Aims

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

“Simulation”, “deliberate practice”, “rehearsal” have been used to describe safe acquisition and practice of skills before patient contact. Simulation resources are being introduced as a General Medical Council mandate. Individual simulators have shown multi-level evidence but there is no guidance to form a simulation curriculum. We devised a pilot arthroscopy course based on a 4-stage model. Stage 1: session covering anatomy, equipment, and skills required; Stage 2: practice on low fidelity simulators (Arthroscopic Skills Acquisition Tools (ASATs), ArthroBox, Synthetic Knee); Stage 3: practice on high fidelity simulators (Cadaveric Knee, Virtual Reality); Stage 4: assessment on performance intra-operatively. This study sought feedback on Stages 1–3 with the aim that the feedback will help identify how trainees wish to use simulators.

Five arthroscopic simulators were used in this one-day pilot course. Prior to commencing, participants were asked which simulator they felt would help them the most. Feedback on each stage, and individual simulator (Likert scale), and how trainees would like to be trained was prospectively collected.

Seven orthopaedic juniors took part. All felt the high-fidelity simulators will be the most useful. All stages were ranked with equal importance, whilst cadaveric, plastic, VR, Arthrobox and lastly ASATs ranked in order of realism respectively. For cadaveric arthroscopy trainees wished the trainers to be there all the time (6/7), whilst for VR all trainees wanted their trainers part of the time.

We have shown that junior trainees value a structured method of skills acquisition and have identified that high fidelity simulation requires trainers to be present to provide relevant feedback. Such feedback mechanisms need to be incorporated in any curriculum so that simulation tools are not seen as a standalone training method.

Tension band wire fixation continues to be the most popular method of fixation for displaced olecranon fractures despite several biomechanical studies questioning the validity of the tension band concept. Our aim was to compare the outcome of the tension band wire (TBW) method with plate fixation. 58 consecutive olecranon fractures underwent internal fixation in 58 patients between September 2000 and December 2004. There were 30 male and 28 female with a mean age at the time of surgery of 52.5 years for the TBW group (range 19 to 88) and 46.1 for the plate group (range 19 to 72). Patients were excluded if they were less than 16 years of age. Choice of fixation was based on surgeon preference, fracture pattern and presence of associated injuries. 43 patients were managed with the AO tension band technique and 15 with plate fixation. Clinical assessment and functional analysis was performed using Helm’s scoring system. Radiographic assessment was performed to assess the quality of reduction. All fractures were displaced and classified according to Colton’s classification. Mean follow up was 13 months (range 6 to 18) and similar for the two groups. For the TBW group 41 (95 %) had a fair or good result. 27 (62.8%) patients had symptomatic metal prominence requiring implant removal. In the plate fixation group 14 (94%) had a fair or good functional result despite having more complex fractures. Only 2 (18%) patients required implant removal for symptomatic metalwork, including one failure due to a technical problem. Similar functional results were seen with plating and tension band wiring of displaced olecranon fractures. Despite meticulous technique, tension band wire fixation still has an unacceptably high complication rate with symptomatic metal prominence requiring further surgery. To avoid this problem, we recommend plating, even for the more simple olecranon fractures.