Related Articles

INTRODUCTION

Abbreviations are commonly used in medical literature. Their use has been associated with medical errors and they can be a source of irritation and misunderstanding. There are strict guidelines for their use. This study analysed the use of abbreviations in orthopaedic literature and compared adherence with guidelines in a general orthopaedic and spinal journal. It also examined orthopaedic professionals& understanding of abbreviations.

SUBJECTS AND METHODS

The use of abbreviations in articles over a 3-month period in a general orthopaedic and spinal journal was analysed. The number of abbreviations and adherence with guidelines was recorded. A group of orthopaedic healthcare professionals were tested for their understanding of abbreviations.

RESULTS

Almost half of all abbreviations were not properly used and 30% of abbreviations were never defined. Abbreviations were used significantly more often in the spinal journal. Only 40% of abbreviations were correctly defined by the orthopaedic professionals tested.

CONCLUSIONS

Guidelines regarding the use of abbreviations are not being adhered to by authors or editors. The poor understanding of abbreviations underlines the importance of minimising their use and defining abbreviations when they are used.

Background

The aim of this survey study was to evaluate the current opinion and practice of trauma and orthopaedic surgeons in the Netherlands in the removal of implants after fracture healing.

Methods

A web-based questionnaire consisting of 44 items was sent to all active members of the Dutch Trauma Society and Dutch Orthopaedic Trauma Society to determine their habits and opinions about implant removal.

Results

Though implant removal is not routinely done in the Netherlands, 89% of the Dutch surgeons agreed that implant removal is a good option in case of pain or functional deficits. Also infection of the implant or bone is one of the main reasons for removing the implant (> 90%), while making money was a motivation for only 1% of the respondents. In case of younger patients (< 40 years of age) only 34% of the surgeons agreed that metal implants should always be removed in this category. Orthopaedic surgeons are more conservative and differ in their opinion about this subject compared to general trauma surgeons (p = 0.002). Though the far majority removes elastic nails in children (95%).

Most of the participants (56%) did not agree that leaving implants in is associated with an increased risk of fractures, infections, allergy or malignancy. Yet in case of the risk of fractures, residents all agreed to this statement (100%) whereas staff specialists disagreed for 71% (p < 0.001). According to 62% of the surgeons titanium plates are more difficult to remove than stainless steel, but 47% did not consider them safer to leave in situ compared to stainless steel. The most mentioned postoperative complications were wound infection (37%), unpleasant scarring (24%) and postoperative hemorraghe (19%).

Conclusion

This survey indicates that there is no general opinion about implant removal after fracture healing with a lack of policy guidelines in the Netherlands. In case of symptomatic patients a majority of the surgeons removes the implant, but this is not standard practice for every surgeon.

Background

Recent epidemiologic and clinical data suggest men and racial and ethnic minorities may receive lower-quality care for osteoporosis and fragility fractures than female and nonminority patients. The causes of such differences and optimal strategies for their reduction are unknown.

Questions/purposes

A panel was convened at the May 2010 American Academy of Orthopaedic Surgeons/Orthopaedic Research Society/Association of Bone and Joint Surgeons Musculoskeletal Healthcare Disparities Research Symposium to (1) assess current understanding of sex/gender and racial/ethnic disparities in the care of osteoporosis and after fragility fractures, (2) define goals for improving the equity and quality of care, and (3) identify strategies for achieving these goals.

Where are we now?

Participants identified shortcomings in the quality of care for osteoporosis and fragility fractures among male and minority populations and affirmed a need for novel strategies to improve the quality and equity of care.

Where do we need to go?

Participants agreed opportunities exist for health professionals to contribute to improved osteoporosis management and secondary fracture prevention. They agreed on a need to define standards of care and management for osteoporosis and fragility fractures and develop strategies to involve physicians and other health professionals in improving care.

How do we get there?

The group proposed strategies to improve the quality and equity of osteoporosis and care after fragility fractures. These included increased patient and physician education, with identification of “champions” for osteoporosis care within and outside of the healthcare workforce; creation of incentives for hospitals and physicians to improve care; and research comparing the effectiveness of approaches to osteoporosis screening and fracture management.

INTRODUCTION

Diagnostic errors in orthopaedics are usually caused by missing a fracture or misreading radiographs. The aim of this study was to document the pick-up rate of the wrong diagnoses by reviewing X-rays and casualty notes in the next-day trauma meeting.

PATIENTS AND METHODS

The casualty notes and radiographs of 503 patients were prospectively reviewed in the daily trauma meeting between August 2002 and December 2002 in a district general hospital. The relevant data were collected and analysed by a single assessor.

RESULTS

The false positive rate for making an orthopaedic diagnosis was 12.6% (i.e.) diagnosing a fracture, when none existed). The false negative (missing) rate was 4%, while 2.4% incidental findings were missed, or at least not documented, after reading the X-rays. There were 7.8% wrong diagnoses made. The majority of the patients were seen by the senior house officers.

CONCLUSIONS

The medicolegal significance of false negative diagnosis is obviously greater. In a busy emergency department, where a large number of patients are seen, there is a greater risk. This study shows the importance in a small-to-medium sized accident and emergency unit as well, where there is no senior cover available out-of-hours for final radiological interpretation. A morning trauma meeting which covers reviewing admitted patients as well as non-admission orthopaedic referrals has an effective risk management solution to early detection of missed and wrong diagnoses.

The purpose of this review is the presentation of the proper orthopaedic treatment of the most frequent fragility fractures associated with low bone mineral density or established osteoporosis. In this particular group of patients, the surgical treatment is difficult for the poor quality of the broken bone that limits the reduction, the hardware fixation and the physiologic process of bone healing. Other important problems are the postoperative management of old patients with chronic diseases and more prone to develop local and general complications with big difficulties to conduct a good rehabilitation program.

Some considerations will be made, lastly, about the role of the orthopaedic surgeon on the treatment of osteoporosis and on the possibility to prevent further fractures.

Background

To develop and psychometrically assess a multiple choice question (MCQ) instrument to test knowledge of depression and its treatments in patients suffering from depression.

Methods

A total of 63 depressed patients and twelve psychiatric experts participated. Based on empirical evidence from an extensive review, theoretical knowledge and in consultations with experts, 27-item MCQ knowledge of depression and its treatment test was constructed. Data collected from the psychiatry experts were used to assess evidence of content validity for the instrument.

Results

Cronbach's alpha of the instrument was 0.68, and there was an overall 87.8% agreement (items are highly relevant) between experts about the relevance of the MCQs to test patient knowledge on depression and its treatments. There was an overall satisfactory patients' performance on the MCQs with 78.7% correct answers. Results of an item analysis indicated that most items had adequate difficulties and discriminations.

Conclusion

There was adequate reliability and evidence for content and convergent validity for the instrument. Future research should employ a lager and more heterogeneous sample from both psychiatrist and community samples, than did the present study. Meanwhile, the present study has resulted in psychometrically tested instruments for measuring knowledge of depression and its treatment of depressed patients.

The American Board of Family Medicine (ABFM) has used a 60-item Multiple Choice Question (MCQ) section followed by a Virtual Patient (VP) exercise in Maintenance Of Certification (MOC) since 2004, and has had an asthma module since 2005. The original asthma VP criteria anticipated some Expert Panel Report-3 recommendations, such as home peak flow monitoring and a written plan, that were added to the MCQ section only when the guideline was updated in 2007. VP completion rates for these criteria improved markedly with the MCQ update, while other criteria completion rates were stable. Asthma criteria completion rates are not predicted by the strength of evidence for the criteria. User interface details influence criteria completion rates, but did not affect the changes observed in 2007. Asthma MCQ content affects Diplomate performance on asthma VP: this translational step suggests that MOC exercises could result in improved care for real patients.

Broken screws after interlocking nailing of long bones are commonly seen in Orthopaedic practice. Removal of such screws can be difficult particularly the distal part which is often held within the bone. We describe a simple technique of using Steinman pin to aid removal of broken screws in a case of non-union fracture tibia with broken interlocking nail and screws. Steinman pin being easily available and the reproducible technique make it a useful aid for removal of broken interlocking screws.

INTRODUCTION

Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting.

METHODS

With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids.

RESULTS

We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73–85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model.

CONCLUSIONS

Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.

Background

Medical diagnosis, like all products of human cognition, is subject to error. We tested the hypothesis that errors of diagnosis in the realm of fracture classification can be reduced by a consensus (group) diagnosis; and that digital imaging and Internet access makes feasible the compilation of a diagnostic consensus in real time.

Methods

Twelve orthopaedic surgeons were asked to evaluate 20 hip radiographs demonstrating a femoral neck fracture. The surgeons were asked to determine if the fractures were displaced or not. Because no reference standard is available, the maximal accuracy of the diagnosis of displacement can be inferred from inter-observer reliability: if two readers disagree about displacement, one of them must be wrong. That method was employed here. Additionally, virtual reader groups of 3 and 5 individual members were amalgamated, with the response of those groups defined by majority vote. The purpose of this step was to see if increasing the number of readers would improve accuracy. In a second experiment, to study the feasibility of amassing a reader group on the Internet in real time, 40 volunteers were sent 10 periodic email requests to answer questions and their response times were assessed.

Results

The mean kappa coefficient for individual inter-observer reliability for the diagnosis of displacement was 0.69, comparable to prior published values. For 3-member virtual reader groups, inter-observer reliability was 0.77; and for 5-member groups, it was 0.80. In the experiment studying the feasibility of amassing a reader group in real time, the mean response time was 594 minutes. For all cases, a 9-member group (theoretically 99% accurate) was amassed in 135.8 minutes or less.

Conclusions

Consensus may improve diagnosis. Amassing a group for this purpose on the Internet is feasible.

The aim of this study was to gain information about how orthopaedic surgeons use evidence-based literature and how this is influenced by their knowledge of evidence-based medicine. We administered a questionnaire to participants at courses of the Association for the Study of Internal Fixation (AO-ASIF) in Davos, Switzerland, in December 2003. Special attention was paid to the surgeons’ educational level, affiliations, and the infrastructure and evidence sources they used. In addition, we tested participants on their knowledge and attitude to evidence-based orthopaedic surgery (EBOS). Of 1,274 course participants, 456 completed the questionnaire. Of 446 respondents, 300 had heard of EBOS, but only 45% could define it correctly. Nearly two thirds identified scientific publications as their main source of scientific knowledge. The respondents’ attitudes to and awareness of EBOS principles was high, but it did not influence their manner of searching for scientific information or their trust in various sources of recommendations.

Humeral shaft fractures respond well to conservative treatment and unite without much problem. Since it is uncommon, there is not much discussion regarding the management of nonunion in the literature, and hence this is a challenge to the treating orthopaedic surgeon. Osteoporosis of the fractured bone and stiffness of the surrounding joints compounds the situation further. The Ilizarov fixator, locking compression plate, and vascularised fibular graft are viable options in this scenario but are technically demanding. We used a fibular strut graft for bridging the fracture site in order to enhance the pull-out strength of the screws of the dynamic compression plate. Six patients in the study had successful uneventful union of the fracture at the last follow-up. The fibula is easy to harvest and produces less graft site morbidity. None of the study patients needed additional iliac crest bone grafting. This is the largest reported series of patients with osteoporotic atrophic nonunion of humerus successfully treated solely using the combination of an intramedullary fibular strut graft and dynamic compression plate.

Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your site program by the American Academy of Orthopedic Surgeon, the sign, mark and X-ray program by the North American Spine Society, and the Universal Protocol program by the Joint Commission, the incidence of wrong-site surgery has not decreased. To prevent wrong-site surgery in spine surgeries, the spine surgeons must put patient safety first, complying with the hospital policies regarding patient safety. In the operating rooms, the surgeons need to do their best to level the hierarchy, enabling all to speak up if any patient safety concerns are noted. Changing the operating room culture is the essential part of the patient safety concerning spine surgery.

INTRODUCTION

Collecting outcome scores in paper form is fraught with difficulty. We have assessed the feasibility of, and patient's attitude towards, entering scores using a touchscreen.

PATIENTS AND METHODS

A touchscreen was installed in the orthopaedic out-patient clinic. If relevant, patients were asked to complete either an Oswestry Disability Index (ODI) or Oxford Shoulder Score (OSS) using the screen. Patients were given written instructions and their hospital number by the receptionist who had no further input. Scores were completed with two identifiers. A paper questionnaire was used to assess computer experience and attitude towards the touchscreen.

RESULTS

A total of 1348 patients, average age 50 years, successfully completed a score in the first 12 months. One-third were over 60 years. Overall, 91% correctly entered their hospital number and date of birth, falling to 84% in patients over 70 years. All patients were identifiable. The average time to complete the scores was 4.7 min rising with age. Of 170 patients completing the paper assessment of the touchscreen, one-third had little or no experience of computers and a third were over 60 years. Of patients, 93% were willing to repeat the score using the touchscreen to monitor progress. Two-thirds found it easier to use than expected. Only 10% would prefer a paper score. These results were maintained among patients over 60 years. Only two were unable to complete the score and 80% of those potentially eligible did so. The remainder were called to clinic before the touchscreen was free.

CONCLUSIONS

Orthopaedic outcome scores can be collected in very large volumes using a touchscreen. Data are then in an immediately usable form. The method is acceptable to patients, independent of age and computer experience. Even in the oldest patients, the accuracy is higher than for paper versions of the score. Combined with operative data, this simple method has the potential to provide a very powerful audit tool indeed.

In recent years, cell therapy for bone regeneration has been found to have different indications in orthopaedic surgery, such as delayed fracture consolidation and the treatment of bone cysts and osteonecrosis.

The aims of regenerative medicine are to obtain healing in the shortest possible time, to use a mini-invasive approach and to reduce management costs.

Delayed consolidation can be defined radiographically as a fracture callus that is poorly evident or absent six months after osteosynthesis and its incidence ranges from 5 to 10% of long-bone fractures; to demonstrate the efficacy of regenerative therapy, we treated six patients aged between 19 and 53 years (mean 39 years) using a mini-invasive technique, preparing the fracture rim and applying, to the site, demineralised bone matrix (DBM) and mesenchymal stem cells (MSCs) obtained by harvesting bone marrow blood from the iliac crest. The sites treated were the tibia and the femur. Osteosynthesis was performed using an endomedullary nail in one case, an external fixing device in two, and a plate in three. Before our treatment, carried out between 4 and15 months after osteosynthesis (mean 8 months), all the patients were experiencing pain and none was completely loading the limb. The follow-up duration ranged from 3 to 18 months (mean 6 months) with checkups performed at 3, 6 and 12 months. Three months after the operation, five of the patients were completely loading the treated limb without pain and showed inter-fragment thickening on radiographic examination that allowed removal of the external fixing device in the two patients in whom it had been used, and at 12 months’ follow up showed complete clinical-radiographic healing.

The application of DBM and MSCs through mini-invasive surgery, performed a short time after osteosynthesis, reduced the healing time in patients with delayed consolidation and considerably reduced the costs of managing the condition itself.

Another field of application for regenerative medicine is the treatment of simple bone cysts, benign bone lesions that regress spontaneously when skeletal maturity is reached; nevertheless, their treatment is justified by the high risk of pathological fracture. To date, numerous techniques have been proposed to treat this disease, from curettage and bone grafting to cycles of cortisone injections. However, these techniques have limitations; either they are highly invasive or they involve a number of procedures carried out in close succession.

In 2007, we began a study comparing two groups of patients: the first treated with multiple cortisone injections and the second with a single injection of DBM associated with MSCs. The minimum follow up was 12 months. The mean follow up was 48 months (range 12–120 months) in the first group, and 19 months (range 12–29 months) in the second. The sites treated were the humerus (137 and 44 respectively) and femur (42 and 16 respectively).

At the end of the treatment, only 38% of the patients treated with cortisone could be defined healed, compared with 67% of those treated with DBM and MSCs. The treatment with a single injection of DBM and MSCs was thus found to be more effective in reducing healing times in patients with simple bone cysts.

Regenerative medicine is also indicated in hip osteonecrosis (ON). We treated 15 patients aged between 17 and 50 years (mean 32 years) with a mini-invasive technique involving decompression of the necrotic area and infiltration of DBM, MSCs and platelet-rich fibrin (PRF). Using the Ficat staging system, the ON was graded IIa–IIb in eight patients and III–IV in seven, with follow up lasting a mean of 6 months (range 3–14); checkups were scheduled at 3, 6 and 12 months. The mean Harris Hip Score showed an improvement: the score of the patients graded IIa–IIb rose from the 61 recorded preoperatively to 75 at 3 months, 82 at 6 months, and 98 at 12 months, whereas that of the patients graded III–IV rose from 57 preoperatively to 75 at 3 months, 76 at 6 months, and 86 at 12 months.

Even though the follow ups conducted are still short and the sample of patients small, the preliminary results of this study on the use of MSCs associated with DBM and PRF are promising.

All this suggests that the use of cells, in regenerative medicine, might be considered an effective and economic treatment possibility in orthopaedics.

Orthopaedic surgical practice is becoming increasingly complex. The rapid change in pace associated with new information and technologies, the physician-supplier relationship, the growing costs and growing gap between costs and reimbursements for orthopaedic surgical procedures, and the influences of advertising on the patient, challenge all involved in the delivery of orthopaedic care. This paper assesses the concepts of professionalism, autonomy, and accountability in the 21st century practice of orthopaedic surgery. These concepts are considered within the context of the complex value chain surrounding orthopaedic surgery and the changing forces influencing clinical decision making by the surgeon. A leading impetus for challenge to the autonomy of the orthopaedic surgeon has been cost. Mistrust and lack of understanding have characterized the physician-hospital relationship. Resource dependency has characterized the physician-supplier relationship. Accountability for the surgeon has increased. We suggest implant surgery involves shared decision making and “coproduction” between the orthopaedic surgeon and other stakeholders. The challenge for the profession is to redefine professionalism, accountability, and autonomy in the face of these changes and challenges.

Four ceftazidime-resistant Escherichia coli strains were isolated from elderly nursing home patients in a New York hospital during 1993. Strains MCQ-2, MCQ-3, and MCQ-4 were determined to be identical by pulsed-field gel electrophoresis and plasmid profiles, whereas strain MCQ-1 was unique. Strain MCQ-1 was determined to produce a TEM-10 beta-lactamase. Strains MCQ-2, MCQ-3, and MCQ-4 were also noted to be resistant to cefotaxime. These three strains produced two beta-lactamases with pIs of 5.4 (TEM-1) and 7.6. beta-Lactamase assays revealed that the pI 7.6 enzyme hydrolyzed cefotaxime faster (at a relative hydrolysis rate of 30% compared with that of benzylpenicillin) than either ceftazidime or aztreonam (relative hydrolysis rates of 13 and 3.3%, respectively). Nucleotide sequencing of the gene encoding the pI 7.6 beta-lactamase from strain MCQ-3 revealed a blaSHV-type gene differing from the gene encoding SHV-1 at four nucleotides which resulted in amino acid substitutions: phenylalanine for isoleucine at position 8, serine for arginine at position 43, serine for glycine at position 238, and lysine for glutamate at position 240. This novel SHV-type extended-spectrum beta-lactamase is designated SHV-7.

This paper is an attempt to produce a guide for improving the quality of Multiple Choice Questions (MCQs) used in undergraduate and postgraduate assessment. Multiple Choice Questions type is the most frequently used type of assessment worldwide. Well constructed, context rich MCQs have a high reliability per hour of testing. Avoidance of technical items flaws is essential to improve the validity evidence of MCQs. Technical item flaws are essentially of two types (i) related to testwiseness, (ii) related to irrelevant difficulty. A list of such flaws is presented together with discussion of each flaw and examples to facilitate learning of this paper and to make it learner friendly. This paper was designed to be interactive with self-assessment exercises followed by the key answer with explanations.

Background

The diagnosis and treatment of fractures of the proximal humerus have troubled patients and medical practitioners since antiquity. Preradiographic diagnosis relied on surface anatomy, pain localization, crepitus, and impaired function. During the nineteenth century, a more thorough understanding of the pathoanatomy and pathophysiology of proximal humeral fractures was obtained, and new methods of reduction and bandaging were developed.

Questions/purposes

I reviewed nineteenth-century principles of (1) diagnosis, (2) classification, (3) reduction, (4) bandaging, and (5) concepts of displacement in fractures of the proximal humerus.

Methods

A narrative review of nineteenth-century surgical texts is presented. Sources were identified by searching bibliographic databases, orthopaedic sourcebooks, textbooks in medical history, and a subsequent hand search.

Results

Substantial progress in understanding fractures of the proximal humerus is found in nineteenth-century textbooks. A rational approach to understanding fractures of the proximal humerus was made possible by an appreciation of the underlying functional anatomy and subsequent pathoanatomy. Thus, new principles of diagnosis, pathoanatomic classifications, modified methods of reduction, functional bandaging, and advanced concepts of displacement were proposed, challenging the classic management adhered to for more than 2000 years.

Conclusions

The principles for modern pathoanatomic and pathophysiologic understanding of proximal humeral fractures and the principles for classification, nonsurgical treatment, and bandaging were established in the preradiographic era.

Background

Defining bone quality remains elusive. From a patient perspective bone quality can best be defined as an individual’s likelihood of sustaining a fracture. Fracture risk indicators and performance measures can help clinicians better understand individual fracture risk. Educational resources such as the Web can help clinicians and patients better understand fracture risk, communicate effectively, and make decisions concerning diagnosis and treatment.

Questions/purposes

We examined four questions: What tools can be used to identify individuals at high risk for fracture? What clinical performance measures are available? What strategies can help ensure that patients at risk for fracture are identified? What are some authoritative Web sites for educating providers and patients about bone quality?

Methods

Using Google, PUBMED, and trademark names, we reviewed the literature using the terms “bone quality” and “osteoporosis education.” Web site legitimacy was evaluated using specific criteria. Educational Web sites were limited to English-language sites sponsored by nonprofit organizations

Results

The Fracture Risk Assessment Tool® (FRAX®) and the Fracture Risk Calculator (FRC) are reliable means of assessing fracture risk. Performance measures relating to bone health were developed by the AMA convened Physician Consortium for Performance Improvement® and are included in the Physician Quality Reporting Initiative. In addition, quality measures have been developed by the Joint Commission. Strategies for identifying individuals at risk include designating responsibility for case finding and intervention, evaluating secondary causes of osteoporosis, educating patients and providers, performing cost-effectiveness evaluation, and using information technology. An abundance of authoritative educational Web sites exists for providers and patients.

Conclusions

Effective clinical indicators, performance measures, and educational tools to better understand and identify fracture risk are now available. The next challenge is to encourage broader use of these resources so that individuals at high risk for fracture will not just be identified but will also adhere to therapy.

Method

A Delphi study was conducted to obtain consensus on the most important criteria for the radiological evaluation of the reduction and fixation of the wrist and ankle. The Delphi study consisted of a bipartite online questionnaire, focusing on the interpretation of radiographs and CT scans of the wrist and the ankle. Questions addressed imaging techniques, aspects of the anatomy and fracture reduction and fixation. Agreement was expressed as the percentage of respondents with similar answers. Consensus was defined as an agreement of at least 90%.

Results

In three Delphi rounds, respectively, 64, 74 and 62 specialists, consisting of radiologists, trauma and orthopaedic surgeons from the Netherlands responded. After three Delphi rounds, consensus was reached for three out of 14 (21%) imaging techniques proposed, 11 out of the 13 (85%) anatomical aspects and 13 of the 22 (59%) items for the fracture reduction and fixation. This Delphi consensus differs from existing scoring protocols in terms of the greater number of anatomical aspects and aspects of fracture fixation requiring evaluation and is more suitable in clinical practice due to a lower emphasis on measurements.

The limbus and the neolimbus are both pathological lesions that form in response to a developmentally dislocated hip. An understanding of these structures is integral to treatment of developmental dysplasia of the hip (DDH). Yet, we believe the current peer-reviewed orthopaedic literature and orthopaedic textbooks commonly fail to correctly use or define these terms. The neolimbus is best defined as a hypertrophied ridge of fibrocartilage in the superolateral region of the acetabulum caused by pressure from the dislocated hip on this region. The limbus is the labrum that is hypertrophied with fibrous and fibrocartilaginous overgrowth, and is a potential block to concentric reduction of a dysplastic hip. We review the early and current literature in an attempt to clarify the use of the terms limbus and neolimbus and provide an overview of the importance and treatment of these abnormal structures associated with DDH.

Level of Evidence: Level V, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Aim

This study examined understandings of basic genetic concepts among Americans.

Method

In a national telephone survey of 1,200 Americans with equal representation among Black and White men and women, subjects responded to 8 items developed by a multidisciplinary team of experts that assessed understanding of basic concepts in multiple domains, including inheritance, genetics and race, and genetics and behavior.

Results

Over 70% of subjects responded correctly on items about the genetic similarity of identical twins and siblings. Less than half of subjects responded correctly on all other items. Understanding of genetics was lowest in three areas: types/locations of genes in the body (29% correct), a genetic basis for race (25% correct), and the influence of single genes on behaviors (24% correct). Logistic regression models controlling for age and education showed some differences by race and gender on specific items but also showed that understandings are generally similar across these groups.

Conclusion

Misunderstandings about genetics are common among Black and White American men and women. Responses appear to reflect personal experiences, group values and interests. These findings emphasize the need for initiatives to improve the public's genetic literacy as well as a need for further investigation in this domain.

Delay in operating on trauma patients leads to increased morbidity, mortality, length of hospital stay and overall cost. The urgency of operative intervention depends on the injury sustained. There are no published guidelines on what constitutes a reasonable delay between admission and operation. As part of the clinical governance in our unit, an audit was undertaken to examine the structure and process of trauma operating. Patients were allocated to groups defined by the Bath Orthopaedic Department, according to urgency of need for surgery. Group A: patients (for example, open fractures and dislocations) should have definitive treatment within 6 h of admission. Group B: patients (for example, hip fractures, long bone injuries and ankle fractures) should have operations on the day that they are presented to the consultant trauma meeting, or on the day that they are declared fit/ready for theatre. Group C: patients (for example, tendon injuries, simple hand fractures) should have operations within 5 days of presentation to the trauma meeting. Over 3 months, there were 401 acute orthopaedic admissions requiring surgery (61 group A, 277 group B, 63 group C). 78% of group A patients, 58% of group B patients and 86% of group C patients were operated on within the target times. In total, 137 out of 401 operations (34%) missed the targets set. 119 of these (87%) were delayed due to lack of available operating time. This was despite the fact that 59 operations (15% of total) were done on lists normally used for elective operating. Most of the other delays were due to the need for an appropriately experienced surgeon to be available. If these targets are to be achieved for the majority of patients, the trauma theatre must become more efficient, or more flexible time must be made available during evenings or weekends to clear the backlog of trauma operations.

INTRODUCTION

This is an audit of patient understanding following their consent for orthopaedic procedures and uses information on new Orthoconsent forms endorsed by the British Orthopaedic Association as the set standard. The objectives were to: (i) assess whether patients& understanding of knee arthroscopy (KA) and total knee replacement (TKR) at the point of confirming their consent reaches the set standard; and (ii) to ascertain whether issuing procedure-specific Orthoconsent forms to patients can improve this understanding.

SUBJECTS AND METHODS

This was a prospective audit using questionnaires consisting of 26 (for KA) or 35 (for TKR) questions based on the appropriate Orthoconsent form in a department of orthopaedic surgery within a UK hospital. Participants were 100 patients undergoing KA and 60 patients undergoing TKR between February and July 2008. Participants were identified from sequential operating lists and all had capacity to give consent. During the first audit cycle, consent was discussed with the patient and documented on standard yellow NHS Trust approved generic consent forms. During the second audit cycle, patients were additionally supplied with the appropriate procedure-specific consent form downloaded from which they were required to read at home and sign on the morning of surgery.

RESULTS

Knee arthroscopy patients consented with only the standard yellow forms scored an average of 56.7%, rising to 80.5% with use of Orthoconsent forms. Similarly, total knee replacement patients& averages rose from 57.6% to 81.6%.

CONCLUSIONS

Providing patients with an Orthoconsent form significantly improves knowledge of their planned procedure as well as constituting a more robust means of information provision and consent documentation.