Aims. Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems. Methods. A cross-sectional survey of 774 orthopaedic surgeons and trainees in five countries (Australia, Canada, New Zealand, UK, and USA) was conducted in 2019. Respondents were asked to complete the Mayo Clinic Well-Being Index and the Stanford Professional Fulfillment Index in addition to 31 personal/demographic questions and 27 employment-related questions via an anonymous online survey. Results. A total of 684 participants from five countries (Australia (n = 74), Canada (n = 90), New Zealand (n = 69), UK (n = 105), and USA (n = 346)) completed both of the risk assessment questionnaires (Mayo and Stanford). Of these, 42.8% (n = 293) were trainees and 57.2% (n = 391) were attending surgeons. On the Mayo Clinic Well-Being Index, 58.6% of the overall sample reported feeling burned out (n = 401). Significant differences were found between nations with regards to the proportion categorized as being at risk for poor outcomes (27.5% for New Zealand (19/69) vs 54.4% for Canada (49/90) ; p = 0.001). On the Stanford Professional Fulfillment Index, 38.9% of the respondents were classified as being burned out (266/684). Prevalence of burnout ranged from 27% for Australia (20/74 up to 47.8% for Canadian respondents (43/90; p = 0.010). Younger age groups (20 to 29: RR 2.52 (95% confidence interval (CI) 1.39 to 4.58; p = 0.002); 30 to 39: RR 2.40 (95% CI 1.36 to 4.24; p = 0.003); 40 to 49: RR 2.30 (95% CI 1.35 to 3.9; p = 0.002)) and trainee status (RR 1.53 (95% CI 1.15 to 2.03 p = 0.004)) were independently associated with increased relative risk of having a ‘at-risk’ or ‘burnout’ score. Conclusions. The rate of self-reported burnout and risk for poor outcomes among orthopaedic surgeons and trainees varies between countries but remains unacceptably high throughout. Both individual and health system characteristics contribute to physician wellness and should be considered in the development of strategies to improve surgeon wellbeing. Level of Evidence: III. Cite this article: Bone Jt Open 2021;2(11):932–939

Introduction. The purpose of bundled payment programs is to reduce cost via risk sharing, while still maintaining quality. If savings are achieved under a historic target price, the orthopedic surgeon will receive a monetary bonus. If costs are higher, a portion is deducted from payment to the orthopedic surgeon. The purpose of this study was to evaluate our experience with the Bundled Payments for Care Improvement Program (BPCI) when run by an orthopedic surgeon group to determine patient safety and who benefited the most financially. Methods. This program ran from January 2015 through September 2018. 3,186 Medicare total hip and knee replacements, elective (DRG 470) and for fracture (DRG 469), performed by our group were included. 90 day hospital and all postoperative expenditures were reconciled against our historic cost. All patients were medically optimized with discharge plans established preoperatively. We developed preferred skilled nursing facilities and home health care agencies with synergistic medical providers so that discharges were recommended as soon as appropriate. We hired two full-time case managers to have direct contact with patients pre-and post-operatively. Waiver assistance such as house and pet sitters were used if necessary at our expense. 35% of savings went to the convener, who acted as a liaison between our group and CMS. Expenditures for the 90-day period for all patients were calculated to determine where savings occurred and which entity benefitted financially. Results. There was an average 9.2% reduction in hospital readmissions. An estimated total savings of $5,100,000 occurred. There was a 17% reduction in hospital costs, a 12.1% reduction in admissions to skilled nursing facilities with a 34% reduction in length of stay, and a 5% reduction in admissions to inpatient rehabilitation facilities. There was a 35% reduction in home health visits, but no change in outpatient physical therapy visits. After group expenses, final bonus to the orthopedic provider was on average $262 per patient. Conclusion. The physician managed program was very successful from Medicare's standpoint, achieving significant monetary savings without reducing quality of care. However, the bonus to the providing and managing physicians was nominal. It also does not take into consideration the 50 plus hours spent in meetings to develop this program. Participation could be considered a defensive posture so as not to lose more reimbursement. However, experience was gained which will be valuable for future gain sharing programs. Physicians and physician organizations need to sit at the head of the table to manage future payment bundles and perhaps also act as the convener. We deserve this, as a result of demonstrating high safety and cost savings. For figures, tables, or references, please contact authors directly

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures

Aims. Social media is a popular resource for patients seeking medical information and sharing experiences. periacetabular osteotomy (PAO) is the gold-standard treatment for symptomatic acetabular dysplasia with good long-term outcomes. However, little is known regarding the perceived outcomes of PAO on social media. The aims of this study were to describe the perceived outcomes following PAO using three social media platforms: Facebook, Instagram, and X (formerly known as Twitter). Methods. Facebook, Instagram, and X posts were retrospectively collected from 1 February 2023. Facebook posts were collected from the two most populated interest groups: “periacetabular osteotomy” and “PAO Australia.” Instagram and X posts were queried using the most popular hashtags: #PAOwarrior, #periacetabularosteotomy, #periacetabularosteotomyrecovery, #PAOsurgery, and #PAOrecovery. Posts were assessed for demographic data (sex, race, location), perspective (patient, physician, professional organization, industry), timing (preoperative vs postoperative), and perceived outcome (positive, negative, neutral). Results. A total of 1,054 Facebook posts, 1,003 Instagram posts, and 502 X posts were consecutively assessed from 887 unique authors. The majority (63.3%) of these posts were from patients in the postoperative period, with a median of 84 days postoperatively (interquartile range 20 to 275). The longest follow-up timeframe postoperatively was 20 years. Regarding perceived outcomes, 52.8% expressed satisfaction, 39.7% held neutral opinions, and 7.5% were dissatisfied. Most dissatisfied patients (50.9%) reported pain (chronic or uncontrolled acute) as an attributing factor. Conclusion. Most PAO-perceived surgical outcomes on social media had a positive tone. Findings also indicate that a small percentage of patients reported negative perceived outcomes. However, dissatisfaction with PAO primarily stemmed from postoperative pain. Social media posts from other sources (physicians, hospitals, professional organizations, etc.) trend towards neutrality. Healthcare providers must consider the social media narratives of patients following PAO, as they may reveal additional outcome expectations and help improve patient-centred care, create informed decision-making, and optimize treatment outcomes. Cite this article: Bone Jt Open 2024;5(1):53–59

Introduction. Bundled budgeting of payments for joint replacement services has become increasing common in an effort to improve quality while lowering cost. In the US, some Medicare bundled payment programs are voluntary whereas some now are mandatory. Large medical care and medical management organizations have largely been assigned or seized control of management of these programs, leaving the surgeon in a subordinate role. The current abstract describes an experience where surgeons provide leadership and accept responsibility in bundled payment program. Methods. We engaged a collective of 16 different private company orthopedic physician groups to apply to become episode initiators under under the Medicare Bundled Payment for Care Improvement (BPCI) models 2 and 3. The application process itself provided historical. cost data, enabling each group to independently decide whether or not to proceed with the BPCI. Results. Ultimately, 7 of the private orthopedic groups decided to continue with the BPCI initiative. At the first quarter reconciliation, savings ranged from 9% to 17% across the participating groups. Conclusion. It is possible and potentially preferable for surgeons to take a primary role in accepting responsibility and leadership in the comprehensive care of joint replacement patients. The surgeons are those who determine the indications for and perform the surgery, accept much of the risk, and typically maintain a career long relationship with the patient. As such, the surgeon is also in the best position to achieve the ultimate goals of improved quality which simultaneously controlling cost. Our experience thus far supports that view that the more leadership surgeons provide in value base care provision, the more our patients and health care system will benefit from optimization of care delivery

Aims. Return to sport following undergoing total (TKA) and unicompartmental knee arthroplasty (UKA) has been researched with meta-analyses and systematic reviews of varying quality. The aim of this study is to create an umbrella review to consolidate the data into consensus guidelines for returning to sports following TKA and UKA. Methods. Systematic reviews and meta-analyses written between 2010 and 2020 were systematically searched. Studies were independently screened by two reviewers and methodology quality was assessed. Variables for analysis included objective classification of which sports are safe to participate in postoperatively, time to return to sport, prognostic indicators of returning, and reasons patients do not. Results. A total of 410 articles were found, including 58 duplicates. Seven articles meeting inclusion criteria reported that 34% to 100% of patients who underwent TKA or UKA were able to return to sports at 13 weeks and 12 weeks respectively, with UKA patients more likely to do so. Prior experience with the sport was the most significant prognostic indicator for return. These patients were likely to participate in low-impact sports, particularly walking, cycling, golf, and swimming. Moderate-impact sport participation, such as doubles tennis and skiing, may be considered on a case-by-case basis considering the patient’s prior experience. There is insufficient long-term data on the risks to return to high-impact sport, such as decreased implant survivorship. Conclusion. There is a consensus that patients can return to low-impact sports following TKA or UKA. Return to moderate-impact sport was dependent on a case-by-case basis, with emphasis on the patient’s prior experience in the sport. Return to high-impact sports was not supported. Patients undergoing UKA return to sport one week sooner and with more success than TKA. Future studies are needed to assess long-term outcomes following return to high-impact sports to establish evidence-based recommendations. This review summarizes all available data for the most up-to-date and evidence-based guidelines for returning to sport following TKA and UKA to replace guidelines based on subjective physician survey data. Cite this article: Bone Jt Open 2022;3(3):245–251

Purpose: Surgery for degenerative lumbar spinal conditions offers tremendous benefit for patients with moderate/severe symptoms failing non-operative treatment. There is little appreciation among referring family physicians (FPs) on factors that identify the ideal surgical candidate. Differences in preferences between patients and physicians leads to wide variation in referrals and impedes the shared decision-making process. Our purpose was to identify the dominant clinical factors influencing patient, FP, and surgeon preferences for lumbar spinal surgery. Method: We used conjoint analysis, a rigorous method for eliciting preferences, in a mailed survey to all orthopaedic and neurosurgeons, a random sample of FPs, and patients in Ontario to determine the importance that respondents place on decisions for lumbar spinal surgery. We identified six clinical factors (walking tolerance, duration of pain, pain severity, neurological symptoms, typical onset, and dominant location of pain) and presented 16 hypothetical vignettes to participants who rated, on a six-point-scale, their preference for surgery. Data were analyzed using random-effects ordered probit regression models and relative importance of each clinical factor was reported. Results: We obtained responses from 131 surgeons, 202 FPs, and 164 patients. We demonstrated that despite wide variations in overall responses, all six clinical factors were highly associated with surgical preference (p< 0.01). Surgeons placed the highest importance on the location of pain (34%), followed by pain severity (19%) and walking tolerance (19%). FPs considered neurological symptoms (23%), walking tolerance (20%), pain severity (20%), and typical onset (16%) to all be of similar importance. Pain severity (29%), walking tolerance (29%), and duration of pain (28%) were the most important factors for patients in deciding for surgery. Orthopaedic (over neurosurgical) specialty was statistically associated with a lower preference for surgery (p< 0.047). Older patient age (p< 0.03) and previous surgical consultation (p< 0.03) were both associated with a greater patient preference for considering surgery. Conclusion: Different preferences for surgery exist between surgeons, FPs and patients. FPs may reduce over- and under-referrals by appreciating surgeons’ importance on location of pain (leg versus back). Surgeons and FPs may improve the shared decision making process by understanding that patients place high importance on duration, severity, and walking tolerance

Aims. The prevalence of scoliosis is not known in patients with idiopathic short stature, and the impact of treatment with recombinant human growth hormone on those with scoliosis remains controversial. We investigated the prevalence of scoliosis radiologically in children with idiopathic short stature, and the impact of treatment with growth hormone in a cross-sectional and retrospective cohort study. Methods. A total of 2,053 children with idiopathic short stature and 4,106 age- and sex-matched (1:2) children without short stature with available whole-spine radiographs were enrolled in the cross-sectional study. Among them, 1,056 with idiopathic short stature and 790 controls who had radiographs more than twice were recruited to assess the development and progression of scoliosis, and the need for bracing and surgery. Results. In the cross-sectional study, there was an unexpectedly higher prevalence of scoliosis (33.1% (681/2,053) vs 8.52% (350/4,106)) in children with idiopathic short stature compared with controls (odds ratio 3.722; p < 0.001), although most cases were mild. In the longitudinal study, children with idiopathic short stature had a higher risk of the development and progression of scoliosis than the controls. Among children with idiopathic short stature without scoliosis at baseline, treatment with growth hormone significantly increased the risk of developing scoliosis (p = 0.015) and the need for bracing (p < 0.001). Among those with idiopathic short stature and scoliosis at baseline, treatment with growth hormone did not increase the risk of progression of the scoliosis, the need for bracing, or surgery. Conclusion. The impact of treatment with growth hormone on scoliosis in children with idiopathic short stature was considered controllable. However, physicians should pay close attention to the assessment of spinal curves in these children. Cite this article: Bone Joint J 2023;105-B(4):439–448

Introduction: Posterior lumbar fusion, in many variations, is one of the frequently performed procedures in spinal surgery. High percentages of good and excellent results are indicated by physicians. On the other hand isolated patient-based outcomes are reported. However, little is known about correlation of these two assessment types. We aimed at their comparison. Methods: The analysis included 567 patients from the international registry ‘Spine Tango’. 453 patients with degenerative disease and posterior lumbar fusion had preop and postop VAS separately indicating back- and leg-pain, surgery and follow up data. Mean age was 57y; female/male ratio was 52% to 48%. Remaining 114 patients with the same diagnoses and treatment had additional preop and postop Oswestry disability indices (ODI). Mean age was 61y; female/male ratio was 55% to 45%. Physician administered McNab criteria “excellent, good, fair and poor” were compared to ODI, VAS back- and leg pain and to the patients answer describing the outcome of the operation with the following options: helped a lot, helped, helped only little, didn’t help and made things worse. Then the concept of minimum clinically important difference (MCID) was applied. Results: In the “excellent” group ODI-improvement was detected for all patients, the proposed MCID was reached in 90% for ODI. According to this model 85.2% of patients reached MCID for VAS leg pain and 54.1% for VAS back pain. All patient said that the treatment helped or helped a lot. In the “good” group 86% (MCID: 51.7%) of patients improved regarding ODI, 81% (MCID: 65,7%) regarding back and 93% (MCID: 89.4%) regarding leg pain. 99% of patients said that the treatment helped a lot, helped or helped only little. 65% (MCID: 40%) of patients in the “fair” group had improved ODIs. Even in this group 88% of patients perceived the treatment as helping a lot, helping or helping only little. Moreover in the “poor” group had 60% (MCID: 40%) of patients improved ODIs, 55% (MCID: 40%) alleviated back and 36% (MCID: 30%) reduced leg pain. But only 30% of patient stated that the treatment helped or helped only little. Spearman correlation coefficients for ODI, VAS back, VAS leg and patient’s verbal statement on overall outcome were 0.42, 0.18, 0.27 and 0.53. Discussion: ‘Spine Tango’ registry, to date containing more than 13.000 documented surgeries and three times more outcome datasets, provides excellent opportunities for comparison of outcomes. The analysis of patient and physician-based outcomes showed good correlation with the highest correlation coefficient for patient’s verbal statement. With this study we can state that there is strong evidence that physicians evaluation of outcome is very good corresponding with the patients’ perception of success or failure of the analyzed procedure

Aims

The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery.

Aims

The aim of this study was to identify factors associated with five-year cancer-related mortality in patients with limb and trunk soft-tissue sarcoma (STS) and develop and validate machine learning algorithms in order to predict five-year cancer-related mortality in these patients.

In the UK, multidisciplinary teamwork for patients with hip fracture has been shown to reduce mortality and improves health-related quality of life for patients, while also reducing hospital bed days and associated healthcare costs. However, despite rapidly increasing numbers of fragility fractures, multidisciplinary shared care is rare in low- and middle-income countries around the world. The HIPCARE trial will test the introduction of multidisciplinary care pathways in five low- and middle-income countries in South and Southeast Asia, with the aim to improve patients’ quality of life and reduce healthcare costs.

Cite this article: Bone Joint J 2024;106-B(12):1369–1371.

Aims

The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury.

Aims

The aim of this study was to understand the experience of mature patients who undergo a periacetabular osteotomy (PAO), a major hip-preserving surgical procedure that treats symptomatic hip dysplasia by realigning the acetabulum. Our aim was to improve our understanding of how the operation affected the lives of patients and their families, with a long-term goal of improving their experience.

London's Air Ambulance (LAA) was first set-up in 1989 as a direct result of a Royal College of Surgeons of England Report highlighting poor trauma care provision. Since its inception, the service's mission is to be an innovative and effective provider of advanced pre-hospital care. The service provides a senior Doctor and senior Paramedic to the scene of any incident within the M25 by helicopter, during the day, and by fast-response car at night. The vast majority of doctors are usually Emergency Medicine Physicians or Anaesthetists. During a 6-month tenure, doctors will usually have completed a number of procedures, which include rapid sequence induction of anaesthesia, pre-hospital blood transfusion, and, procedural sedation. In terms of innovations, the organisation was the first in the UK to provide a 24/7 service. It was also the first to start pre-hospital Rapid Sequence Induction of Anaesthesia for the severely injured; Resuscitative Thoracotomy for the victims of penetrating trauma; and pre-hospital Blood Transfusion for shocked polytrauma patients. The service also has a very thorough induction programme, for new Doctors and Paramedics, and a highly structured Clinical Governance process. The post offers a unique and privileged opportunity to treat the most severely injured at the roadside.

Purpose

To describe the implication of Family Physicians (FPs) in the management of osteoporosis revealed by a fragility fracture.