Telemedicine is the delivery of healthcare from a remote location using integrated computer/communication technology. This systematic review aims to explore evidence for telemedicine in orthopaedics to determine its advantages, validity, effectiveness and utilisation particularly during our current pandemic where patient contact is limited. Databases of PubMed, Scopus and CINHAL were systematically searched and articles were included if they involved any form of telephone or video consultation in an orthopaedic population. Findings were synthesised into four themes: patient/clinician satisfaction, accuracy and validity of examination, safety and patient outcomes and cost effectiveness. Quality assessment was undertaken using Cochrane and Joanna Briggs Institute appraisal tools. Twenty studies were included consisting of nine RCTs across numerous orthopaedic subspecialties including fracture care, elective orthopaedics and oncology. Studies revealed high patient satisfaction with telemedicine for convenience, less waiting and travelling time. Telemedicine was cost effective particularly if patients had to travel long distances, required hospital transport or time off work. No clinically significant differences were found in patient examination nor measurement of patient reported outcome measures. Telemedicine was reported to be a safe method of consultation. However, studies were of variable methodological quality with selection bias. In conclusion, evidence suggests that telemedicine in orthopaedics can be safe, cost effective, valid in clinical assessment with high patient/clinician satisfaction. Further work with high quality RCTs is required to elucidate long term outcomes. This systematic review presents up-to-date evidence on the use of telemedicine and provides data for organisations considering its use in the current COVID-19 pandemic and beyond

Introduction. Knee osteoarthritis (KOA) causes impairment through pain, stiffness and malalignment and knee joint replacement (KJR) may be necessary to alleviate such symptoms. There is disagreement whether patients with KJR increases their level of physical activity after surgery. The aim of this study is to investigate whether patients with KJR have a higher level of physical activity than patients with KOA, as measured by accelerometer-based method. Furthermore, to investigate whether patients achieve the same level of activity as healthy subjects five years post TJR. Material and method. 54 patients with KOA (29 women, mean age 62±8.6, mean BMI 27±5), 53 patients who had KJR five years earlier (26 women, mean age 66±7.2, mean BMI 30±5) and 171 healthy subjects (76 women, mean age 64±9.7, mean BMI 26±5) were included in this cross sectional study. The level of physical activity was measured over a mean of 5.5 days with a tri-axial accelerometer mounted on the thigh. Number of daily short walking bouts of. Results. Patients with KJR had 10.1 fewer short walking bouts (p=0.04), 745 fewer steps (p=0.19) and 6.2 fewer transfers (p=0.09) per day than patients with KOA. In addition, patients with KJR performed 21.7 fewer short walking bouts (p=0.001), 281 fewer steps (p=0.60) and 3.2 fewer transfers (p=0.32) per day than healthy subjects. Conclusion. Patients with KJR do not seem to be more physically active than patients with KOA. Neither do the seem to be as active as healthy subjects, However, the results may suffer from selection bias and thus the results ought to be confirmed in a bigger cohort study

Objectives. Electronic forms of data collection have gained interest in recent years. In orthopaedics, little is known about patient preference regarding pen-and-paper or electronic questionnaires. We aimed to determine whether patients undergoing total hip (THR) or total knee replacement (TKR) prefer pen-and-paper or electronic questionnaires and to identify variables that predict preference for electronic questionnaires. Methods. We asked patients who participated in a multi-centre cohort study investigating improvement in health-related quality of life (HRQoL) after THR and TKR using pen-and-paper questionnaires, which mode of questionnaire they preferred. Patient age, gender, highest completed level of schooling, body mass index (BMI), comorbidities, indication for joint replacement and pre-operative HRQoL were compared between the groups preferring different modes of questionnaire. We then performed logistic regression analyses to investigate which variables independently predicted preference of electronic questionnaires. Results. A total of 565 THR patients and 387 TKR patients completed the preference question. Of the THR patients, 81.8% (95% confidence interval (CI) 78.4 to 84.7) preferred pen-and-paper questionnaires to electronic questionnaires, as did 86.8% (95% CI 83.1 to 89.8) of TKR patients. Younger age, male gender, higher completed level of schooling and higher BMI independently predicted preference of electronic questionnaires in THR patients. Younger age and higher completed level of schooling independently predicted preference of electronic questionnaires in TKR patients. Conclusions. The majority of THR and TKR patients prefer pen-and-paper questionnaires. Patients who preferred electronic questionnaires differed from patients who preferred pen-and-paper questionnaires. Restricting the mode of patient-reported outcome measures to electronic questionnaires might introduce selection bias. Cite this article: Bone Joint Res 2013;2:238–44

Background. Training within surgery is changing from the traditional Halstedian apprenticeship model. There is need for objective assessment of trainees, especially their technical skills, to ensure they are safe to practice and to highlight areas for development. In addition, due to working time restrictions in both the UK and the US, theatre time is being limited for trainees, reducing their opportunities to learn such technical skills. Simulation is one adjunct to training that can be utilised to both assess trainees objectively, and provide a platform for trainees to develop their skills in a safe and controlled environment. The insertion of a dynamic hip screw (DHS) relies on complex psychomotor skills to obtain an optimal implant position. The tip-apex distance (TAD) is a measurement of this positioning, used to predict failure of the implant. These skills can be obtained away from theatre using workshop bone simulation, however this method does not utilise fluoroscopy due to the associated radiation risks. FluoroSim is a novel digital fluoroscopy simulator that can recreate digital radiographs with workshop bone simulation for the insertion of a DHS guide-wire. In this study, we present the training effect demonstrated on FluoroSim. The null hypothesis states that no difference will be present between users with different amounts of exposure to FluoroSim. Methods. Medical students were recruited from three London universities and randomised into a training (n=23) and a control (n=22) cohort. All participants watched a video explanation of the simulator and task and were blinded to their allocation. Training participants completed 10 attempts in total, 5 attempts in week one, followed by a one week wash out period, followed by 5 attempts in week 2. The control group completed a single attempt each week. For each attempt, 5 metrics were recorded; TAD, procedural time, number of radiographs, number of guide-wire retires and cut-out rate (COR). Results. No significant difference was present for any metric between the groups at baseline; randomisation had produced heterogeneous groups minimising selection bias. Intragroup training effect (comparison of initial and last attempt) was significant for all metrics in the training group (p < 0.05) but for no metrics in the control group. The intergroup training effect (comparison of training group attempt ten to control group attempt ten) was present for procedural time, number of radiographs and number of guide-wire retries (p < 0.05). Significance was not reached for TAD and COR. Conclusion. FluoroSim shows skill acquisition with repeat exposure, so the null hypothesis can be rejected. This study has demonstrated the merits of FluoroSim as a training adjunct for psychomotor skill development in a DHS setting

Background. Multiple randomised controlled trials have demonstrated that arthroscopy provides little benefit in patients with knee osteoarthritis. In 2008, NICE released guidelines to reflect this evidence. Implementation has been sporadic, and arthroscopy for knee osteoarthritis is commonly performed with an annual incidence of 9.9 per 10,000 in England. Our aim was to establish whether previous arthroscopy affects Patient Reported Outcome Measures (PROMs) in Total Knee Replacement (TKR) patients. Methods. Data was retrospectively collected from 2010–2012 from a University hospital. Pre-operative and one-year post-operative PROMs were collected on patients who had undergone arthroscopy and then TKR, or only TKR. The change in PROMs score over TKR was then compared between groups. Results. Complete data was available for 85 patients: 36 had arthroscopy prior to TKR, with 49 receiving only TKR. There was no difference between the groups with regard to age and gender. Oxford Knee Score (OKS) before TKR for both groups were similar (arthroscopy group 41.9, non-arthroscopy 40.8). At arthroscopy 81% of patients had grade IV arthritis, with 19% demonstrating grade III. Patients who had arthroscopy before TKR had a worse response to TKR compared to those who did not have an arthroscopy (respective mean change of 23.79%, 38.4%, p< 0.001). Conclusions. Although this exploratory study is small and subject to selection bias, our data suggest that arthroscopy may have a detrimental effect on patient function after TKR. This may be due to psychological factors, as there is growing evidence to suggest stress and anxiety negatively affect PROMs4. Medicalisation of patients through arthroscopic procedures may contribute to poor PROMs. This study offers a potential pre-operative factor that may explain some of the variability in outcome seen with TKR. This relationship requires confirmation and exploration in larger studies with correction for confounding factors. Level of evidence. III

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Given the function of adiponectin (ADIPOQ) on the inflammatory condition of obesity and osteoarthritis (OA), we hypothesized that the ADIPOQ gene might be a candidate gene for a marker of susceptibility to OA.

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To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice.

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We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change.

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To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA).

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To explore the therapeutic potential of combining bone marrow-derived mesenchymal stem cells (BM-MSCs) and hydroxyapatite (HA) granules to treat nonunion of the long bone.

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Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making.

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The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

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The clinical utility of routine cross sectional imaging of the abdomen and pelvis in the screening and surveillance of patients with primary soft-tissue sarcoma of the extremities for metastatic disease is controversial, based on its questionable yield paired with concerns regarding the risks of radiation exposure, cost, and morbidity resulting from false positive findings.