Common questions Flashcards
Why do you want to do orthopaedics?
Variety within the work
Ability to achieve excellent outcomes and patient satisfaction
Skillset aligns with my own abilities
Enjoy collegiate nature
What are three strengths of yours?
Organised
Ability to stay calm and perform under pressure
Good teacher
Understand the limitations of my abilities
How would you set up a bone school session (3 key subjects)
Topic - gather information, lit review
Find a patient
Consultant
AOA 21 key points
Initiative launched 2014 - to improve quality and patient care through world recognised orthopaedic SET program
Intro to orthopaedics 1 year, core orthopaedics 2 years, transition to practice 1 year
Components
- research component - 3 pathways including conduct a research project, complete a Masters or PhD
- education - bone camp / ASSET / CCRISP / TIPS / EMST / bone school
- exams - OPBS and final fellowship exam
- feedback and assessment - feedback entries, logbook, workplace based assessments (consultation, management, case discussion, surgical skills)
- performance review with supervisor and director of training
Why is research important
Progresses medical field and evidence based practice
Collaborative / communication skills
Critical analysis of papers
Presentation skills
Ethical research discussion points
Informed consent
Data management
Avoiding bias
How do you conduct a research project
Literature review - relevant? answered before?
Research question
Supervisor + team
Research plan and ethics proposal
Research structure (PICOTS)
- population / intervention / control / outcome / time period / statistics
Aims of AOA research and strategic plan 2022-2024
Aim - to be world-recognised for the advancement of orthopaedic surgery through
- Training and education
- Culture diversity and inclusion
- Clinical practice and research
- Advocacy and engagement
Key points for orthopaedics managing COVID
Communication
Organisation
Adaptability
Telehealth
Recent advances in orthopaedics - surgical and non-surgical
3D printing
- Teaching tool
- Surgical planning
- Arthroplasty
- Communication tool
Multi-D approach - NOFs and infections
What is clinical governance / what are its pillars / what is an example
Systematic approach to maintaining and improving the quality of patient care in a healthcare system
REPAT
- research
- evidence based medicine
- patient care and safety
- audit
- teaching
Surgical safety checklist
4 fields of AOA continued professional development
Surgical audit and peer review
Clinical services
self-directed learning
scientific meetings and research
Steps of an audit
Determine the scope Set the standard Collect the data Present and interpret the data Make the changes and monitor the process
Examples of audits
Self
- AOA SET logbook
- MALT (morbidity audit and logbook tool) from RACS
System
- National joint registry
- South Australian Audit of Peri-operative Mortality (SAAPM) from RACS
New technologies
- ASERNIP-S (Australian Safety and Efficacy Register of New Interventional Procedures - Surgical)
Difference between audit and research
Audit - systematic critical analysis of care, aims to ensure standard of care compares to gold standard
Research - scientific process undertaken to increase knowledge
Informed consent definition and elements
Person’s voluntary decision about medical care that is made with knowledge and understanding of the risks and benefits involved. It is a continuous and dynamic process.
Must be able to understand, retain information for a short time, and adequately communicate their decision
Voluntary choice
Full disclosure
Adequate comprehension
Able to communicate decision
Approach to an adverse event
Assessment and gather information
Discuss up chain of command and come up with plan
Rectify the situation
Open disclosure to patient
Document
Long-term - SLS, self audit, insurance, hospital legal team
What is a sentinel event, what are the 3 priorities to deal with
Subset of adverse patient safety events that are preventable and result in serious harm or death
- deal with the situation
- investigate how it occurred
- prevent it from happening again
Levels of evidence
Defined by Australian national health and medical research council
- Level I – a systematic review of level two studies
- Level II – randomised controlled trial
- Level III-1 - pseudorandomised controlled trial. For example a randomised control trial among non-consecutive patients
- Level III-2 - a comparative study with concurrent controls
- Level III-3 - a comparative study without controls
- Level IV - a case series
- Level V - case reports / literature reviews
What is an impact factor?
Indicator of how frequently the articles in a publication are cited
Ratio given by the number of citations in the current year of articles pubslied in the previous two years, divided by the number of articles published
Bolam principle and Gillick competence
Bolam - doctor not guilty of negligence if acted in a way common within the profession
Gillick - Minors under 16 can give consent if understand the nature, risks and benefits | treatment is in their best interest | opinion corroborated by another medical practitioner
Negligence vs recklessness
Negligence - treatment not up to standard required
Recklessness - undertaking risk being aware of the risk
Mandatory notifications
AHPRA requirement for all health practitioners
When practitioner undertaking notifiable conduct that puts the public at risk
- impaired by alcohol / drugs
- sexual misconduct
- practicing with an impairment
- practicing with significant departure from acceptable standard
Mandatory reporting to DCP
- Physical abuse
- Sexual abuse
- Mental or emotional abuse
- Neglect
Difficult situation approach
SPIES Seek information patient safety initiate escalate support
Steps for introducing new technologies
Prior evaluation - register with ASERNIP-S, literature review
Clinical governance - conflict of interest, costs
Training of staff
Introduction - consent, learning curve, audit
Three principles for RACS position on interaction with industry
Best interest of patient is paramount
Surgeons must be accountable and transparent
Perceived, potential and actual conflict of interest must be acknowledged
Important qualities for a team
Example of working well in a team
Example of team working breaking down, compromising outcome
Communication
Organised
Honesty and trustworthy
Adaptable
Example - meningococcal patient at TQEH
Example - elbow dislocation on ward / revision arthroplasty patient Hb 80
Leadership qualities
Example of leadership
Example of a leader
Approachable
Leads by example
Supports team members
Good decision maker
Example - Dislocated paediatric elbow in Alice Springs
Example - change to first on call roster
David Hayes - Fiji
Teaching examples
Maths and physics tutor
Medical student teaching - bedside tutorials and surgical society anatomy
Intern teaching programs
Priorities when dealing with an underperforming junior
Example
- Patient
- Junior
- Team
Junior team in Alice Springs, COVID affected
Ways to improve indigenous health
Contribution to indigenous health workforce
Training in cultural and awareness safety
Research scholarships in indigenous health
Building partnerships with indigenous health care groups and organisations
4 principles of the doctor-patent relationship
Example of communication
Beneficence - doing good
Non-maleficence - avoiding harm
Autonomy
Justice (equal treatment)
Meningococcal patient TQEH
NJRR
- established when
- capture rate
- funding
- data collected
SA in 1999, national in 2002
98%
federal department of health
patient demographics, type of prosthesis, method of fixation, surgical technique. Now collects PROM data
Differences between NJRR and clinical trial
Not designed to explain causality No exclusion criteria Ongoing vs defined period Trial answers a specific question Registry higher numbers
Two new chapters in 2021 AOANJRR
COVID and its impact on joint replacement surgery
Initial findings of patient-reported outcome measures
Key points NJRR
- COVID
- PROMS
- THR
COVID
- 11,000 procedures not done due to COVID
- greatest impact on primary knee replacement
PROMS
- undertaken for primary TKR, THR, reverse TSR for OA and for RC arthropathy
- all groups demonstrated improvement in QOL, function, joint-specific pain 6 months after surgery
- little variation between scores in public vs private - but public patients lower pre-operative QOL and joint-specific pain
THR
- bipolar hemiarthroplasty increasing in use, associated with lower revision rate
- dual mobility THR same risk of revision as standard, but half the risk of revision for dislocation
- approach overall has no difference, but anterior worse for loosening and early fracture, posterior/lateral worse for dislocation and infection
General considerations for VTE prophylaxis in arthroplasty patients
Early mobilisation Spinal anaesthetic No tourniquet TXA and delaying chemical anticoagulation Stopping pre-operative anticoagulation Compression devices
Arthroplasty guidelines for chemical DVT prophylaxis
Routine risk
- aspirin 100-300mg per day OR LMWH/warfarin/DOAC
- duration 3-6 weeks
High risk
- LMWH/warfarin/DOAC for 3-6 weeks
- consider IVC filter
Major criteria risk of PE
hyper coagulable condition previous ischaemic stroke metastatic cancer COPD sepsis
MOA for TXA | NOAC | warfarin | clopidogrel | aspirin | enoxaparin | cefazolin
TXA - inhibits plasminogen activation, prevents fibrin breakdown
NOAC - inhibit clotting cascade factors to reduce conversion of prothrombin to thrombin
warfarin - vitamin K antagonist, required for clotting cascade
clopidogrel - inhibits binding ion ADP in platelets, thus reducing aggregation
aspirin - irreversible COX enzyme inhibitor, inhibits platelet aggregation
enoxaparin - accelerates the activity antithrombin III
cefazolin - first generation cephalosporin, inhibits bacterial cell wall biosynthesis
Skin knife paper
- Study published in 2021 in Journal of American Academy of orthopaedic surgery
- Aimed to look at the theoretical advantage of using a separate blade for the skin incision and for the deep layers, to present infection by carrying bacteria from the skin down to the deeper layers
- 344 knife blades were tested for organisms immediately after the skin incision for orthopaedic cases (THA, TKA, lumbar and cervical spine surgery), vs 344 control blades
- 5.1% of specimens had a positive result and no difference was noted between the groups
- accounted for type of surgery, case order, changeover time
CROSSBAT trial
- Weber B ankle fracture treatment - randomised and observational study in BMJ 2017
- 160 patients, randomised between 2010 and 2013 across 22 Aus/NZ hospitals
- isolated Weber B with <2mm medial clear space widening compared to superior clear space, surgical management not superior to non-surgical for function and health-related QOL at 12 months
- higher adverse events in surgical group
Standards of care for NOF patients
Standards from the Australian Commission on safety and quality in healthcare
- care at presentation
- pain management
- orthogeriatric model of care
- timing of surgery - aim within 48h
- mobilisation and weight bearing
- minimising risk of another fracture
- transition from hospital care
Generic start to trauma case examples
- Have had a lot of experience managing trauma cases in ED and find that good communication is key
- I would first assess the patient according to EMST principles, ideally in a resuscitation room in ED in conjunction with a mulit-D trauma team
- When primary and secondary surveys were complete I would take a targeted history, including PMHx and fasting status
- Examination fo the patient as a whole and then of the area of interest
- Arrange relevant imaging and further investigations
- Consider primary management including pain management and immobilisation
Tourniquet complications
Nerve injury compartment syndrome alcohol burns pressure sores VTE rhabdomyolysis Post-tourniquet syndrome Digital necrosis
Contraindications to tourniquet use
PVD
Open fractures / crush injuries
Malignant tumours
Skin grafts
Safe working hours
- RACS has a position statement on safe working hours
- Acknowledges that a standard 38 hour week is not realistic or ideal for surgical training
- Also acknowledges that at times surgical trainees work hours that would be considered unsafe
- Optimised between 50-60 Horus a week, maximum of 65, averaged over a 4 week period
- Rostered hours should include time for teaching, audits, required assessments
- Time made for recreational and study leave
Contraindications to TXA
- Allergy
- Active clotting e.g. concurrent VTE
- History of thrombosis
- Coronary stent past 12 months
- Uncontrolled seizure disorder
Red flags of back pain
- Infection - fevers, IVDU, immunosuppression
- Fracture - trauma mechanism, midline tenderness
- Tumour - weight loss, fatigue, history of malignancy
- Neurological deficit - motor weakness, bladder or bowel changes
How does diathermy work
- Diathermy is a high frequency alternate polarity radio-wave electrical current, used to coagulate or cut during surgery
- Cutting - continuous waveform at low voltage
- Coagulate - pulsating waveform at high voltage
Dangers of diathermy use
- Channeling effect - using monopolar on structure with narrow pedicure
- Ignition of flammable material e.g. chlorhex
- Return plate burns - even contact, off bony prominences or metal prosthesis
- Inadvertent activation burning skin
- Personal injury - diathermy tip can remain very warm after use
- Pacemakers - consult cardiology pre-op, have pacemaker checked. Use bipolar if possible, otherwise place plate so that correct directed away from pacemaker
RACS surgical competence and performance guide
- 10 Topics
- Cultural competence and cultural safety
- Communication
- Collaboration and teamwork
- Health advocacy
- Judgement and clinical decision making
- Professionalism
- Scholarship and teaching
- Leadership and management
- Technical expertise
- Medical expertise
Kocher criteria
- • Child with painful hip
- o Non weight bearing
- o ESR > 40
- o Fever >38.5
- o WCC > 12
- 4/4 criteria = 99% chance
- 3/4 criteria = 93% chance
- 2/4 criteria = 40% chance
- 1/4 criteria = 3% chance
What is credentialing?
What is scope of practice?
RACS has position paper on the subject
Credentialing - process used to verify a surgeon’s qualifications, experience and professional standing for the purpose of forming a view about their ability to deliver services in a particular health service
Scope of practice - refers to the range of practice or type of procedures that an individual can perform. It is dependent upon the local environment
What is harassment, bullying and discrimination?
Harassment - behaviour that makes a person feel humiliated, intimidated, degraded, insulted or offended
Bullying - harassment that occurs repeatedly and forms a pattern of behaviour
Discrimination - treating a person less favourably on the bases of legally protected attributes or personal characteristics such as their race or sex
Methods of reducing waiting lists
Optimise medically to avoid cancellations
Careful selection for surgery and correct categorisation with consultant involvement
Theatre efficiency, audit the process
Thorough pre-admissions process
Short stay arthroplasty
3x advantages
3x risks
Canadian paper
Advantages - Early mobility | Reduced hospital complications | Cost effective
Risks - Compromising patient safety | Slow recovery at home | Readmissions
Canadian paper 2019 - 30 day readmission rate of 2.6% comparable. BMI and ASA associated with readmission
Single point on robotic assisted THA / TKA
Encouraging early results for partial joint replacements, however insufficient evidence currently to demonstrate superiority
Position statement on surgical approach for hip arthroplasty
No published level 1 evidence that endorses one approach over another
Each has advantage and disadvantage, often patient specific
Successful long-lasting result can be achieved with a number
Surgeons should claim approach best in their hands, but not claim advantage over other surgeons
AOA president
First female AOA president elected 2021 - Dr Annette Holian
Specifically wishes to act on areas of bias towards women in training
Advertising
- must comply with…
- must not…
AOA ethical framework | AOA code of conduct | AHPRA regulations
Must not
- use testimonials
- create unreasonable expectations
- offer gifts or discounts
- provide statements that are false, misleading, or unsupported by evidence
Points on overlapping surgery
Difference between concurrent and overlapping
Advantages - learning opportunities and efficiency
Disadvantages - risk of complication relating to critical steps overlapping
Little literature on the subject, generally only from US - overlapping not shown to be unsafe, but potential benefits of efficiency have not been shown either
RACS statement on M&M meeting
Has a matrix that gives standards for a good M&M meeting Challenges - logistical issues of data collection - lack of understanding - lack of attendacne
How to approach which risks to mention in informed consent
RACS statement
Would a reasonable person in the patient’s position attach significant to the risk?
Is the doctor aware of a reason why a particular patient would attach significance to the risk?
Open disclosure should include:
Apology Factual explanation Opportunity for questions Discussion of potential consequences Explanation of steps being taken
Kocher approach
- internervous plane
- structures at risk
ECU (PIN) and ancones (radial)
PIN
Kaplan approach
- internervous plane
- structures at risk
ECRB (radial or PIN) and EDC (PIN)
PIN / lateral cutaneous nerve of the forearm
Henry’s
- internervous plane
- structures at risk
FCR (median) and brachioradialis (radial)
SRN / radial artery / PIN proximally
Anterior humerus approach
- internervous plane
- structures at risk
proximally - deltoid (axillary) and pec major (pectoral nerves)
distally - medial (M/C) and lateral (radial) fibres of brachiallis
Proximal structures - axillary, M/C, anterior circumflex humeral Vessels
Distal structures - radial nerve in lateral anterior compartment
Posterior humerus approach
- internervous plane
- structures at risk
no true internervous plane
radial nerve / posterior cutaneous branch / deep brachial artery
Deltopectoral approach
- internervous plane
- structures at risk
deltoid (axillary) and pec major (pectoral)
axillary nerve, M/C nerve, anterior circumflex humeral artery, cephalic vein
Lower limb fasciotomies
- structures at risk
medial - saphenous vein and nerve, NV bundle in deep compartment
lateral - SPN
forearm fasciotomies
- incision locations
- internervous planes
volar
- medial epicondyle to ulna styloid
- FCU and FDS (both ulna)
dorsal
- lateral epicondyle to Lister’s tubercle
- no inter-nervous plane, release both dorsal and mobile wad compartments
Ex fix pins into:
- humerus
- ulna
- radius
- 2nd metacarpal
- pelvis
- femur
- tibia
- calcaneus
humerus - proximal lateral, middle anterior, distal medial
ulna - anywhere
radius - not proximal, rest dorsal/lateral
2nd metacarpal - base and head from dorsal
pelvis - 2x pins immediately posterior to ASIS, drill only cortex, angle towards ischial spine
femur - lateral, or anterior distally
tibia - anywhere anterior
calcaneus - medial to lateral transfixing
Smith-Petersen approach
- incision
- internervous plane
- structures at risk
longitudinal incision, inferior and lateral to ASIS
TFL (superior gluteal) and sartorius (femoral)
structures - LFCN, femoral nerve and artery, ascending branch lateral femoral circumflex
posterolateral ankle
- internervous plane
- structures at risk
peroneal tendons (SPN) and FHL (tibial) structures - short saphenous vein, rural nerve
ankle and shoulder arthroscopy ports
ankle
AL - peroneus tertius and lateral mal
AM - TA and medial mal
shoulder
posterior - 2cm inferior, 1cm medial to posterolateral tip of acromion
anterior - midpoint between coracoid process and anterior acromion
Advantages of new AOA21 program
Flexibility - can take 9 years, promotes diversity and work-life balance
Transition to practice period - extra training, allow time to determine subspeciality
Competency based program, rather than time
Disadvantage - tick-box mentality
Pros and cons of publishing surgeon and hospital results
Pros
- informed decisions for patients
- self auditing process, motivate improvements
Cons
- reluctancy to risk complications with comorbid patients
- supply / demand issues for hospitals
ASR hip
Australia first country to take regulatory action and remove ASR hip from the market in 2009
Acted upon data from the joint registry
Diversity programs within AOA
Orthopaedic women link - encourages and supports women in orthopaedics
Champions of change working group - works with AOA and OWL to address diversity within the organisation
Cultural inclusion working group - advises and makes recommendations to the AOA Board on matters of cultural inclusion and diversity
Maintaining high standards of care
Self-auditing and logbook
NJRR data
Departmental audits
Attending conferences / research meetings
Critically appraise a research project
CASP - critical appraisal skills program level of evidence evaluate study design consider bias application to specific population
Challenges being a trainee
Added responsibility
Leadership role within the team
Additional pressures of exams / assessments
Cost cutting measures
Rostering and staffing
Theatre efficiency
Reducing waste in theatre and optimising implants
AOA ethical framework points
integrity respect quality empathy teamwork service stewardship
leadership conflict setback advocate good outcome bad teamwork compromising outcome good leader diagnostic dilemma difficult colleague angry patient stressful situation mistake gave feedback received criticism prevented harm describe one of your complications
leadership - roster / ASH elbow
conflict - dislocated elbow on ward
setback - Bain research
patient advocate - revision hip Friday pm
good outcome - meningococcal
teamwork for good outcome - meningococcal
bad teamwork compromising outcome - revision Hb 80
good leader - Hayes
diagnostic dilemma - nec fasc in indigenous patient LMH
difficult colleague - registrar ASH
angry patient - patient cancelled on day didn’t stop DMARD at LMH
stressful situation - PNG dislocated hip, Kurmis revision
mistake - Kurmis revision
gave feedback to staff - intern ASH
received criticism - anaesthetics in theatre not aware of cases
prevented harm - DMARD foot
Describe one of your complications - ankle fixation failed young T1DM patient
Pros and cons to MBS changes
Pros - reflect contemporary changes - allows resources to be distributed fairly - appropriate renumeration Cons - surgeons adjusting to changes
