Introduction: Newer techniques like the active apex correction (APC) provide an excellent surgical alternate; designed to avoid apical fusion amongst having other benefits when tackling EOS. The objective is to simulate and explore the effect of apical remodulation using the APC technique over a 6-month follow-up period for 4 patient-specific FE models. Methods: Four representative scoliotic models were developed to match patient AP and lateral radiographs provided by the surgeon. To simulate the APC technique; the apex was pushed medially followed by compression of the convex side of apex (using screws implanted proximal and distal to the most wedged vertebrae), followed by spinal growth simulation. Relevant clinical output parameters were recorded and compared with the clinical data. Results: All patients showed a significant reduction in the the primary curve (26% - 59%) following the APC surgery. The AVT was significantly reduced with the surgical correction along with kyphosis & vertebral wedging in the apical region. Furthermore, at the gravity loading and 6-month spinal growth time points, the output parameters showed a consistent maintenance of the correction achieved by the APC technique for all patients. Conclusions: The output parameters indicate excellent preliminary clinical outcomes. While this study is limited in terms of follow-up time as well as sample size, it paves the way for additional research to get a broader understanding of the APC. The results also indicate the potential of this novel technique as a legitimate alternative; employed as-is or in hybrid with incumbent techniques for effective patient management.

Aim:COVID-19 pandemic has resulted in disruption of elective surgery across the UK. The primary aim was to assess the quality of life of patients on the waiting lists for elective foot and ankle surgery during the COVID-19 pandemic.Material and methods : All patients on the waiting list for foot and ankle surgery able to complete EQ- 5D questionnaire were included. EQ-5D evaluates five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. This index is on a scale of -0.594 to 1, 1 represents perfect health and 0 represents death. Patients scoring < 0 are considered to be in a state worse than death (WTD).Results :27/32 patients waiting for elective foot and ankle surgery responded. The mean age was 56.4 (range 22 - 81). 20 patients were female. The median EQ5D score was 0.294; much worse compared to the UK age-specific normative values. 3/27 patients (11%) had an EQ-5D SCORE < 0, all three were waiting for hindfoot procedures. Medical co-morbidities were minimal and did not explain such low scores.Discussion:There has been no evaluation of the impact of disruption of elective foot and ankle surgery. Around 10% of patients were in a state WTD irrespective of their medical co-morbidities. Patients waiting for hindfoot procedures were more likely to report a WTD state.

Introduction: There are a multitude of factors that can contribute to promotion of physicians in an academic setting. The purpose of this study was to investigate factors that may contribute to academic promotion to full professorship among academic orthopaedic surgeons. We hypothesized that gender, race, scholarly productivity (as measured by H-index), years in practice, and fellowship selection would be associated with academic rank. Methods: We collected publicly available data on surgeons’ fellowship training, gender, , faculty rank, region, and years since residency from institutional websites for academic orthopaedic surgeons in the United States. Research productivity data was obtained as H-index from Scopus. Chi-square test was used to evaluate the distribution of academic ranks among orthopedic subspecialties. A linear regression was performed using Stata. Results: There were 2468 academic orthopaedic surgeons included in the study. There were significant differences in the proportion of academic ranks between the different subspecialties (p<0.001). Among all orthopaedic subspecialties, spine surgeons had the highest proportion of full professors (33.4%). After controlling for other variables, completing fellowship training in trauma (β=0.08; p<0.01) or musculoskeletal oncology (β=0.05; p=0.04) increased the likelihood of being a full professor. H-index (β=0.43; p<0.001) and years in practice (β=0.40; p<0.001) were both positively correlated with full professorship. Gender was not associated with full professorship. Conclusion: Among orthopaedic surgeons, years of experience, research productivityand subspecialty selection were independently associated with academic promotion to full professor. Of the orthopaedic subspecialties, only trauma and musculoskeletal oncology surgeons had increased likelihood of being a full professor.

Aim: To determine the amount of waste produced, and the percentage recycled, in Orthopaedic theatres, and to determine methods for reducing waste production and improving waste recycling.
Method: Electronic searches were carried out using Pubmed, with limitations for English language studies from 1992 to present. The final search was done in February 2021.
Results: There were ten articles related to orthopaedic waste. There were six on large joint surgery, two on hand surgery, one on spine, and one on the orthopaedic theatre anaesthetic waste. All reported on either waste management or improving theatre waste recycling. Orthopaedic theatres produce up to 11.7kg of clean waste for large joint arthroplasty, 0.22kg in the anaesthetic room, 0.8 kg per injection procedure, and 4.9kg per hip arthroscopy. Up to 99% of the non-contaminated waste may be recyclable, and up to 36% constitutes recyclable plastic waste. Redirecting waste from biohazard streams by education and segregation methods reduces biohazard production and results in higher recycling rates.
Conclusion: The orthopaedic theatre produces significant amount of waste, a lot of which is incorrectly segregated, and when appropriately categorised most is potentially recyclable, with cost and environmental benefits to the hospital and wider community

Background: Research has led to substantial improvement in health and quality of life. It is pertinent for doctors to participate in research to keep up with the advances of modern medicine. However, clinicians face multiple barriers to participate in research.

Aim: Identifying barriers that prevent surgical junior doctors from participating in research and recognising measures to improve their engagement.

Methodology: Surgical junior doctors in south Wales (UK) were asked to complete a web-based survey with 15 questions about barriers to participation and what would encourage them to take part in research.

Results: A total of 103 completed forms were received with response rate of 88%, of which 67 were registrars and 36 were senior house officers.
43% of participants were not aware of any ongoing research. 48% were not familiar with the process of taking part in research. 67% acknowledged they have time constraints. 56% felt there is too much paperwork. However, many agreed that taking part in research is worth the effort (58%), with majority interested in research-related work (71%).
Majority responded that they would more likely take part in research if there were formal training sessions (86%), dedicated research sessions (86%), more rewards/recognition for participation (74%), and if there was a peer who could guide them (75%). Majority participants (74%) believe that taking part in research is relevant to their training role.

Conclusion
Research is essential to junior doctors in training. Multiple barriers are faced by junior clinicians, however, these could be mitigated by implementing simple interventions.

Background:In response to the COVID-19 pandemic, courses and deanery teaching sessions that previously required the attendance of Trauma & Orthopaedic trainees in person were moved to an online format. To obtain a multi-centre and national perspective, a web-based survey was conducted to compare online learning to in-person physical attendance.
Methods:Participants were asked to use a 4-point Likert scale to express their extent of agreement with 23 statements. The questionnaire was developed and validated using a multi-round Delphi technique with 5 experts. Median (±median absolute deviation [MAD]) and Bonnet-Price 95% confidence intervals were presented. The questionnaire abided by the CHERRIES statement.
Results:All 76 responders agreed or strongly agreed that online learning provided an important source of learning during the pandemic. 69% of responders affirmed that in-person teaching should still be considered the gold-standard (3±0 [95%CI:3– 3]). 97% of responders found online teaching more convenient, more accessible and offered more flexibility than attending teaching in-person (4±0 [95%CI:4-4] for all). When comparing the extents of pooled agreements to pooled disagreements all 23 questions reached statistical significance (p<0.0001).
Conclusions:Online learning can be utilised to deliver effective teaching in more convenient, flexible and accessible ways than is possible through in-person attendance. In-person teaching was only preferred to online teaching if held on-site as opposed to cross-site. This gave a more decisive reflection of opinions seen in Orthopaedic trainees throughout the world. It is thought that a blended approach of online and in-person teaching going forward is likely to provide the best education to Orthopaedic trainees.

Aim
The aim of the study was to assess outcomes after a proximal femoral replacement (PFR). More PFRs are being performed in accordance with the British Orthopaedic Oncology Society best practice guidance 2016. The population studied was patients with metastatic proximal femoral disease with actual or impending fractures. The intervention and comparator was PFR and intra-medullary nailing (IMN) respectively. The primary outcome was hospital readmission rate (all cause). Secondary outcomes were reoperation rate (all cause, infection) and dislocation rate.

Method
A literature search was performed in Medline, Embase, Web of Science and Cochrane Library. The search strategy combined free and MeSH search terms related to population (e.g., “femoral neoplasms” OR “pathological femoral fracture"), intervention and comparator (e.g., “osteosynthesis” “surgery” OR “proximal femoral replacement "). Freeman–Tukey double arcsine transformation was used to pool outcome data. Readmission rates were generated based on complications requiring absolute hospital admission.

Results
After exclusions, the search provided 12 studies. The pooled rate of hospital readmission (all cause) was 0.08 (95% CI 0.04 - 0.12) (Figure 2). The pooled rate of reoperation (all cause), reoperation for infection and dislocation rate was 0.05 (95% CI 0.03 – 0.08), 0.01 (95% CI 0.00 – 0.04) and 0.02 (95% CI 0.00 – 0.05) respectively.

Conclusions
Following a PFR for proximal metastatic femoral disease, patients have low rates of hospital readmission and reoperation. Compared to IMN, reoperations are performed for deep infection and dislocations. The major complication with IMNs of metalwork fatigue and failure is overcome with the use of PFRs.

Introduction: The public hospital is always available, runs an Emergency service and is readily available for anyone who needs urgent care. Often the only place for already privately operated patients with various complications - infection, periprosthetic fracture, aseptic implant loosening, etc. Our observation is that the vast majority of the complicated hip protheses are treated predominantly in the public sector.

Background
Articular cartilage is prone to damage and has a limited ability to regenerate. Multipotent mesenchymal stromal cells (MSCs) are considered an accessible therapeutic tool for regenerative medicine. In our project, we compared the growth kinetics, immunophenotypic and immunomodulatory properties, gene expression and secre-tome profile of MSCs derived from human adult bone marrow (BM-MSCs), adipose tissue (AT-MSCs) and Wharton’s jelly (WJ-MSCs).

Methods
We compared MSCs derived from human adult bone marrow (BM-MSCs), adipose tissue (AT-MSCs) and Wharton’s jelly (WJ-MSCs), focusing on the growth kinetics, immunophenotypic and differentiation properties, immunomodulatory activity and gene expres-sion.

Results
We confirmed that MSCs from all sources were able to differentiate into adipogenic, osteogenic and chondrogenic lineages. The positive expression of CD10, CD29, CD44, CD73, CD90, CD105, HLA-ABC was observed in more than 90% of cells, independently of the tissue of origin. The CD271 and HLA-DR were expressed in less than 5–7% of MSC population depending on the tissue of origin. There were no significant differences in the expression of CD14, CD45, CD235a and VEGFR2 markers between MSCs from different sources.

Conclusions
We have evaluated the differences and similarities of MSCs derived from human bone marrow, adipose tissue and Wharton’s jelly in vitro, using equal cell culture conditions. The results confirm the non-equivalency of the MSCs in growth kinetics in vitro, immunophe-notype and immunomodulatory properties, as well as their gene expression and secretome content. The maintenance of metabolic properties and growth factor production in stress conditions may indirectly indicate the therapeutic potential of cells after transplantation.

Background:
Most patients with orthopaedic pathology in low to middle-income countries are treated by nonspecialists. The aim of this study was to establish and prioritize a list of core orthopaedic-related knowledge topics, clinical cases, and skills that are relevant to medical students in southern Africa.

Methods:
A modified Delphi consensus study was conducted with 3 interactive iterative rounds of communication and prioritization of items by experts from Africa, Europe, and North America. Preferred priorities were selected but were limited to 50% of all of the possible items. Percent agreement of ≥75% was defined as consensus on each of these items.

Results:
Most of the 43 experts who participated were orthopaedic surgeons from 7 different countries in southern Africa, but 28% were general practitioners or doctors working in primary or secondary-level facilities. Experts prioritized cases such as patients with multiple injuries, a limping child, and orthopaedic emergencies. Prioritized skills were manipulation and immobilization of dislocations and fractures. The most important knowledge topics included orthopaedic infections, the treatment of common fractures and dislocations, any red flags alerting to specialist referral, and back pain.

Conclusions:
A wide geographic, academic, and expertise-specific footprint of experts informed this international consensus through their various clinical and academic circumstances. Knowledge topics, skills, and cases concerning orthopaedic trauma and infection were prioritized by the highest percent agreement. Acute primary care for fractures and dislocations ranked high. This study can inform national curricula in southern Africa and assist in the allocation of student clinical rotations.

Introduction: The shortened hamstring syndrome produces a lack of flexibility in the hamstring muscle producing a decrease of the mobility in pelvis and rachis, especially in teenagers.
Objective: Relationship between the shortening of the hamstring muscle, the stretching performed and the practice of sport.
Material and methods: Descriptive, prospective, and observational study of the hamstring muscle in adolescents depending on whether they practice sports activity. The variables were: age, gender, weight, sport practice, type of sport, the performance of stretching, and the presence of any disease in the different muscle groups, and we carried out using different longitudinal and angular assessment tests.
Results: We had a total of 100 participants, 2 of them were excluded, an average age of 14 years old, 68 were men, a weight of 55 kg, a BMI of 20 and a daily sitting of 8 h. 92 of the participants competed it the sports and 69 performed stretching after training. 79 had not muscular lesions and 34 reported lumbar pain. Respect to the exploratory tests, some significate differences were observed in the participants who practiced a sport regularly and performed stretching.
Conclusions: The practice of sports regularly is related to less sedentary and less shortening of the hamstring muscles. There were significant differences in the shortening of the hamstring muscle between participants who performed stretching and those who did not perform them regularly.
Keywords: hamstrings muscle length, shortening, sport and stretching.

Abstract: We investigated the hierarchical principal agent relationship between outpatient physicians and physiotherapists in the German postoperative trauma care to examine the influence of interprofessional social barriers as peer group effects on the innovation adoption and the influence of collaboration quality and physiotherapists’ job crafting behavior on this relationship. The principal agent theory examines relationships between individuals in which a principal, here outpatient orthopedists and general practitioners, assigns agents, outpatient physiotherapists, a certain task. The hierarchical power distance, the lack of control on the agent’s side and the information asymmetry between the principal and agent cause problems in the common innovation development. Therefore, we claim that this is also one latent source of interprofessional antipathy and that a non-peer-group origin of innovation has a negative influence on the adoption decision. Based on the same line of argumentation, it can be assumed that improved cross-sectoral collaboration as collaborative treatment planning and a higher proactive work behavior, job crafting, of physiotherapists have a positive effect and thus, weakens the negative interprofessional social barriers. The data of this quantitative study were collected through an online survey with an experimental vignette design with German physiotherapists. The findings show that physiotherapists tend to adopt digital innovations that have their origin in their own peer group in contrast to innovations that were developed by physicians. Furthermore, the results confirm that job crafting behavior of physiotherapists and the quality of the collaboration with physicians plays an essential role as driver of the peer driven innovation adoption barriers.

Treatment options for metastatic osteosarcoma are limited. The present study aimed to evaluate whether radiofrequency ablation (RFA) combined with intratumoural OK-432 injection induces systemic anti-tumour immunity in rat osteosarcoma model. Eighty of 145 rats were assigned to four groups to evaluate overall survival and tumour size: control (no treatment), RFA-only, OK-432, and RFA-OK-432. The remaining 65 were assigned for histological examination. Maximum diameters of tibial and lung tumours were determined. Tumour samples were histologically examined using haematoxylin-eosin and immunohistochemical staining. Overall survival was significantly prolonged in the RFA-OK-432 group compared to the RFA-only and OK-432 groups. Only rats in the RFA-OK-432 group exhibited significant decreases in maximum tumour diameter after treatment. Ki-67-positive tumour cells in the RFA-OK-432 group were significantly stained negative on immunohistochemical analysis as opposed to those in the RFA-only and OK-432 groups. The number of CD11c+, OX-62+, CD4+, and CD8+ cells significantly increased in the RFA-OK-432 group compared to the RFA-only group. RFA with intratumoural OK-432 injection resulted in distant tumour suppression, prolonged survival, and increased dendritic cells, cytotoxic T cells, IFN-γ, and TNF-α, whereas RFA or OK-432 alone did not produce this effect. This combination may induce an abscopal effect in human osteosarcoma.

In bone tumor biopsy, the width of the biopsy hole may be associated with the risk of pathological fracture. This study aimed to identify this potential association using the rabbit femoral head compression test. Multiple rounds of compression testing were performed on rabbit femurs. First, rectangular biopsy holes of four different widths were cut into rabbit femurs. Fifty rabbit femurs were randomly classified into Control (no defect), Type 1 (10% width), Type 2 (20% width), Type 3 (30% width), and Type 4 (40% width) groups (n=10 in each group). Second, rectangular biopsy holes of three different lengths were artificially cut in a separate set of rabbit femurs. Another 20 rabbit femurs were categorized into Control (no defect), Type A (27% length), Type B (40% length), and Type C (53% length) groups (n=10 in each group). Performing compression testing with this experimental design allowed each parameter to be calculated individually. The maximum compressive load was significantly higher for Type 1 than for the other Types when testing the widths of the rectangular defects. In contrast, no significant differences were observed between the three groups when testing for defect length. It may be useful for orthopedic oncologists to make a rectangular biopsy hole with a width measuring less than 10% of the circumference in the cortex wall to avoid pathological fracture. Similarly, it may be important to enlarge biopsy holes longitudinally to obtain sufficient tumor tissue.

Objectives: To investigate the spinal and sagittal values of Korean adults using EOS. Materials and Methods: From February, 2017 to April, 2019, 426 patients who have no symptoms were underwent EOS evaluation. The patients were divided into 5 groups according to age. The groups were 20s, 30s, 40s, 50s, 60s. Measured parameters were pelvic incidence(PI), sacral slope(SS) and Sagittal pelvic tilt(SPT), sagittal vertical axis(SVA), thoracic kyphosis, lumbar lordosis. Results: PI of 20s averaged 44.96±2.71 °, SS averaged 34.41±2.04 °, and SPT averaged 10.54±2.01 °. SVA averaged -10.69±6.30mm, Kyphosis averaged 35.94±2.45 °, and Lordosis averaged 49.22±2.89 °. PI of 30s averaged 47.23±1.50 °, SS averaged 36.58±1.03 °, and SPT averaged 10.63±1.14 °. SVA averaged -8.91±3.80mm, Kyphosis averaged 37.40±1.53 °, and Lordosis averaged 51.01±1.59 °. PI of 40s averaged 46.71±1.50 °, SS averaged 35.46±1.33 °, and SPT averaged 11.27±1.13 °. SVA averaged -10.86±3.77mm, Kyphosis averaged 40.49±1.55 °, and Lordosis averaged 51.03±1.84 °. PI of 50s averaged 49.81±1.98 °, SS averaged 35.65±1.67 °, and SPT averaged 14.24±1.75 °. SVA averaged -4.95±4.54mm, Kyphosis averaged 41.01±2.29 °, and Lordosis averaged 51.31±2.46 °. PI of the 60s averaged 46.53±3.22 °, SS averaged 34.29±3.42 °, and SPT averaged 12.47±2.29 °. SVA averaged 1.59±12.69mm, Kyphosis averaged 43.06±4.80 °, and Lordosis averaged 49.24±6.58 °. PI, SS, SPT, SVA, and lordosis were not statistically significant. Kyphosis was the smallest in 20s, and 30s, 40s, and 50s were not different from each other, and 60s were statistically significant. Conclusions: The normoactive values can be used as a guideline for sagittal balance.

Purpose: The purpose of this study was to analyze the comparative efficiency of secondary blood test and NAT to determine the donor suitability of allogenic bone grafts.
Methods: Allogenic bones were retrieved from 452 living donors. A secondary blood test was conducted in 182 patients and NAT was performed in 270 patients. The initial blood tests including hepatitis B, hepatitis C, AIDS, and syphilis were conducted before retrieving grafts. The results were analyzed after the secondary blood test was performed at least 3 to 6 months after the first test. NAT was performed within 2 months after the first blood test.
Results: Sixty-seven of the 452 cases (14.8%) were discarded. In the secondary blood test group, 50 out of 182 cases (27.4%), and in the NAT group, 17 out of 270 cases (6.3%) were discarded. None of the 132 donors tested positive in the secondary blood test after testing negative in the first test. However, the grafts from 28 donors (8.7%) were discarded because the secondary blood test was not evaluated or refused.
Conclusions: It is extremely rare that the secondary blood test yields positive results in donors who tested negative in the initial test. However, quite a few grafts are discarded only because the secondary blood test is not available. In terms of economics and ethics, the secondary blood test may not be necessary or if required, a single test such as NAT for infectious diseases may be performed to determine donor suitability of allogenic bone.

Purpose : Viruses exhibit varying “window” periods during which time infection may not be detected by serological testing. For this reason, a second blood test is performed at least 3-6 months after the first test to ensure the suitability of the allogeneic bone graft from the living donor. Currently, unless the second test is conducted and confirmed negative, the allograft is discarded. The purpose of this study was to analyze the efficiency of the second blood test for determining allogeneic bone graft donor suitability.
Methods : Between 2005 and 2011, allogeneic bones were retrieved from 321 donors with hip or knee replacement arthroplasty. Donors were tested for hepatitis B, hepatitis C, AIDS and Syphilis before retrieving grafts. The donors were re-tested 3-6 months later to cover the “window” period of the viruses.
Results : Of the 321 donors testing negative in the first test, none tested positive 3-6 months later. However, the grafts from 28 donors (8.7%) were discarded, because the second test was not conducted or was refused.
Conclusions : The results demonstrate that the probability of a positive result for viral retesting of live donors at 3-6 months is extremely low. However, a substantial number of grafts had to be discarded because results for the second test were not available. In terms of economics and ethics, consideration should be given to replacing the retest requirement with nucleic acid amplification testing (NAT) prior to retrieval for determining allogeneic bone, donor suitability.

Introduction:
Fat embolism is a reoccurring complication after intramedullary reaming and nailing. Several lipid subgroups show high concentration in bone marrow fat. In this study, we investigated the post-interventional intravasation of 233 specific lipids in a porcine polytrauma model with a femur fracture.
Methods:
54 male Pigs underwent general anesthesia for 6 hours. Pigs were split in polytrauma (PT), monotrauma (MT) and sham (S). MT received an isolated femoral shaft fracture, while PT received additional blunt chest trauma, liver laceration and controlled hemorrhagic shock. After resuscitation, we used different means of intramedullary reaming and nailing (SynReam (SR), Reamer-Irrigator-Aspirator System (RIA) and introduction without reaming (NO)). Venous blood was taken regularly from baseline (B) to 6h post trauma. Lipid concentrations and lipid composition were investigated using mass spectrometry. 233 specific lipids were analyzed.
Results:
We organized lipids into 17 subgroups based on molecular characteristics. Total lipid concentration showed a significant decrease after polytrauma and remained low over the course of observation. In PT, Di- and Triacylglycerols (DAGs and TAGs) show a significant increase after intervention. In MT, DAGs and TAGs show significant increase after fracture and intervention remain elevated for 4 hours. SR and NO showed significant increase of circulating DAGs and TAGs after intervention in every group (MT/PT/MT+PT), RIA never did.
Conclusion:
Our data clearly suggests significant changes to circulating lipid composition after trauma and treatment. Furthermore, we showed a significant decrease of intravasation of DAGs and TAGs by using RIA. Collation with data from the clinical setting is needed.

The bibliometric studies are helpful to determine the most-influential papers and their characteristics in specific subjects. This study aimed to identify and analyze the characteristics of 50 most-cited articles related to hallux rigidus. The available literature about hallux rigidus on Web of Science database until January 2021 were analyzed and 50 most-cited articles were determined. The characteristics of the articles were analyzed for any relationship or correlation with total citation or citation per year (citation density) numbers. The highest cited article had a citation number of 243 and the average citation number was 52.8. The average citation density was 3±2.1. The average author number was 3.4 while the average institution number was 1.9. The authors from USA contributed with 29 articles, followed by UK with 5 articles. Among the first authors, 3 were from La Trobe University (Australia) and 3 were from Medical College of Wisconsin (USA), with the highest contributions as institution. 26 papers were case-series, 7 were narrative reviews, 5 were case-control study, while randomized-controlled, prospective cohort, retrospective cohort and systematic reviews were 3 for each. Only 3 studies had Level 1, and 2 studies had Level 2 evidence. 5 studies were multicentric and 35 were single center. Citation density was positively correlated with increased number of pages, institution number, total reference count and publication year, indicating higher citation density in more recent papers and in papers with contributions from different institutions.

Aim: The aim of this study was to compare medico legal perceptions between surgeons and clinical negligence lawyers
Method: A questionnaire based survey was designed using a Likert scale with input from legal and clinical experts. Following distribution amongst surgeons and lawyers data was explored in terms of awareness, utility, perception and fears due to changing orthopaedic practice during COVID 19 crisis and the potential for resultant clinical negligence incidences. Results: 129 responses were collected from both Orthopaedic surgeons and 32 responses from lawyers. More than 80% of surgeons were aware of the BOAST emergency guidelines whereas less than 20% of lawyers were aware. More lawyers felt the guidelines would be useful to prevent a negligence claim in comparison to surgeons. The commonest specialty for redeployment was Emergency medicine (20.5%). 43.4% of surgeons were not redeployed at all. Confidence working in different roles was higher amongst junior doctors compared to any other grade (p<0.05). Confidence in government protection schemes offered during the pandemic was lower among surgeons compared to lawyers. The perception of rising negligence claims was similar among both surgeons and lawyers (median score 4 out of 6). Lawyers perceived that favourable public perception about NHS workers would mitigate the number of claims although the doctors didn’t feel the same. Both surgeons and lawyers felt that the Covid 19 crisis as a pretext is unlikely to influence legal decisions in favour of surgeons.Conclusion: Our study highlights the disparity between the orthopaedic surgeons and lawyers in relation medico legal concerns.

Introduction: Assessment of distraction osteogenesis regenerates has traditionally relied on quantitative assessment on plain radiographs. Quantitative methods like the pixel density ratio (PDR) have been described, but these have certain limitations. We describe a novel technique to quantify regenerates from plain digital radiographs.
Methods: 11 subjects underwent distraction osteogenesis; each patient was followed up monthly with digital radiographs and regenerate bone mineral density (BMD) assessment by DEXA scan monthly for a minimum 6 months. Quantitative analysis was performed by the ImageJ software, and Area Fraction (AF) & Fractal Dimension (FD) of the regenerates were assessed.
Results: Area Fraction increased steadily and Fractal dimension was found to decrease steadily as the regenerate matured. A strong negative correlation was found between BMD and Fractal Dimension (r = -0.68). A moderate correlation was found between BMD and Area Fraction (r = 0.34).
Conclusion: Area Fraction and fractal dimension can be used to quantify distraction osteogenesis regenerate. However, the results need to be validated in larger patient cohorts.

Background: Elbow arthroscopic procedure has been widely expanded, however, the arthroscopic assessment for LCL complex deficiency is still out of consensus until now. Arthroscopic assessment is reliable for LCL complex deficiency of the elbow by measuring radiocapitellar joint (RCJ) and ulnohumeral joint (UHJ)
Material and Method: Eight fresh human cadaveric elbows were placed in a simulated lateral decubitus position. RCJ gap and UHJ gap (mm) was measured with different sized probes from the posterolateral viewing portal. The elbow was 90 degrees flexed with neutral forearm rotation for RCJ gap measurement and 30 degrees flexed with full supination for UHJ gap measurement. Sequential testing was performed from Stage 0 to Stage 3 (Stage 0: Intact, Stage 1: the release of anterior 1/3 LCL-complex, Stage 2; release of anterior 2/3 LCL-complex, and Stage 3; release of entire LCL-complex) on each specimen. The mean joint gap of radiocapitellar and lateral ulno-humeral joint was used for the comparison between stages with the intact elbow.
Results: The mean gap distance both in radiocapitellar and ulnohumeral joint was increased significantly in Stage 2 and Stage 3 compared to that in Stage 0. In contrast, release of the anterior 1/3 of LCL-complex (Stage 1) did not significantly increase the mean joint gap distance.
Conclusion: Arthroscopic measurement in RCJ and UHJ is the reliable assessment to detect the LCL complex deficiency that involved anterior 2/3 or more.

Introduction: Platelet-rich plasma (PRP) has shown to induce improvements in pain and mobility of osteoarthritic (OA) joints. However, PRP present high variability during manufacturing. This is overcome by hyperacute serum, which is a standarized and stable blood-derived product obtained from the serum fraction of platelet rich fibrin. Our aim is to test if intraarticular hyperacute serum injections result in an improved outcome for OA patients. Methods: 24 OA patients underwent autologous intraarticular injections of hyperacute serum in OA knees. Clinical monitoring was followed up to 3 and 6 months and the outcome was validated by VAS, KOOS and Lysholm-Tegner scores. Synovial fluid (n=9) was collected prior hyperacute serum injections and cytokine profile was analyzed. Results: VAS, KOOS and Lysholm-Tegner scores showed an important improvement in pain and mobility of OA knees during the follow-up after hyperacute serum treatment. Patients with knee effusion showed more severe symptoms than patients without effusion; however, after 6 months, both groups equalized and improved notably. Multivariate factor analysis of cytokine levels revealed that instead of having an individual reaction to hyperacute serum, fluctuation was grouped. Two subgroups with a high correlation between the proteins included were identified. Group A consisted on: IL-8, MMP-9, fractalkine, IFNγ, IL-1β, IL-10, IL-1ra, IL-33, resistin and RANKL. Group B included MMP-3, IL-2, IL-5, VEGF-A, aggrecan, CCL-3, COL1a, IL-12p70, IL-2, IL-23, LIF, OSM and TNFα. The high correlation within each subgroup suggests that by measuring a few cytokines, the expression of the whole subgroup may be predictable.

Introduction: Hyperacute serum is a stable and standardized blood-derived product that has demonstrated equivalent outcomes in osteoarthritis as the well-known platelet-rich plasma (PRP), overcoming its variability disadvantages. In this study we focused on optimizing a final lyophilized product and to test its regenerative capacities in tissue engineering in OA, alone and in combination with hyaluronic acid (HA). Methods: Two-dimensional cultures of primary chondrocytes were kept in culture under different supplementation conditions, including three versions of hyperacute serum (one liquid and two lyophilized). XTT analysis and gene expression quantification were performed. Hyperacute serum was tested on a human co-culture of synovium, bone, and cartilage explants. Cytokine profile will be analyzed. Results: Filtered lyophilized hyperactute serum did not present the same strong effect than the liquid format in promoting cell viability (P=0.0047). We hypothesize that due to the further filtration process, nutrients including growth factors were removed. Therefore, a new non-filtered lyophilized hyperacute serum was produced, which showed no significant difference in promoting cell viability when compared to the liquid format and PRP; furthermore, surpassing the supplementation gold standard FCS (P=0.03). Gene expression of OA-related genes including Col1a1, Col2a1, Acan, Sox9, Mmp3, Mmp13 and Prg4 presented high variability between patients, leading to not significant differences between the groups. However, a tendency suggesting that hyperacute serum supports more extracellular matrix protein secretion than PRP was noticed. Moreover, the presence of HA did not have an added effect on cell viability and gene expression when cultured together with the lyophilized formulations of hyperacute serum.

Introduction: Work-family conflict may act as a deterrent to women when considering orthopaedic surgery as a specialty. Our objective is to identify differences in work-family balance between female and male orthopaedic surgeons in the United States.
Methods: An anonymous survey was completed by 501 orthopaedic surgeons (219 female, 282 male) for the domains of demographics, work, family, and career and work-family balance satisfaction. Differences between males and females and risk factors for career dissatisfaction were identified.
Results: Female surgeons were younger than males (mean 38.1 vs. 44.3 years), earlier in their careers, reported lower salaries, and less commonly had opportunities for consulting, course faculty, and academic title. Females were more likely never married (21.9%), married at a later age, to have no children (44.3%), require fertility treatment (23.7%), have children after training (55.7%), and/or have children at an advanced maternal age (37.2%). Female surgeons reported increased responsibility in parenting and household duties. 91% of surgeons were satisfied with their career, though female gender independently predicted dissatisfaction. Work-family balance satisfaction was 48% in females and 62.7% in males.
Discussion: Female surgeons delay a family, carry more home responsibility, have fewer academic and leadership opportunities, earn lower incomes, and are less satisfied with work-family balance relative to males. The discrepancy in work-family balance must be addressed to narrow the gender gap so to allow women to achieve their personal and professional goals concurrently, as well as continue to attract and retain women as successful orthopaedic surgeons.

Introduction: This study looked to document incidental findings in preoperative CT scans obtained for robotic-arm assisted surgery for patients who underwent either total hip arthroplasty (THA) or total knee arthroplasty (TKA) and determine whether these incidental findings affected patient management. Methods: A retrospective review was conducted of pre-operative CT scans for patients who underwent primary THA or TKA from 2016 to 2020. CT’s with incidental findings were flagged. Results: 1519 total CT scans were identified, 849 (55.9%) of which were completed on females and 670 (44.1%) of which were completed on males. Seventy-three (4.81%) patients had incidental findings, 48 (65.8%) of which were females and 25 (34.2%) of which were males. Twenty-five (1.65%) patients had imaging with significant incidental findings which required physician follow-up. Of these significant incidental findings, 20 (80.0%) were found on females and 5 (20.0%) were found on males (p = 0.025). Four patients (16%) required additional imaging and intervention was required for two patients. Conclusion: This study documents the incidental findings associated with preoperative planning CT for THA and TKA. Females had a higher incidence of both significant and non-significant incidental findings than males. Many of the findings required physician follow-up, but only some required procedural or imaging intervention. The study showed that preoperative scans may influence patient management. With the increasing popularity of robotic assisted total joint arthroplasty, it will be important to consider the overall value of robotic surgery, additional costs incurred from preoperative imaging, as well as detection and management of incidental findings.

Biomaterials are playing an increased role in the regeneration of damaged or absent bone tissue in the context of trauma, nonunion, infection or congenital abnormality. Restoration of not only the physical scaffold that bone provides, but also of its homeostatic functions as a calcium store and hematopoietic organ are the gold standards of any regenerative procedure.

Bioactive glasses are of interest as they can bond with the host bone and induce further both bone and blood vessel growth. The composition of the bioactive glasses can be manipulated to maximise both osteogenesis and angiogenesis, producing 3D scaffolds that induce bone growth whilst also providing a structure that resists physiological stresses.

As the primary endpoints of studies looking at bioactive glasses are very often the ability to form substantial and healthy tissues, this review will focus on the methods used to study and quantify osteogenesis and angiogenesis in bioactive glass experiments. These methods are manifold, and their accuracy is of great importance in identifying plausible future bioactive glasses for clinical use. We also outline future avenues for research in this field

Introduction: Osteoarticular tuberculosis is an infrequent form of presentation of extra-pulmonary tuberculosis and accounts for about 1-5% of cases. Unawareness of the treating physician because of the absence of classical clinical signs and symptoms leads to a delay in diagnosis and prompt treatment.
Case report:41 year old male presented with left wrist pain. Swelling over the dorsoradial aspect of the wrist.No constitutional symptoms.Local examination revealed bony tenderness over styloid region. No warmth was present. Special tests revealed positive gring test, prossier’s relocation test positive and pisiform boost test positive. ROM dorsiflexion-70 deg, palmar flexion-60 deg. Supination and pronation was 70 deg. Esr 21mm/hr and CRP 2.4mg/dl. Radiological examination revealed a lytic lesion in the distal radius. CT showed two well defined lytic lesions in the epiphyseal region of distal radius measuring about 1.4*1.0*1.2cm on lateral aspect aspect with cortical break in the articular margin. Another lesion measuring 1.0x0.6 cm with cortical break on medial aspect. patient was posted for biopsy and the material was curetted out and extended cauterisation was done with bone cement. HPE revealed granulomas . The patient was suspected to have tuberculosis and was started on anti-tuberculosis drugs HRZE for two months and the continuation phase was given for 9 months as per our institution protocol. Now the patient at two year follow is completely asymptomatic without recurrence of lesion.Conclusion:In our case we want to emphasize tuberculosis as one of the important differential diagnosis in diagnosing a lytic lesion in enedemic countries like India.

Background: With the constantly evolving communication technologies, it is essential for all healthcare professionals to try utilising various methods in communicating with patients. This will lead to better healthcare outcomes and patient satisfaction.

Objective: The aim of the study was to compare a patient’s preference to various communication methods regarding their appointments and to evaluate if we’re giving our patients an appropriate notice period prior to their operation.

Methods: A questionnaire was given to 111 patients who underwent elective orthopaedic procedures.
Methods of communication included conventional letters, emails, phone calls, and phone texts. Patients could choose more than one preferred communication method. We also enquired about preferred notice period for them to be contacted prior to their surgery date, whether they received a confirmation letter, and overall satisfaction with the communication process.

Results: Factors like age and gender affect the choice of communication method. Traditional letters still have a role for an older population aged 65 and over. However, younger patients showed higher preference for other communication methods such as phone calls, texts, and e-mails. Most patients stated they received an appropriate notice period, with 88% of patients stating they would like to be notified one-two weeks prior to their operation.
Conclusion: More research needs to be conducted into using text messages and e-mails in communicating with elective surgical patients, in addition to implementing newer technologies like mobile phone applications and secure online messaging portals, as this has the potential to reshape the communication process with our patients.

Purpose: Assessment of serum vitamin D (Vitamin D) levels in healthy North-Indian sportspersons and its correlation with serum parathyroid hormone (PTH) levels and bone mineral density (BMD). Methods: Three-hundred and sixty-nine healthy athletes age 18-45 years were registered for the study. Serum Vitamin D levels were measured in all the athletes and depending upon the Vitamin D levels athletes were categorized into 3 groups- deficient (<20 ng/ml), insufficient (20-30 ng/ml), and sufficient (>30 ng/ml). BMD of all athletes was calculated using the DEXA scan of the hip and spine. Serum PTH levels were also assessed in all the athletes. Correlation of Vitamin D levels were compared with BMD and PTH levels in all the athletes. Results: Two-hundred and fifty-eight (69.9%) athletes were Vitamin D deficient, 51/369 (13.8%) were Vitamin D insufficient and 60/369 (16.3%) athletes were Vitamin D sufficient. There was a direct correlation between low serum Vitamin D levels and low BMD (r = 0.473; p < 0.05). Overall, 114/369 (30%) athletes had low BMD and out of these 114 athletes, 108 (95%) were Vitamin D deficient. Serum PTH levels were found to have inverse relations to both Vitamin D (r = -0.629) and BMD (r = -0.267). Conclusions: Vitamin D deficiency is highly prevalent among the North-Indian athletes and the presence of low Vitamin D (<20 ng/ml) levels are associated with low BMD and high PTH levels.

Introduction: Royal College of Surgeons set standards of operation notes to meet the requirements set out by the General Medical Council. We conducted an audit study to assess the standard of documentation, identify and address any areas in which the standards are not upheld. Methods: A retrospective review of the operation notes collected from 28 patients in the first week April 2019 was undertaken. We identified deficiencies in the documentation on several standards and recommendations were made to all concerned including placing posters in the operation theatres. Re-audit was conducted in the first week of November 2019 and 38 patients operation notes were reviewed retrospectively. Results: We noticed there was significant improvement in the documentation especially on mentioning the time of the procedure, blood loss and post op instructions in the second round. There were modest improvements in other standards such as operative diagnosis and grade of the surgeon. However there was some deterioration in the documentation against some standards such as antibiotic and VTE prophylaxis. A subgroup analysis showed the documentation improved when the junior surgeons were completing the operation notes. We also noticed the documentation is better when the notes were typed compared to handwritten operation notes. Conclusion: Overall there was an improved documentation in the operation notes in the second cycle of 88% compared to first cycle of 84%. We plan to undertake further studies in the near future to ensure continued improvement of the documentation of operation notes which impacts the patients care and their outcomes.

Introduction
Femoroacetabular impingement (FAI) leads to pain and disability resulting in muscle adaptation. This often results in gait alteration to compensate for the pain and changes in joint mechanics. The aim of this study was to assess the various biomechanical gait parameters in cam-type FAI, through a systematic search.

Materials and Methods
A systematic review of the literature from PubMed, Scopus, and Medline and EMBASE via OVID SP was undertaken from inception to April 2020 using PRISMA guidelines. Studies that reported kinematics, kinetics, and/or estimated muscle forces during level ground gait for patients with cam-type FAI and sex, age and BMI matched healthy controls were identified and reviewed.

Results
The search strategy identified 404 articles for evaluation. Removal of duplicates and screening of titles and abstracts resulted in full-text review of 37 articles with 12 meeting inclusion criteria. The 12 studies reported biomechanical data on a total of 173 cam FAI (151 cam specific 22 mixed stance compared to the control groups.

Conclusions/Discussion
Cam-type FAI patients walk with lower hip abduction and extension, which may be associated with secondary higher pelvic incidence angles and suboptimal muscle function, as demonstrated by lower iliopsoas, rectus femoris and vasti force. There is a need for further studies looking at physiotherapy in the management of symptomatic cam FAI patients as a means of strengthening dominant hip flexors.

In the advent of the digital age and advancements in modern technology, learning has also evolved incorporating different tools that can augment learning. One of these is the spaced repetition system (SRS). This system creates an environment of strategic spacing of learning concepts that theoretically creates more synapses for long-term memory, therefore, increasing retention and recall. This study aims to identify if the SRS is effective and applicable within the rigors of Orthopedic residency training by measuring the improvement of scores (in percentage correct) from the pre-test against the 1st month, 2nd month, and 3rd month post-tests. Then a post-program evaluation was administered to measure the ease, adequacy, and acceptability of the program as an adjunctive learning tool during residency. Eleven participants were recruited which consists of the 1st year, 2nd year, 3rd year, 4th year and 5th year residents of the Orthopedic residency program. Results showed that there were statistically significant (P<0.001) increases in the scores for the 1st(29.18%), 2nd (32.45%), and 3rd (34.82%) month post-tests when compared to the pre-test (24.45%). However, there were no significant differences between the 1st and 2nd-month post-tests and 2nd and 3rd-month post-tests. The participants also subjectively agreed that the SRS system was easy to use, clear and easy to study, not time-consuming, and not difficult to follow. Likewise, the participants also think that the method of adjunctive learning is acceptable and adequate during training and can be of benefit in the future.

We aim to report clinic outcomes and patient satisfaction of a telephone triage service during the COVID-19 pandemic in a fracture clinic setting. We implemented a triage style method to ensure patient safety whilst reducing face-to-face contact.A total of 314 patients were identified on the follow-up fracture clinic list as suitable for telephone triage in April 2020.Patient records were reviewed by a clinician who performed a telephone triage consultation prior to their planned appointment.297 patients had completed telephone consultations with 14 patients uncontactable and 3 followed-up at another hospital.Anonymised patient satisfaction questionnaires were sent to all patients with a pre-paid envelope to return.Questionnaires were designed using a 5-point Likert scale for 10 questions,modelled on previous GMC and CQC validated patient questionnaires.During triage consultations, 110 patients were discharged(37%),174 had their follow-up rescheduled(58.6%),5 remained on a surgical waiting list(1.7%)and 8 needed to be seen face-to-face.Post-triage consultation,3 patients raised concerns(1%) and were seen in the clinic with no further problems.101 patient questionnaires were returned(34% response rate).82.2% of patients either strongly agreed or agreed that their injury had been managed appropriately at the end of the phone call.62.4% of patients were positive about recommending the telephone triage service in the future whilst 20.8% were neutral and 15.8% disagreed or strongly disagreed.Our study shows that telephone consultation can act as an effective triage tool in safely reducing face-to-face patient contact.Overall, patients were satisfied with the clinician and consultation,but were less positive about continuing this consultation medium in the future, outside of the COVID-19 pandemic.

Introduction: The role of digital health in the management of patients with spinal pathology has significantly increased during the Coronavirus disease 2019 (COVID-19) pandemic. Digital health modalities, such as mobile health, telemedicine, wearable devices, patient engagement platforms (PEPs), augmented and virtual reality, artificial intelligence, and 3D-printing, have been implemented in greater scale to meet the unique constraints of pandemic-dictated care. The purpose of this review is to examine the most promising digital health tools in the context of the COVID pandemic and highlight opportunities for future research and technological advancement. Methods: In this narrative review, Pubmed and Google Scholar databases were queried systematically to evaluate the most current literature on digital health tools being implemented in the care of spine patients. The most promising digital health modalities for patient care include mobile health, telemedicine, wearable devices, patient engagement platforms (PEPs), augmented and virtual reality, artificial intelligence, and 3D-printing. Providers who utilize mobile health, telemedicine, wearable devices and patient engagement platforms have the ability to engage with patients remotely to ensure continued delivery of standardized care. Augmented reality, virtual reality, artificial intelligence and 3D printing are all modalities that can be used to potentially enhance quality of care and reduce the burden of time spent in the intensive care unit (ICU). Conclusion: In the era of COVID-19, where resources are limited and social distancing is required, digital health modalities offer diverse avenues to improve spine patient care.