'Out of hours' orthopaedics in an Irish regional trauma unit and the impact of COVID-19.

INTRODUCTION: MRHT is the regional trauma service for the Midlands, providing 24/7 orthopaedic cover. 'Out of hours' surgery is reserved for those occasions where waiting for the next operating list during normal working hours would result in an unacceptable outcome for the patient. AIMS: To identify how many 'out-of-hours' surgeries were performed and what proportion of the total workload was made up by these cases. Secondly, to identify the impact of COVID-19 on our workload as an acute trauma service. METHODS: We performed a retrospective analysis of all operations performed in the emergency orthopaedic theatre between January 2017 and October 2020. Included were all emergency orthopaedic procedures performed after 6 p.m. and before 8 a.m. We compared this to the total number of trauma surgeries performed in the same time period to calculate the percentage of our total operations. RESULTS: There were a total of 7615 orthopaedic trauma operations performed in the 193 weeks. 164 of these were 'out-of-hours'. This represents 2.2% of the total operations performed and is equal to 0.84 cases per week. 55 of the 164 (33.5%) were performed in children under the age of 18. 62 were performed between 6 and 8 p.m., 61 between 8 and 10 p. m., 31 between 10 p.m. and midnight, and the remaining 10 were performed between midnight and 3 a.m. CONCLUSION: Surgery out of hours has been associated with increased complications, and so decisions to perform emergency surgery should not be made lightly. However, sometimes they are unfortunately necessary and are some of the most important operations we can perform as orthopaedic surgeons.

Orthopaedic Hand Surgical Simulation Training: A Review

In recent years, new orthopaedic surgical simulation and virtual reality (VR) training models have emerged to provide unlimited education medium to an unlimited number of trainees with no time limit, especially in response to trainee work-hour restrictions. Surgical simulators range from simple wooden boxes to animal and cadaver models to three-dimensional-printed and VR simulators. The coronavirus disease 2019 pandemic further highlighted the need for at-home learning tools for orthopaedic surgical trainees. Advancement in simulating shoulder and knee arthroscopies using VR simulators surpasses the other fields in orthopaedic surgery. Despite the high degree of precision needed to operate at a microscopic level involving vessels, nerves, and the small bones of the hand, the simulation tools have limited advancement in the field of orthopaedic hand surgery. This narrative review summarizes the status of surgical simulation and training techniques available to orthopaedic hand surgical trainees, factors affecting their application, and areas in hand surgery that still lag behind their surgical subspecialty counterparts.

Spontaneous Avascular Necrosis of the Humeral Head Following COVID-19 Vaccination.

We report a case of a 40-year-old man who presented with left shoulder pain and marked functional impairment two days after receiving the second dose of the Pfizer COVID-19 vaccine. Advanced imaging demonstrated focal avascular necrosis (AVN) of his humeral head. Initial management included simple analgesics, activity modification, and an ultrasound-guided intra-articular hydrodilatation injection. The patient subsequently had an improved range of motion but persistent severe shoulder pain. He has now been offered surgical intervention. Despite having risk factors for developing AVN previously, the patient did not demonstrate any recent risk factors for developing the disease. COVID-19 vaccination is known to cause severe joint pain and stiffness rarely. However, avascular necrosis is not a known or documented side effect. His symptoms arose directly after the administration of the vaccine, with no other demonstrable cause. Therefore, we are reporting COVID-19 vaccination as a potential new risk factor for AVN of the humeral head.

Smart Phone Chat Apps for Teaching and Assessment in Orthopaedic Residency Training.

Introduction: Smart Phone Chat Apps (SPCA) is an integral part of people's daily routine including orthopaedic education. SPCA facilitates efficient communication and learner-based management especially now as remote flexible learning is becoming the new norm in this COVID-19 pandemic medical training. The study described the use of a chat app (Viber) as experienced by residents and consultants in the Section of Adult Orthopaedics of the institution of the principal author. It described the mode and dynamics of the chat discussion amongst its participants, its perceived usefulness in teaching and learning specifically its relevance and applicability, its potential as a supplementary assessment tool, as well as its perceived effects. Materials and methods: This is a phenomenological study and strictly adhered to data privacy. The principal author conducted a participant observation of residents' three-month clinical rotation at the study site. Mobile phone screenshots of the chat interactions and focus group discussions with consultants and residents were done. Residents were also requested to complete a questionnaire. All qualitative data were iteratively content analysed and emerging themes were summarised using NViVO-12. Frequencies and percentage distribution were used to analyse quantitative data. Results: Respondents included eleven senior, four junior residents, and nine consultants. Results show that SPCA is a useful, applicable, and relevant teaching and assessment tool. Influxes of multiple ideas per case were discussed real-time as the chat exchanges and interactions helped in the planning of the surgical management and eventual decision-making. SPCA also served as an effective surgical case log and online library, as well as an efficient, rapid, economical mode of information dissemination. The residents reported that it helped in developing their emotional maturity through self-reflection and self-criticism in the performance of their cases. The consultants concurred and added that they too were updated professionally in certain fields in orthopaedics. Conclusion: The SPCA is a helpful, relevant, and acceptable adjunct teaching and learning tool for clinical teaching and can be, to a certain extent, a supplementary formative assessment tool of the resident's communication skills, work ethics, initiative, and diligence.

COVID-19 is associated with increased care needs and a decreased likelihood of returning home following a hip fracture: The IMPACT frailty study.

PURPOSE: The primary aim was to evaluate the impact of COVID-19 on frailty in patients surviving a hip fracture. Secondary aims were to assess impact of COVID-19 on (i) length of stay (LoS) and post-discharge care needs, (ii) readmissions, and (iii) likelihood of returning to own home. METHODS: This propensity score-matched case-control study was conducted in a single centre between 01/03/20-30/11/21. A 'COVID-positive' group of 68 patients was matched to 141 'COVID-negative' patients. 'Index' and 'current' Clinical Frailty Scale (CFS) scores were assigned for frailty at admission and at follow-up. Data were extracted from validated records and included: demographics, injury factors, COVID-19 status, delirium status, discharge destination, and readmissions. For subgroup analysis controlling for vaccination availability, the periods 1 March 2020-30 November 2020 and 1 February 2021-30 November 2021 were considered pre-/post-vaccine periods. RESULTS: Median age was 83.0 years, 155/209 (74.2%) were female and median follow-up was 479 days (interquartile range [IQR] 311). There was an equivalent median increase in CFS in both groups (+1.00 [IQR 1.00-2.00, p = 0.472]). However, adjusted analysis demonstrated COVID-19 was independently associated with a greater magnitude change (Beta coefficient [ß] 0.27, 95% confidence interval [95% CI] 0.00-0.54, p = 0.05). COVID-19 in the post-vaccine availability period was associated with a smaller increase versus pre-vaccine (ß -0.64, 95% CI -1.20 to -0.09, p = 0.023). COVID-19 was independently associated with increased acute LoS (ß 4.40, 95% CI 0.22-8.58, p = 0.039), total LoS (ß 32.87, 95% CI 21.42-44.33, p < 0.001), readmissions (ß 0.71, 95% CI 0.04-1.38, p = 0.039), and a four-fold increased likelihood of pre-fracture home-dwelling patients failing to return home (odds ratio 4.52, 95% CI 2.08-10.34, p < 0.001). CONCLUSIONS: Hip fracture patients that survived a COVID-19 infection had increased frailty, longer LoS, more readmissions, and higher care needs. The health and social care burden is likely to be higher than prior to the COVID-19 pandemic. These findings should inform prognostication, discharge-planning, and service design to meet the needs of these patients.

The rise in trauma & orthopaedic trainee-led research and audit collaborative projects in the United Kingdom since the start of the COVID-19 pandemic.

Background and Objective: A significant increase has been observed globally in multi-centre trainee-led trauma & orthopaedic (T&O) research collaborative projects with more emphasis have been on tackling important research questions since the start of the COCID-19 pandemic. The objective of our analysis was to determine the number of trainee-led research collaborative projects in T&O in the United Kingdom that were started during the COVID-19 pandemic. Methods: A retrospective analysis was conducted to determine how many trainee-led national collaborative projects in T&O were conducted since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021) and the number of projects identified were compared to the previous year (2019). Any regional collaborative projects, projects that were started before the onset of COVID and projects of other surgical specialities were not included in the study. Results: There were no projects identified in 2019 while in the Covid pandemic lockdown we identified 10 trainee-led collaborative trauma & orthopaedic projects with six of them being published with level of evidence from three to four. Conclusion: Covid was unprecedented and has placed considerable trials across healthcare. Our study highlights an increase in multi-centre trainee-led collaborative projects within the UK and it underlines the feasibility of such projects especially with the advent of social media and Redcap® which facilitate recruitment of new studies and data.

Online case-based educational meetings can increase knowledge, skills, and widen access to surgical training:The nationwideVirtualTrauma & Orthopaedic Meetingseries.

BACKGROUND: Access to surgical training is challenging for undergraduate and early postgraduate trainees due to a greater focus on developing generic knowledge and skills, and a drive to recruit greater numbers into internal medicine and primary care. COVID-19 accelerated the declining access to surgical training environments. Our aims were to: 1) establish the feasibility of an online, specialty-specific, case-based surgical training series, and 2) evaluate its suitability for meeting the needs of trainees. METHODS: A nationwide audience of undergraduate and early postgraduate trainees were invited to a series of bespoke online case-based educational meetings in Trauma & Orthopaedics (T&O) over a six month period. The six sessions, which simulated real-world clinical meetings, were constructed by Consultant sub-specialists and involved the presentation of cases by registrars, followed by structured discussion of basic principles, radiological interpretation, and management strategies. Mixed qualitative and quantitative analyses were conducted. RESULTS: There were 131 participants (59.5% male), consisting mostly of doctors in training (58%) and medical students (37.4%). The mean quality rating was 9.0/10 (SD 1.06), further supported by qualitative analysis. 98% enjoyed the sessions, 97% reported improved knowledge of T&O, and 94% reported a direct benefit to clinical practice. There was a significant improvement in knowledge of T&O conditions, management plans, and radiological interpretation (p = <0.05). CONCLUSION: Structured virtual meetings, underpinned by bespoke clinical cases, may widen access to T&O training, increase flexibility and robustness of learning opportunities, and mitigate the effects of reduced exposure on preparation for surgical careers and recruitment.

The impact of the COVID-19 pandemic on the orthopaedics outpatient clinic

OBJECTIVE: The COVID-19 pandemic has significantly impacted orthopaedic practice since it started. In our study, we aimed to examine these effects on outpatient services. PATIENTS AND METHODS: The patients who applied to the orthopedic outpatient clinic (n=1,518) in six months period under the effect of the COVID-19 pandemic (September 2020-March 2021) and patients (n=1,207) who applied during the same period before the pandemic (September 2019-March 2020) were analyzed according to the demographic characteristics (age, gender), reasons for admission, duration of complaints, treatments applied, surgical acceptance rate, and compliance with treatment. RESULTS: The m ean age in the pre-pandemic outpatient clinic admissions was 39.1 years (1-91 years), the gender ratio was 635/572 (Female/Male), the mean age of the patients was 38.1 years (1-95), and the sex ratio was 793/ 725 (F/M) during the pandemic. Admissions of patients with acute complaints decreased after the pandemic, and applications for subacute or chronic complaints increased. Applications for sports medicine, pediatrics, and hand surgery increased, applications for trauma, foot and ankle surgery decreased, and applications for oncology and spine did not change. Conservative treatment recommendations decreased, the surgical treatment recommendation did not change, and the rate of patients who were given only follow-up decisions increased. There was no significant difference in the treatment rejection and surgical acceptance rate. CONCLUSIONS: We observed that the number of traumas decreased, and the hospital admission duration extended. The increase in the consultation rate and follow-up preference indicates that the treatment is more conservative in this period. In this process, patients should be adequately informed about the precautions taken, and their treatment should not be interrupted.

Predicted waiting times for orthopaedic surgery : an urgent need to address the deficit in capacity.

Cite this article: Bone Joint Res 2022;11(12):890-892.

Telemedicine in orthopaedics and trauma surgery during the first year of COVID pandemic: a systematic review.

PURPOSE: Prior to the COVID-19 pandemic, telemedicine in orthopaedics and trauma surgery had mostly developed for joint arthroplasty, fracture management, and general pre- and postoperative care including teleradiology. With the corona-outbreak, telemedicine was applied on a broad scale to prevent assemblage and to guarantee access to medical care protecting critical areas. The purpose of the present study was to give an overview of the spectrum of clinical applications and the efficacy of telemedicine in orthopaedic and trauma surgery as published in times of the COVID-19 pandemic. METHODS: All published studies investigating the application of telemedicine related to orthopaedics and trauma during the COVID-19 pandemic were accessed and screened for suitability. The primary outcome of interest was the efficacy of telemedicine in various clinical applications. The secondary outcome of interest was the spectrum of different applications in which telemedicine applications were investigated. RESULTS: The literature search resulted in 1047 articles. After the removal of duplicates, 894 articles were screened of which 31 finally met the inclusion criteria. Dimensions that were described by studies in the literature to have positive effects were preoperative patient optimisation, the usefulness of telemedicine to correctly diagnose a condition, conservative treatment, willingness to and feasibility for telemedicine in patients and doctors, and postoperative/post-trauma care improvement. The efficacy of telemedicine applications or interventions thereby strongly varied and seemed to depend on the exact study design and the research question addressed. CONCLUSION: Various successful applications of telemedicine have already been reported in orthopaedics and trauma surgery, with a strong increase in scientific output during the COVID-19 years 2020-2021. Whether the advantages of such an approach will lead to a relevant implementation of telemedicine in everyday clinical practice should be monitored after the COVID-19 pandemic.

Satisfaction and feasibility of videoconsultation (VC) in orthopaedic and trauma surgery in the context of the COVID-19 pandemic: Prospective study of 783 patients.

BACKGROUND: The COVID-19 pandemic has required that specialists use videoconsultation (VC) to maintain continuity of care. As in-person consultations (IPCs) and surgical procedures were cancelled, VC became the tool of choice. No recent French study has assessed VC as the main consultation modality. The objective of this prospective study was to evaluate: 1) patient satisfaction, 2) access to and the future of VC, 3) and the reasons for VC refusal in the setting of the pandemic. HYPOTHESIS: Patients responded favourably to VC. PATIENTS AND METHOD: We conducted a prospective, single-centre, observational study of consecutive patients who were invited to switch from IPC to VC during the lockdown of March 16 to May 11, 2020, when IPCs were not available. All patients were included in the study, regardless of whether they accepted the VC. The reasons for refusal were recorded at the time of the invitation. The surgeons sent the patients who accepted an emailed satisfaction questionnaire after the VC. RESULTS: Of the 783 patients with scheduled IPCs, 291 (37.2%) accepted a VC instead, 408 (52.1%) refused the VC, and 84 (10.7%) could not be contacted by telephone and were therefore excluded. The VC acceptance rate was 37% (291/783). Of the 291 VC patients, 233 (80.1%) returned the satisfaction questionnaire, although 2 questionnaires had too many missing data to be included, leaving 231 patients for the analysis. The VC was the first consultation with the surgeon for 66 (28.6%) patients. Of the 165 (71.4%) other patients, 51.6% (85/165) were receiving post-operative follow-up. On a 0-5 scale, the global VC experience was scored 4.3±0.8. Of the 231 VC patients, 161 (69.7%) felt that the VC was equivalent to an IPC, 18 (7.8%) that it was poorer, and 7 (3%) that it was better than an IPC; 45 (19.5%) had no opinion on this point. If choosing between a VC or an IPC had been possible during this first lockdown, 168/231 (72.7%) patients would have chosen an IPC. In contrast, 198/231 (85.7%) patients said they would choose an IPC after the lockdown. The group that refused the VC had a significantly older mean age (57.8±16.4 years vs. 48.0±14.4 years, p<0.0001) and lived closer to the institution (p<0.0001), whereas the sex distribution was comparable, with 42.9% of males (175/408) refusing and 46.8% (108/231) accepting the VC (p=0.39). The main reason for refusal was a wish for an in-person encounter with the surgeon (268/408, 65.7%). Patients aged ≥65 years were more likely to refuse due to technical considerations (access to electronic equipment and to the Internet), whereas patients ≤35 years were more likely to wait for an IPC. CONCLUSION: The rate of satisfaction with the VC was high. Satisfaction was not significantly associated with the reason for the consultation (joint involved, degenerative or post-traumatic condition, first VC, first consultation, or follow-up before or after surgery). Although most patients who accepted the VC felt that this modality was equivalent to an IPC, many remained desirous of an in-person encounter with the surgeon, notably among the youngest individuals. Outside the setting of a pandemic, the IPC remains the consultation modality of choice for most of our patients. LEVEL OF EVIDENCE: V, prospective study without a control group.

Virtual Arthroplasty Follow-Up: Better for the Trust, Patients, and the Planet.

Background The Virtual Arthroplasty Follow-Up (VARF) Quality Improvement Project was initiated in March 2020 with the aim of improving patient experience while reducing costs to the trust, the patient, and the planet. Methodology This retrospective study was conducted in a district general hospital. Patients were assessed based on their Oxford Hip Score (OHS), University of California, Los Angeles (UCLA) activity score, and an X-ray. A patient satisfaction survey was undertaken via phone call using a 10-point questionnaire. These responses were then correlated to age, distance travelled, and OHS/UCLA scores. The environmental impact was estimated using CO2 emissions for driving and outpatient clinics taken from relevant literature. Results A total of 132 patients were enrolled in the project. Overall, 75% demonstrated a good outcome from both their X-ray and OHS/UCLA scores. Further, 23% of patients required an additional phone call, of which a further 77% were re-enrolled in the VARF pathway. Only five of 132 (3.8%) patients required a face-to-face review. The patient satisfaction survey enrolled 52 patients, 90% of whom were satisfied with the service. Only one patient stated being dissatisfied with the service. Overall, 77% of patients felt that the service saved them time, money, or both. The strongest predictor of patient satisfaction was the OHS (r = 0.52) where a score of <35 was associated with a nine-fold increase in either responding neutral or dissatisfied with the service. Accounting for both travel and clinic space, approximately 8 tonnes of CO2 equivalent were saved. Once time and cost-saving from virtual clinics were included, this project saved the trust £21,408 and patients £948. Conclusions VARF has been shown to be an appropriate way to follow up arthroplasty patients which maintains high patient satisfaction while reducing the environmental impact, saving patients' time and money, and freeing up clinic space for other uses. A potential improvement of the process would be to triage those with low OHS to a more intensive follow-up.

Lessons From a Near-Peer Junior Doctor Teaching Program in Trauma and Orthopedics.

INTRODUCTION:  A junior doctor teaching program delivered by near-peers can foster collaboration in a less-pressured and conducive learning environment. The aim of this study was to provide an analysis of an orthopedic teaching program in a high-resource environment utilizing readily available tools and resources that are potentially available in most hospitals globally.  Methods: This study involved the utilization of an outcome-based learning approach with regular formal feedback. An anonymized Google Forms survey using a 10-point Likert scale was conducted after a 30-week period. The survey tool was sent out to 28 doctors and two senior nurse practitioners who participated in the program either as tutors, learners, or both. A total of 19 out of 30 respondents completed the survey giving a 63% survey completion rate. The setting for this study was the trauma and orthopedics department in a United Kingdom district general hospital. RESULTS:  Learners' confidence in their orthopedic knowledge and skills pre-program had a median response of eight with a mode of seven whereas confidence following engagement on the program improved with a median response of nine and a mode of 10. At an alpha level of 0.05, this observed improvement was statistically significant using the Mann-Whitney U test (p=0.466). Tutors' perception of the usefulness of the teaching feedback had a median response of nine with a mode of 10. Relevance of the selected topics had a median response of nine and a mode of 10. Inclusion in the teaching program to cater to learner diversity had a median response of nine and a mode of 10. The effectiveness of a blended approach for learning had a median response of nine and a mode of 10.  Conclusion: This study has provided evidence of the benefits of a near-peer teaching program. This is especially important in the post-coronavirus disease (COVID) pandemic recovery period where easily accessible and well-grounded educational programs will be useful to complement the deanery teachings for trainees. This is important as this may be the main source of formal teaching for non-trainee junior doctors in many hospital settings. Additional research will be needed to further explore the pros and cons of such programs within a surgical specialty like orthopedics with an emphasis on the various pedagogical approaches to teaching and learning for junior doctors working in a busy clinical setting.

The Impact of the COVID-19 Pandemic on Orthopaedic Knee Procedures: A National Multicentered Analysis.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic strained the United States healthcare system, and associated policies resulted in the postponement or cancellation of many elective surgeries. While most orthopaedic surgeons are aware of how the pandemic affected their patients' care, broader national trends in the operative treatment of orthopaedic knee pathology are poorly characterized. Therefore, the purpose of this study was to identify trends in orthopaedic knee procedures during the COVID-19 pandemic. METHODS: The TriNetX database was queried for orthopaedic knee procedures performed from March 2018 to May 2021. Procedures were classified as arthroplasty (total knee arthroplasty (TKA), revision total knee arthroplasty) or non-arthroplasty (tendon or ligament repair, fracture fixation). Procedural volume per healthcare organization was determined over five seasons from March 2020 to May 2021 and compared to overlapping pre-pandemic periods from March 2018 to May 2019. Descriptive analysis was performed, and comparisons were made using a Student's T-test. RESULTS: Compared to the pre-pandemic period, there were significant decreases in primary TKA (p=0.016), femoral or entire tibial component revision TKA (p=0.005), and open treatment of femoral shaft fractures (p=0.007) in spring 2020. Procedural volume returned to baseline in summer 2020 through winter 2021. In spring 2021, primary TKA (p=0.017) and one component revision TKA (p=0.003) increased compared to the pre-pandemic period. CONCLUSION: The greatest decrease in knee procedures occurred early in the pandemic. Rates of these procedures have since rebounded, with some exceeding pre-pandemic levels. Hospitals are now better able to accommodate orthopaedic surgical volume while continuing to care for patients with COVID-19.

Telemedicine Satisfaction and Preferences in an Orthopaedic Spine Clinic.

The use of telemedicine has expanded amid the COVID-19 pandemic and office closures and cancellation of elective surgeries early in the pandemic helped propagated its use. Previous studies have described the feasibility of telemedicine, however, little has been reported on patient perception and preferences within orthopaedics. The objective of this study was to evaluate satisfaction and preferences of telemedicine from the perspective of patients within an orthopaedic spine clinic. A cross-sectional, anonymous survey was implemented as a prospective quality improvement initiative. The survey was sent to patients who had an in-office or telemedicine visit with a provider in our orthopaedic spine clinic. Statistical analysis was performed on the results of the survey. The survey was sent to 1129 patients and a total of 316 patients responded. Twenty-one percent of respondents had a telemedicine appointment. There was no difference in satisfaction among groups (P = .288) and those with telemedicine appointments were more likely to have had a previous experience with this type of visit (P = .004) and were more inclined to use it in the future (P < .001). Patients preferred telemedicine because of the ability to get earlier appointments (P < .001) and the convenience of the visits (P < .001). Patients preferred in-office visits because they received hands-on physical exams (P = .003) or imaging (P = .041). Telemedicine is a viable alternative to in-office appointments for spine patients, as evidenced by similar levels of patient satisfaction. Sooner appointments and convenience are attractive elements of telemedicine visits, while the desire for physical examination remains a barrier to adoption in this population.

Change in orthopedics and traumatology admissions during the COVID-19 pandemic at a university hospital in Turkey

Objective: The rapidly increasing cases of coronavirus disease 2019 (COVID-19) in Turkey required the reorganization of the health system. The first response to the pandemic in our university hospital was to stop elective surgery on March 30, 2020, minimize outpatient consultations and reduce the number of patients in the wards. To determine the change in the number of patients admitted to our hospital, we examined the data during the pandemic process and compared them with the data of the previous year. Methods: The number of patients admitted to Pamukkale University Orthopedics and Traumatology Outpatient CI inic and Emergency Service for orthopedic and trauma injuries between March 1, 2020 and October 31, 2020 was documented and compared with the data of the same period in 2019. Results: During the pandemic period, the number of emergency and outpatient orthopedics and traumatology admissions decreased significantly by 15% and 42.93% respectively (p<0.001). The highest decrease in outpatient admissions was in April 2020 with 79.29%, and the highest decrease in emergency admissions was in March 2020 with 31.35%. Conclusion: In conclusion, due to fear of getting infected, curfews, and decreased human mobility, there was a dramatic decrease in the number of hospital admissions between March 1, 2020, and October 31, 2020. The COVID-19 pandemic has impacted healthcare in many ways, putting some healthcare systems under great pressure and pushing others beyond their capacity New strategies can be determined to ensure the continuity of health services and to maximize resources.

Crash Course in Orthopaedics: Development and Evaluation of a 12-Week Online Trauma and Orthopaedics Teaching Program for Medical Students During the COVID-19 Pandemic.

Introduction The COVID-19 pandemic caused significant disruption in clinical placements of medical students in the United Kingdom (UK), including trauma and orthopaedic surgery (T&O) rotations. Based on the British Orthopaedic Association (BOA) undergraduate syllabus, a 12-week online teaching program was designed to supplement T&O teaching for medical students across the UK while lockdown and social-distancing restrictions were in place. This study aims to describe the process of designing an online teaching program, evaluate the effectiveness of online education, explore medical student perceptions of the virtual learning environment, and report the lessons learned from this 12-week online program. Methods The "Crash Course in Orthopaedics" consisted of 12 webinars, with topics covering a range of acute and chronic T&O conditions, and was delivered through the online platform Zoom. Attendees were invited to complete a post-course questionnaire retrospectively and the results were used in this study. Qualitative data was assessed using thematic analysis. Quantitative data were presented as descriptive statistics.  Results The webinar series was attended by approximately 5150 participants, with the largest demographic group being clinical medical students (49%). Results from the survey revealed three broad themes which were: 1). Interactivity: question + answer (Q+A), multiple choice questions (MCQs), online tools 2). Content: case examples, orthopaedic examinations, objective structure clinical examination (OSCE) tips  3). Accessibility: slides, recordings, duration of the session. Our study found that the online teaching program improved students' clinical knowledge of T&O and they found learning through interactive methods such as polls, the chat function on zoom, and case-based discussions to be most useful. Also, from the results of this study, a guide on "How to Run a Successful Webinar Series for Medical Students" was developed. Conclusion Online webinars effectively supplement T&O teaching and experience for medical students whose T&O placements were disrupted during the COVID-19 pandemic. The results will be a helpful guide to those planning medical education webinars in the future.

Initial Impact of the COVID-19 Pandemic on a US Orthopaedic Foot and Ankle Clinic.

Background: In the United States, the COVID-19 pandemic led to a nationwide quarantine that forced individuals to adjust their daily activities, potentially impacting the burden of foot and ankle disease. The purpose of this study was to compare diagnoses made in an orthopaedic foot and ankle clinic during the shelter-in-place period of the COVID-19 pandemic to diagnoses made during the same months of the previous year. Methods: A retrospective review of new patients presenting to the clinics of 4 fellowship-trained orthopaedic foot and ankle surgeons in a major United States city was performed. Patients in the COVID-19 group presented between March 22 and July 1, 2020, during the peak of the quarantine for this city. Patients in the control group presented during the same period of 2019. Final diagnosis, chronicity of symptoms (acute: ≤1 month), and mechanism of disease were compared between groups. Results: A total of 1409 new patient visits were reviewed with 449 visits in the COVID-19 group and 960 visits in the control group. The COVID-19 group had a significantly higher proportion of ankle fractures (8.7% vs 5.4%, P = .020) and stress fractures (4.2% vs 2.2%, P = .031), but a smaller proportion of Achilles tendon ruptures (0.7% vs 2.5%, P = .019). The COVID-19 group had a higher proportion of acute injuries (35.4% vs 23.5%, P < .001). Conclusion: There was a shift in prevalence of pathology seen in the foot and ankle clinic during the COVID-19 pandemic, which may reflect the adoption of different activities during the quarantine period and reluctance to present for evaluation of non-urgent injuries. Level of Evidence: Level III, retrospective cohort study.

COVID-19 during the index hospital admission confers a 'double-hit' effect on hip fracture patients and is associated with a two-fold increase in 1-year mortality risk.

PURPOSE: The aims were to: (1) determine 1-year mortality rates for hip fracture patients during the first UK COVID-19 wave, and (2) assess mortality risk associated with COVID-19. METHODS: A nationwide multicentre cohort study was conducted of all patients presenting to 17 hospitals in March-April 2020. Follow-up data were collected one year after initial hip fracture ('index') admission, including: COVID-19 status, readmissions, mortality, and cause of death. RESULTS: Data were available for 788/833 (94.6%) patients. One-year mortality was 242/788 (30.7%), and the prevalence of COVID-19 within 365 days of admission was 142/788 (18.0%). One-year mortality was higher for patients with COVID-19 (46.5% vs. 27.2%; p < 0.001), and highest for those COVID-positive during index admission versus after discharge (54.7% vs. 39.7%; p = 0.025). Anytime COVID-19 was independently associated with 50% increased mortality risk within a year of injury (HR 1.50, p = 0.006); adjusted mortality risk doubled (HR 2.03, p < 0.001) for patients COVID-positive during index admission. No independent association was observed between mortality risk and COVID-19 diagnosed following discharge (HR 1.16, p = 0.462). Most deaths (56/66; 84.8%) in COVID-positive patients occurred within 30 days of COVID-19 diagnosis (median 11.0 days). Most cases diagnosed following discharge from the admission hospital occurred in downstream hospitals. CONCLUSION: Almost half the patients that had COVID-19 within 365 days of fracture had died within one year of injury versus 27.2% of COVID-negative patients. Only COVID-19 diagnosed during the index admission was associated independently with an increased likelihood of death, indicating that infection during this time may represent a 'double-hit' insult, and most COVID-related deaths occurred within 30 days of diagnosis.