and chorioretinal lacunae. As new cases emerge and new common phenotypic features are being described in subsequent reports, new modified diagnostic criteria have been proposed that now classify the observed costovertebral abnormalities as supporting diagnostic features. To our knowledge there are no previous studies focusing and describing the scoliosis observed in children with ACS. We screened billing lists to identify patients seen in the Division of Orthopaedic Surgery at our institution with a diagnosis of ACS that were treated for scoliosis after 2001. A total of 5 patients were identified. Medical records and radiographs were retrospectively reviewed in all cases. In all of the patients the diagnosis of ACS had been confirmed through complete genetic evaluation and advanced imaging. The mean age when scoliosis was first noticed was 3.9±4.2 years (range, 0.5 to 10.5 y) with a mean Cobb angle of 22.5±6.7 degrees (range, 10 to 27 degrees). The mean age at the first orthopedic visit was 5.8±5.0 years (range, 1.5 to 13 y) with a progressed mean Cobb angle of 39.5±17.3 degrees (range, 15 to 57 degrees). Congenital vertebral anomalies were observed in 1 patient. Three patients were treated surgically; 1 of the 3 patients had a surgical complication with loss of intraoperative neuromonitoring signals. Two patients had not undergone surgery at the last visit with a mean Cobb angle of 75.5 degrees. The mean postoperative follow-up for the surgical group (cases 1 to 3) was 3±3.6 years (range, 0.6 to 7.2 y) and the mean total follow-up for both groups was 6.6±2.5 years (range, 2.6 to 8.6 y). Scoliosis in ACS can represent a clinically significant problem that is underdiagnosed and overshadowed by the other severe medical complications associated with the syndrome. Our data suggest that scoliosis in patients with ACS is rapidly progressive and bracing is ineffective; early screening, close observation, and low threshold for referral to an orthopedic surgeon are crucial. Level IV-case series.

Title: Network Meta-analysis: Users' Guide for Surgeons: Part II - Certainty. Citation: Clinical orthopaedics and related research, Jul 2015, vol. 473, no. 7, p. 2172-2178 (July 2015)

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Author(s): Chaudhry, Harman, Foote, Clary J, Guyatt, Gordon, Thabane, Lehana, Furukawa, Toshi A, Petrisor, Brad, Bhandari, Mohit Abstract: In the previous article (Network Meta-analysis: Users' Guide for Surgeons-Part I, Credibility), we presented an approach to evaluating the credibility or methodologic rigor of network meta-analyses (NMA), an innovative approach to simultaneously addressing the relative effectiveness of three or more treatment options for a given medical condition or disease state. In the second part of the Users' Guide for Surgeons, we discuss and demonstrate the application of criteria for determining the certainty in effect sizes and directions associated with a given treatment option through an example pertinent to clinical orthopaedics.

Title: Costs Versus Benefits of Routine Histopathological Examination in Total Ankle Replacement. Citation: Foot & ankle international, Jul 2015, vol. 36, no. 7, p. 801-805 Author(s): Soukup, Dylan S, O'Malley, Martin J, Ellis, Scott J Abstract: Routine histopathological examination has previously been scrutinized as a source of extraneous cost in orthopedic foot and ankle care. As an increasingly prevalent joint replacement operation, total ankle replacement poses a notable cost to the health care market in an era of cost containment. The purpose of this study was to compare the costs and benefits of routine histopathological examination of specimens removed during total ankle replacement. We hypothesized that a new diagnosis would rarely be found and such examination would seldom alter patient care. A retrospective review was conducted of all total ankle replacement operations between 2006 and July 2014 at the investigators' institution. Medical records for 90 patients, undergoing a total of 95 total ankle replacement operations, were reviewed to determine the clinical and pathological diagnoses for each operation and, subsequently, the rates of discrepancy and discordance. Professional charges were determined using estimated reimbursement rates for the Current Procedural Terminology (CPT) codes billed: 88304 (level III microscopic examination), 88305 (level IV microscopic examination), and 88311 (decalcification). Degenerative joint disease was diagnosed by the pathologist in 93.7% of cases (89/95), pseudogout in 4.2% (4/95), and rheumatoid arthritis in 2.1% (2/95). The 4 diagnoses of pseudogout were the only cases of new diagnoses based on pathological review. A total of $16 536.81 was spent for examination of all specimens, for an estimated $4 134.20 spent per discrepant diagnosis. Patient care was unaffected by pathological examination. A new diagnosis was rarely found by histopathological examination, and patient care remained unaltered in all cases. The costs of routine histopathological examination of tissue specimens removed during total ankle replacement, therefore, outweigh clinical benefits, and such examination should be left to the discretion of the operating surgeon. Level IV, retrospective case series.

Title: Contemporary Medical and Surgical Management of X-linked Hypophosphatemic Rickets.

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Citation: The Journal of the American Academy of Orthopaedic Surgeons, Jul 2015, vol. 23, no. 7, p. 433-442 Author(s): Sharkey, Melinda S, Grunseich, Karl, Carpenter, Thomas O Abstract: X-linked hypophosphatemia is an inheritable disorder of renal phosphate wasting that clinically manifests with rachitic bone pathology. X-linked hypophosphatemia is frequently misdiagnosed and mismanaged. Optimized medical therapy is the cornerstone of treatment. Even with ideal medical management, progressive bony deformity may develop in some children and adults. Medical treatment is paramount to the success of orthopaedic surgical procedures in both children and adults with X-linked hypophosphatemia. Successful correction of complex, multiapical bone deformities found in patients with X-linked hypophosphatemia is possible with careful surgical planning and exacting surgical technique. Multiple methods of deformity correction are used, including acute and gradual correction. Treatment of some pediatric bony deformity with guided growth techniques may be possible.

Patient care and management

Title: Orthopaedic Surgeons as Clinical Leaders in the National Health Service, United Kingdom (NHS UK): Can the World Learn From Us? Citation: Journal of the College of Physicians and Surgeons--Pakistan : JCPSP, Jul 2015, vol. 25, no. 7, p. 531-533 Author(s): Javed, Mustafa, Moulder, Elizabeth, Mohsen, Amr Abstract: This article outlines some of the key concepts in leadership (both styles and theories) to provide a platform for further learning and to help the modern day orthopaedic surgeons to apply these concepts to their current practice. It is focused on two major aspects: management of medical organizations and effective twenty-first century care by surgeons through proper leadership guide and aimed in improving patient care outcomes. Practicing proper leadership skills based on evidence resulted in effective management of organization. Thus achieving patient's satisfaction.

Title: Prevention training of wrong-site spine surgery. Citation: Journal of surgical education, Jul 2015, vol. 72, no. 4, p. 680-684 Author(s): Mesfin, Addisu, Canham, Colin, Okafor, Louis Abstract: Wrong-site surgery (WSS) is considered a sentinel event by the Joint Commission. The education of spine surgery fellows on WSS is unknown. Our objective was to evaluate North American spine surgery fellows' education, awareness, and experience with WSS. Observational survey study. Spine surgery fellows in North America. From April 2013 to July

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2013 and in July 2014 anonymous questionnaires were sent to 156 spine surgery fellows participating in 75 programs. Demographic information (fellowship location and Accreditation Council for Graduate Medical Education accreditation of the fellowship) were collected. We also collected data on the following: if didactics on WSS are offered during fellowship, spine surgery fellows' experience with WSS, WSS prevention methods used during fellowship, and whether spine surgery fellows are interested in didactics or webinars on the prevention of WSS. Of 152 spine surgery fellows, 46 (30.3%) completed the questionnaires. Among them, 39 (84.6%) were orthopedic surgeons and 7 (15.4%) were neurosurgeons. Most were in non-Accreditation Council for Graduate Medical Education-accredited programs (70%) and were in training in the Midwest (37%), the South (30.4%), the Northeast (15.2%), and the West (15.2%). Furthermore, 30.4% had experienced WSS. Only 15 fellows (33%) had formal didactics on WSS during their fellowship. Most spine surgery fellows (61%, p = 0.03) were interested in a formal didactics on the prevention of WSS during their fellowship curriculum. Most (58.7%) were also interested in a Webinar on the prevention of WSS. We found of the 14 fellows that experienced WSS, 11 (79%) were significantly interested in formal didactics on WSS compared with those who had not experienced WSS (14/32, 44%; p < 0.02). This is the first study evaluating spine surgery fellowship education on WSS. Among the spine surgery fellows, 30% had already experienced WSS and only 33% had formal fellowship didactics on WSS. Owing to the significant patient care and medicolegal ramifications from WSS, spine surgery fellowships should consider adding WSS prevention didactics to their curriculum.

Title: Costs Versus Benefits of Routine Histopathological Examination in Total Ankle Replacement. Citation: Foot & ankle international, Jul 2015, vol. 36, no. 7, p. 801-805 Author(s): Soukup, Dylan S, O'Malley, Martin J, Ellis, Scott J Abstract: Routine histopathological examination has previously been scrutinized as a source of extraneous cost in orthopedic foot and ankle care. As an increasingly prevalent joint replacement operation, total ankle replacement poses a notable cost to the health care market in an era of cost containment. The purpose of this study was to compare the costs and benefits of routine histopathological examination of specimens removed during total ankle replacement. We hypothesized that a new diagnosis would rarely be found and such examination would seldom alter patient care. A retrospective review was conducted of all total ankle replacement operations between 2006 and July 2014 at the investigators' institution. Medical records for 90 patients, undergoing a total of 95 total ankle replacement operations, were reviewed to determine the clinical and pathological diagnoses for each operation and, subsequently, the rates of discrepancy and discordance. Professional charges were determined using estimated reimbursement rates for the Current Procedural Terminology (CPT) codes billed: 88304 (level III microscopic examination), 88305 (level IV microscopic examination), and 88311 (decalcification). Degenerative joint disease was diagnosed by the pathologist in 93.7% of cases (89/95), pseudogout in 4.2% (4/95), and rheumatoid arthritis in 2.1% (2/95). The 4 diagnoses of pseudogout were the only cases of new diagnoses based on pathological review. A total of $16 536.81 was spent for examination of all specimens, for an estimated $4 134.20 spent per discrepant diagnosis.

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Patient care was unaffected by pathological examination. A new diagnosis was rarely found by histopathological examination, and patient care remained unaltered in all cases. The costs of routine histopathological examination of tissue specimens removed during total ankle replacement, therefore, outweigh clinical benefits, and such examination should be left to the discretion of the operating surgeon. Level IV, retrospective case series.

Title: "WhatsApp"ening in orthopedic care: a concise report from a 300-bedded tertiary care teaching center. Citation: European journal of orthopaedic surgery & traumatology : orthopédie traumatologie, Jul 2015, vol. 25, no. 5, p. 821-826 Author(s): Khanna, Vishesh, Sambandam, Senthil N, Gul, Arif, Mounasamy, Varatharaj Abstract: Smartphones have emerged as essential tools providing assistance in patient care, monitoring, rehabilitation, communication, diagnosis, teaching, research and reference. Among innumerable communication apps, WhatsApp has been widely popular and cost effective. The aim of our study was to report the impact of introduction of a smartphone app "WhatsApp" as an intradepartmental communication tool on (1) awareness of patient-related information, (2) efficiency of the handover process and (3) duration of traditional morning handovers among orthopedic residents in a 300-bedded tertiary care teaching center. Written handovers and paging used for communication at our center led to occasional inefficiencies among residents. Widespread use, low cost, availability and double password protection (phone lock and WhatsApp lock) made WhatsApp's group conversation feature an ideal tool for intradepartmental patient-related communication. Twenty-five consecutive admissions before and after WhatsApp (BW, AW) were included in the study. Eight orthopedic residents attempted fifty randomly arranged questions based on the twenty-five patients in each study period. A null hypothesis that introduction of WhatsApp group would neither increase the awareness of patient-related information nor improve the efficiency of the handovers among residents was assumed. A significant improvement observed in scores obtained by residents in the AW group led to rejection of the null hypothesis. The residents also reported swifter and efficient handovers after the introduction of WhatsApp. Our results indicate that the introduction of a smartphone app "WhatsApp" as an intradepartmental communication tool can bring about an improvement in patient-related awareness, communication and handovers among orthopedic residents.

Title: Metaphyseal osteomyelitis in children: how often does MRI-documented joint effusion or epiphyseal extension of edema indicate coexisting septic arthritis? Citation: Pediatric radiology, Jul 2015, vol. 45, no. 8, p. 1174-1181 Author(s): K Schallert, Erica, Herman Kan, J, Monsalve, Johanna, Zhang, Wei, Bisset, George S, Rosenfeld, Scott Abstract: Joint effusions identified by MRI may accompany osteomyelitis and determining whether the joint effusion is septic or reactive has important implications on patient care.

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Determine the incidence of epiphyseal marrow edema, joint effusions, perisynovial edema and epiphyseal non-enhancement in the setting of pediatric metaphyseal osteomyelitis and whether this may be used to predict coexisting septic arthritis. Following IRB approval, we retrospectively evaluated children who underwent MRI and orthopedic surgical consultation for suspected musculoskeletal infection between January 2011 and September 2013. Criteria for inclusion in the study were microbiologically/pathologically proven infection, MRI prior to surgical intervention, long bone involvement and age 0-18 years. MRI exams were independently reviewed by two faculty pediatric radiologists to confirm the presence of appendicular metaphyseal osteomyelitis, to evaluate extent of edema, to determine subjective presence of a joint effusion and to assess perisynovial edema and epiphyseal non-enhancement. Any discrepant readings were reviewed in consensus. Charts and operative notes were reviewed to confirm the diagnosis of osteomyelitis and septic arthritis. One hundred and three joints with metaphyseal osteomyelitis were identified (mean age: 7.1 years; M:F 1.3:1), of whom 53% (55/103) had joint effusions, and of those, 75% (41/55) had surgically confirmed septic arthritis. The incidence of coexisting septic arthritis was 40% in the setting of epiphyseal edema, 74% in epiphyseal edema and effusion, 75% with perisynovial edema, 76% with epiphyseal non-enhancement and 77% when all four variables were present. Of these, the only statistically significant variable, however, was the presence of a joint effusion with a P-value of <0.0001 via Fisher exact test. Statistical significance for coexisting septic arthritis was also encountered when cases were subdivided into intra-articular vs. extra-articular metaphyses (P-value = 0.0499). No statistically significant difference was found between patients younger than 24 months and those older than 24 months. Patients with joint effusions identified by MRI, in the setting of metaphyseal osteomyelitis, should be presumed to have septic arthritis until proven otherwise. Epiphyseal extension of edema, perisynovial edema and epiphyseal non-enhancement in the setting of metaphyseal osteomyelitis are not helpful predictors in differentiating reactive and pyogenic joint effusions. Osteomyelitis at a site with an intra-articular metaphyses, however, is more likely to have concurrent septic arthritis.

Title: Do Elderly Patients Use Patient-Controlled Analgesia Medication Delivery Systems Correctly? Citation: Orthopedic nursing, Jul 2015, vol. 34, no. 4, p. 203-208 Author(s): Brown, Amanda, Boshers, Bridget, Chapman, Lindsey Floyd, Huckaba, Kim, Abstract: Although prior studies have shown patient-controlled analgesia (PCA) to be appropriate for use by children and adults, no studies have specifically evaluated the ability of elderly patients to use the technology correctly. To determine whether elderly, postoperative patients can properly use PCA devices. Using a descriptive study design, a convenience sample of elderly, postoperative orthopedic patients was observed while using a PCA device and surveyed about the proper use of the device. Participants were observed and surveyed 12 to 20 hours after admission to the postoperative patient care unit. Frequency and amount of analgesic medication administration over the postoperative time period were also recorded. Data were summarized with descriptive statistics and multiple regression analysis was used to determine whether confounding variables explained problems using the PCA device correctly. A total of 58 orthopedic patients were studied

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during the first day after surgery. Patients had used the PCA device for 16.6 ± 3.0 (mean ±SD) hours at the time of the observation and survey. Virtually all patients correctly identified and depressed the PCA activation button when instructed, knew when to use the PCA device, and who was allowed to depress the PCA button. Slightly more than half of the patients (57%) correctly identified how often they could have PCA medication, with 38% not sure of PCA medication frequency. The PCA medication was requested an average of 23.3 ± 52.7 times during the study period. The majority of the patients (86%) requested PCA medication less than 25% of the times that they could receive PCA medication. All patients in the study had PCA devices programmed to deliver up to 5 doses per hour of PCA medication, yet an average of 11.2 ± 10.8 doses of PCA medication were actually delivered during the entire study period (average 16.6 hours). Average doses of fentanyl and morphine sulfate received by patients were 13.5 μg/hour and 1.0 mg/hour, respectively. Elderly patients were very knowledgeable about how to use the PCA device but not about how often they could receive PCA medication. This lack of knowledge may have influenced how often they requested pain medication, because almost 90% of patients received less than 25% of the PCA allowable medication dose. This low usage of PCA medication delivery calls into question the cost-effectiveness of this method of medication delivery for the elderly. Additional studies are needed to verify these findings in other elderly patients.

Title: Two admission pathways for elderly patients with hip fracture: Clinical outcomes at a single institution Citation: Current Orthopaedic Practice, July 2015, vol./is. 26/4(387-394) Author(s): Godin J., Brown C., Mardam-Bey S., Deshpande C., Manson M., Boling J., Olson S., Zura R. Abstract: Background: The incidence of hip fractures increases exponentially after the age of 65, and that number will continue to rise over the coming decades as the population ages. In an attempt to provide better patient care for elderly patients with hip fractures and multiple co-morbidities, some centers have created various forms of shared-responsibility services, multidisciplinary care teams, or hospitalist models of care for these patients. The purpose of this study was to examine the clinical outcomes of two different admission pathways for elderly patients with hip fractures. Methods: We conducted a retrospective review of 389 consecutive patients 65 yr of age and older with the diagnosis of a low-energy hip fracture between January 2006 and May 2010 at a single institution. Patients who presented to the study institution before October 2008 were admitted to either the orthopaedic surgery or the internal medicine service (old pathway, OP). Beginning in October 2008, all elderly patients with a low-energy hip fracture were admitted to the internal medicine service with a more structured, uniform clinical pathway in place (new pathway, NP). We evaluated differences in perioperative complication rates, readmission rates, time to surgery (TTS), and length of hospital stay (LOS) between the two pathways. Results: There were no significant differences in LOS, TTS, 30-day re-admission rates, rapid response codes, perioperative complications or death between the care models. The NP did demonstrate a significant increase in blood product transfusions over the OP (51.85% compared with 36.56%, respectively) and the number of patients diagnosed with vitamin D deficiency (42.12% compared with 20.70%, respectively). Conclusions: While our change in

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protocol did not alter the rate of perioperative complications, TTS, readmissions rates, or LOS it did provide more comprehensive osteoporosis care to our patients.

Other

Title: Does Fracture Care Make Money for the Hospital? An Analysis of Hospital Revenues and Costs for Treatment of Common Fractures. Citation: Journal of orthopaedic trauma, Jul 2015, vol. 29, no. 7, p. e219. Author(s): Kleweno, Conor P, OʼToole, Robert V, Ballreich, Jeromie, Pollak, Andrew N Abstract: To determine the relative profitability for a hospital of treatment of common fractures within a state-regulated reimbursement system. Retrospective cohort. Regional trauma referral center with state-regulated hospital reimbursement system. We reviewed hospital medical and financial records of 1228 patients admitted from 2008 through 2012 with a principle diagnosis of acute traumatic fracture requiring surgical treatment. Patients whose principle diagnosis fit into 1 of 6 common anatomic categories were included. Sixty-five pelvic, 275 acetabular, 277 hip, 255 femoral shaft, 148 tibial shaft, and 208 ankle fractures were identified. Patients with a different principle diagnosis were excluded. Net revenue, total cost of inpatient care, and direct margin for each patient's acute inpatient hospital course were recorded. Direct margins, costs. Per patient, the overall mean net revenue was $39,813, overall mean cost of inpatient care was $21,231, and overall mean direct margin (profitability) was $18,582. Mean direct variable expense was $14,898 per patient, and mean direct fixed expense was $6333 per patient. Factors most influencing cost included length of stay, supplies, and operating room use. Of 1228 patients, 46 (3.7%) had a negative direct margin (net loss to hospital). The most profitable diagnosis was pelvic fracture (mean direct margin, $21,767). The state-regulated reimbursement system allows analysis of hospital profitability in the context of a normalized revenue stream that should approximate the overall fiscal realities of other states. Providing orthopaedic trauma care can be economically feasible and profitable for a hospital. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Title: The 50 Most-cited Articles in Orthopaedic Surgery From Mainland China. Citation: Clinical orthopaedics and related research, Jul 2015, vol. 473, no. 7, p. 2423-2430 Author(s): Jia, Zhiwei, Ding, Fan, Wu, Yaohong, He, Qing, Ruan, Dike Abstract: Citation analysis has been widely used to evaluate the impact of articles in medical and surgical specialties. Although China is the most populous country in the world, and although more than 50,000 orthopaedic surgeons practice there, to our knowledge no formal citation analysis of Chinese orthopaedic articles has been performed. We identified the 50 most-cited orthopaedic articles from mainland China and evaluated these articles in terms of their language of publication, source journals, and topics. Science Citation Index Expanded was searched in July 31, 2014 for citations of articles published in 70 selected

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journals since the inception of the database. The 50 most-cited orthopaedic articles originating in mainland China were identified. Basic information, including title, authors, year of publication, article type, journal in which the work was published, city, institution, number of citations, decade published, and topic or subspecialty of the research were recorded. The number of citations for the top 50 papers ranged from 181 to 31 (mean, 52). These articles were published between 1981 and 2010. The decade of 2000 to 2009 was the most prolific, with 36 of the top 50 articles published during this time. All articles were written in English and they were published in a total of 16 journals. The journal Spine published the largest number of articles (12), followed by Clinical Orthopaedics and Related Research (®) (seven). The journal Lancet had the highest impact factor (39.207 for 2013) among any of the journals that published articles we identified. The top 50 articles originated mainly from Beijing (16) and Shanghai (12), with basic research being the focus of the majority (27 of 50; 54%); the remaining were clinical studies. Bone was the most-investigated topic in basic research; the spine was the most-common topic among the identified clinical studies. The 50 most-cited articles that we identified should be considered influential, although a large gap remains between mainland China and the global orthopaedic community in terms of citations per article. Nevertheless, insofar as the most-recent decade of our survey generated the most articles in this top-50 list, we would characterize mainland China's effect on musculoskeletal research as increasing, and as funding increases to programs in mainland China, we anticipate this trend will continue in the future.

Title: Undergraduate and foundation training in trauma and orthopaedics: junior doctors have their say. Citation: British journal of hospital medicine (London, England : 2005), Jul 2015, vol. 76, no. 7, p. 415-419, 1750-8460 (July 2015) Author(s): Ghani, Yaser, Thakrar, Raj R, Palmer, Jon, Konan, Sujith, Donaldson, James, Olivier, Andre, Gikas, Panos, Briggs, Tim Abstract: Undergraduate education in musculoskeletal health is currently insufficient in most medical schools worldwide, in both basic sciences and clinical training. A national survey was carried out to obtain views of current doctors from various specialties about undergraduate and foundation training in trauma and orthopaedics.

Title: Going Paperless? Issues in Converting a Surgical Assessment Tool to an Electronic Version. Citation: Teaching and learning in medicine, Jul 2015, vol. 27, no. 3, p. 274-279 (2015 Jul-Sep) Author(s): Dudek, Nancy L, Papp, Steven, Gofton, Wade T Abstract: Construct: The competence of a trainee to perform a surgical procedure was assessed using an electronic tool. "Going paperless" in healthcare has received significant attention over the past decades given the numerous potential benefits of converting to

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electronic health records. Not surprisingly, medical educators have also considered the potential benefits of electronic assessments for their trainees. What literature exists on the transition from paper-based to electronic-based assessments suggests a positive outcome. In contrast, work done examining the transition to and implementation of electronic health records has noted that hospitals who have implemented these systems have not gone paperless despite the benefits of doing so. This study sought to transition a paper-based assessment tool, the Ottawa Surgical Competency Operating Room Evaluation (which has strong evidence for validity) to an electronic version, in three surgical specialties (Orthopedic Surgery, Urology, General Surgery). However, as the project progressed, it became necessary to change the focus of the study to explore the issues of transitioning to a paperless assessment tool as we identified an extremely low participation rate. Over the first 3 months 440 assessment cases were logged. However, only a small portion of these cases were assessed using the electronic tool (Orthopedic Surgery = 16%, Urology = 5%, General Surgery = 0%). Participants identified several barriers in using the electronic assessment tool such as increased time compared to the paper version and technological issues related to the log-in procedure. Essentially, users want the tool to be as convenient as paper. This is consistent with research on electronic health records implementation but different from previous work in medical education. Thus, we believe our study highlights an important finding. Transitioning from a paper-based assessment tool to an electronic one is not necessarily a neutral process. Consideration of potential barriers and finding solutions to these barriers will be necessary in order to realize the many benefits of electronic assessments.

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Journal Tables of Contents

The most recent issues of the following journals:

Journal of Bone and Joint Surgery

Journal of Orthopaedic Trauma

Injury

Strategies in Trauma and Limb Construction

Clinical Orthopaedics and Related Research

Click on the links for abstracts. If you would like any of these papers in full text then get in touch: librarys@uhbristol.nhs.uk

Journal of Bone and Joint Surgery Vol. 97, iss. 15, August 2015

Journal of Orthopaedic Trauma Vol. 29, iss. 8, Augustl 2015

Injury Vol. 46, iss. 8, August 2015

Strategies in Trauma and Limb Construction

Vol. 10, iss. 1, April 2015

Clinical Orthopaedics and Related Research

Vol. 473, iss. 8, August 2015

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