Identifying the core competencies of musculoskeletal medicine has been the basis for the development of the Australian Musculoskeletal Education Competencies (AMSEC) project. AMSEC aims to ensure Australian health professionals are suitably equipped through improved and appropriate education to address the increasing burden of both acute and chronic musculoskeletal disease. The AMSEC project has consisted of four distinct phases. The first two phases were consultative and highlighted concerns from medical educators, specialists and students that current curricula inadequately address the increasing scientific information base in MSK medicine and management. In phase three, Multidisciplinary Working Groups were established to detail competencies in MSK areas such as physical examination, red flag emergencies, basic and clinical science, patient education and self-management, procedural skills and rehabilitation and a web portal was developed. Phase four will see the core competencies completed, endorsed by the relevant professional colleges and integrated into Australian Medical School curricula.

By bringing together experts from different groups involved in musculoskeletal education, it has been possible to agree on the core competencies required of a graduating medical student and from these determine the required underlying basic knowledge, skills and attitudes. These competencies are based on actual needs determined from current disease impact studies and the experience of professionals working in the various areas of musculoskeletal related clinical practice. This multidisciplinary and multi-professional approach, which includes consumer groups, has allowed a broader and more complete perspective of requirements. Both improved horizontal and vertical integration are facilitated and more efficient implementation is possible. By linking these core competencies to specific anatomy and basic science knowledge requirements, justification of the need to address current deficits in these areas was achieved. A standardised evidenced based approach to physical examination was developed allowing a unified approach to the resourcing and teaching of this skill by orthopaedic surgeons, rheumatologists and others.

The ability to outline competency requirements vertically from medical student to resident, general practitioner and specialist is greatly facilitated by combining specialist educators with those of the universities and general practitioners. For the specialists, this approach yields excellent education leverage for very little additional effort.

AMSEC has undertaken significant inter and intra disciplinary consultations to identify and classify core MSK competencies at a basic, median and advanced level of specialisation across professions. This novel national integrated model to address education needs offers many benefits and could be translated into other areas of medicine.

Introduction: Differentially loaded radiostereometric analysis (DLRSA) uses RSA whilst simultaneously applying load to the bones under investigation. This technique allows measurement of interfragmentary displacements under measured weightbearing and joint movement. We have used this technique to prospectively monitor tibial plateau fractures and present the results of the first nine patients with six month follow up.

Method: Nine 41-B3 fractures were treated with open reduction internal fixation by one surgeon. At operation, RSA beads were inserted in the depressed osteochondral fragment and the adjacent non-fractured metaphysis. Postoperative weightbearing was restricted to 20kg and knee flexion to 60° for the first six weeks. Follow up included clinical and radiological examinations and patient reported outcome scores (Lysholm, KOOS). DLRSA examinations included RSA radiographs in 60° flexion and under measured weightbearing at six weekly intervals up to six months postoperatively. Significant interfragmentary displacement was defined as translations greater than 0.5mm and/or rotations greater than 1.5°.

Results: No postoperative displacement was identified on plain radiographs, except in one patient who fell two weeks postoperatively.

RSA: Longitudinal Results: In all patients, the osteo-chondral fragment continued to migrate up to six months, with one exception that stabilised at three months. At six months, the osteochondral fragment translated between 0.02 and 4.15 mm and rotated between 0.2 and 7.2° (> 0.5mm and/or > 1.5° in five cases).

Discussion: Tibial plateau fractures continue to migrate up to six months after treatment. Active range of motion, partial weightbearing to six weeks and weightbearing up to one body weight after six weeks was proven a safe postoperative regimen. Greater displacements recorded over time may be attributed to loading of more than one body weight, for example, the patient that fell recorded the largest amount of migration over time.

A consensus for the best treatment for acute Achilles tendon ruptures has not yet been reached. Non-operative functional treatment using ankle foot orthosis has shown a reduction in re-rupture rate. This study aims to compare operative, cast immobilisation and functional treatment with cam- walker for acute Achilles tendon ruptures.

A retrospective review of medical records of patients with acute Achilles tendon rupture between 1999–2770 was carried out. Open repairs were carried out in the surgical group. In the cam- walker group, patients were immobilised in equines backslab for 2 weeks and then transferred to cam- walker with 3 heel-wedges giving plantar flexion of 20–30 degrees. One wedge was removed weekly after 4 weeks. After 6 weeks, patients removed the cam-walker at night. After 10 weeks, they mobilised in a shoe with a raise. After 12 weeks, the cam-walker was removed. There were 56 patients reviewed of whom 20 were treated operatively, 23 were treated non- operatively in a cast and 13 were treated functionally in a cam-walker. The average age of operative group was 39 years with average post operative immobilisation in a cast of 7.4 weeks. 15% had major complications with 2 DVTs and 1 re-rupture and 45% minor complications with 4 wound infections, 3 sural nerve damage and 2 patients complained of pain. The average age of non-operative group in a cast was 46 years with average immobilisation of 8 weeks. 12% had minor complications with 2 DVTs, 1 re-rupture and 12% healing complications with 1 non- healing and 2 delayed healing.

The average age of functional group treated with cam- walker was 44.5 years. They were immobilised in a cast for 2.5 weeks and cam-walker for 9 weeks. There were 35% major complications with 3 DVTs and no re-ruptures. 2 DVTs were treated and 1 DVT spontaneously resolved.

Metz et al. (2007) conducted a similar study and found that 34% of surgically treated patients suffered from complications other than rerupture. The main advantage they found with conservative treatment is the elimination of wound complications and intra-operative sural nerve damage. This retrospective review shows that surgical treatment provides a lower re-rupture rate but higher complication rate. A prospective study is currently underway to look at re-rupture rates and functional outcome after non-operative functional treatment with cam-walker.

Differentially loaded radiostereometric analysis (DLRSA) uses RSA whilst simultaneously applying load to the bones under investigation. This technique allows measurement of interfragmentary translations and rotations under measured weight bearing and joint movement. We have recently introduced this technique to monitor tibial plateau fracture healing. This paper presents our preliminary results.

Twelve patients with a 41 B2, B3, C2, or C3 fracture were followed for a minimum of three months. RSA beads were inserted in the largest osteochondral fragment and the adjacent metaphysis. Knee flexion was restricted to 60° for 6 weeks. After partial weight bearing (20kg) between 2 and 6 weeks, patients progressed to full weight bearing. Follow up included clinical and radiological examinations and patient reported outcome scores (Lysholm, KOOS). DLRSA examinations included RSA radiographs in 60° flexion and under measured weight bearing. Significant interfragmentary displacement was defined as translations greater than 0.5mm and/or rotations greater than 1.5°.

There was no loss to follow-up. Longitudinal RSA follow-up: Follow-up RSA radiographs were compared to postoperative examinations. Osteochondral fragment depression was less than 0.5mm in seven patients and between 2 and 4mm in the remaining five patients. Significant interfragmentary displacement after three months was recorded in three patients. DLRSA flexion results: Under 60° of flexion, translations over 0.5mm were recorded in five patients (one postoperatively; one at 2 weeks; two at 6 weeks; and one postoperatively, at 2 weeks and at 3 months). Rotations over 1.5° were recorded in six patients (one postoperatively; two at 2 weeks; one at 6 weeks; one at 2 weeks, 3 months and 4.5 months; and one postoperatively, at 2 weeks, 3 months and 6 months). DLRSA weight bearing results: Under partial weight bearing at two weeks, two patients recorded significant translations, one involving a significant rotation. Under weight bearing as tolerated, three patients recorded significant translations (one at 6 weeks; and two at 18 weeks) and four patients recorded significant rotations (one at 6 weeks; one at 18 weeks; and two at 12 and 18 weeks). Patient Reported Outcomes: Both the Lysholm and KOOS scores improved between 6 weeks and 3 months. DLRSA provides new insight and perspective in tibial plateau fractures. Some fractures take more than three months to heal. Our current rehabilitation protocol was safe in most patients, however significant interfragmentary displacement was encountered in 17% at the 2 week followup, raising questions about the quality of the initial stability.

Differentially loaded radiostereometric analysis (DLRSA) uses RSA whilst simultaneously applying load to the bones under investigation. This technique allows measurement of interfragmentary translations and rotations under measured amounts of weight bearing. The aim of this paper was to measure the mechanical stiffness of distal femoral fractures during healing.

Six patients with a 33A2, 33A3, 33B2 and 33C2 fracture were treated with open reduction, internal fixation using a long bridging plate. All patients had a DLRSA examination at 6, 12, 18 and 26 weeks postoperatively. Each DLRSA examination consisted of RSA radiographs taken without load (pre-load), under different increments of load, and finally, without load (post-load). The direction and magnitude of the interfragmentary displacements in six degrees of freedom were recorded at each examination.

DLRSA examinations were able to monitor the inter-fragmentary displacements of the distal femoral fragment relative to the femoral shaft. The interfragmentary displacement recorded, progressively increased as more load was applied in all patients, at all follow-up time points. The two dimensional (2D) translations under maximum tolerated load, progressively decreased over time in three patients. The 2D translations recorded under 60 kg of load at 26 weeks for these patients was 0.18, 0.21 and 0.27mm. The 2D translations of two patients did not decrease progressively between 6 and 18 weeks but did decrease at 26 weeks to 0.47 and 0.75mm. One patient recorded 2D translations of 4.11, 3.48 and 4.53mm under 30kg at 12, 18 and 26 weeks respectively. In the majority of examinations, post-load radiographs enabled the interfragmentary displacements under load to be identified as elastic in nature.

The DLRSA stiffness data confirmed that at 26 weeks three patients had united; two were delayed but improving; and one was a clear non-union without progression. DLRSA examinations may be used as a clinical research tool. to monitor in vivo the stiffness of healing femoral fractures fixed with “relative stability”.