Jan Duedal Rölfing

Background: Surgical postgraduate training is often debated in an economically squeezed health care system, particularly regarding the effectiveness of massed training, when considering the impact on Cognitive Load (CL). However, the relationship between CL and massed training in surgical education has not been extensively studied. Objective: This study aimed to explore how a five-day simulation-based orthopedic course affected cognitive load among orthopedic residents. Methods: Surgical residents (N = 40) in their final phase of medical specialization were enrolled in a surgical skill simulations course from spring 2022 till fall 2023. Questionnaires were administered to course participants to measure CL using NASA-TLX. Fluctuations in CL during the five-day course were analyzed using ANCOVA and Spearman correlation. Results: Forty out of the 41 course participants agreed to participate. The findings revealed fluctuations in CL among orthopedic residents during the five-day course. NASA-TLX scores increased significantly after day 1 ( P = .017, P < .001) and decreased on day 4. ANCOVA showed a significant effect of day on total workload scores ( P = .014), with no significant associations between workload and covariates. No specific factors were identified as key drivers of cognitive load variation. Conclusion: The findings revealed variations in perceived workload over the five days, with no single factor identified as the primary driver of changes in CL. While the study did not find a detrimental impact from massed training, further research is needed to understand the connection between training approaches and their impact on CL and learning outcomes.

Background: Intramedullary bone transport nails (BTNs) have become an increasingly common method for managing bone defects. The Precice BTN (Globus Medical, Inc.) was previously associated with mechanical failures including intramedullary disintegration during elective nail removal. These issues were reportedly resolved in the second generation BTN. Results: Adhering to the CARE checklist, we describe a case involving a 23‐year‐old male with a posttraumatic bone defect following a motorcycle accident. He sustained a Gustilo–Anderson Type IIIB comminuted right fracture with a 5 cm bone defect. The leg was initially stabilized with external fixation. After several debridements, the fracture was internally stabilized using a regular trauma nail while the soft‐tissue defect was covered with a free flap and split‐thickness skin grafting. Subsequently, the 5 cm bone defect was managed using a second‐generation BTN. After 8 months, the patient underwent a planned nail removal according to the manufacturer′s instructions. Just as with the first‐generation BTN, the nail disintegrated within the medullary canal during the procedure and separated into multiple components. These internal components were cumbersomely removed using long forceps. Conclusion: Mechanical failure, specifically intramedullary disintegration, still occurs with the second‐generation BTN upon nail removal. The retention plug of the first‐generation BTN should thus be used despite instructions from the manufacturer that the problem has been solved in the current generation BTN. Appropriate instruments to manage potential nail disintegration should be present. The case underlines the need for further design improvements in future generations of BTN.

Background: Paediatric orthopaedic surgery is rarely supported by high-quality evidence, with treatment decisions generally informed by experience or case series. The European Paediatric Orthopaedic Society recognises the need to establish research priorities in the field. This study builds on previous UK research priorities to discover the most important unanswered clinical effectiveness research questions in elective and trauma care and basic science, amongst Paediatric Orthopaedic surgeons across Europe. Methods: A modified Delphi technique, including an initial scoping survey and a two-round Delphi process conducted amongst paediatric orthopaedic surgeons in Europe. Results: An average of 113 surgeon responses were received in each round, scoring questions from 1 (low priority) to 5 (high priority). The mean score for importance was 3.59 in elective questions, 3.13 in trauma and 3.54 in basic science. The top questions in each group were identified. The top five research priorities for elective care related to the care of – Perthes Disease, Slipped Upper Femoral Epiphysis and Developmental Dysplasia of the Hip. Those in trauma related to the treatment of fractures around the elbow, forearm and femur Basic science priorities related to pharmaceuticals in the management of paediatric orthopaedic conditions and the pathology of Perthes’ Disease and Developmental Dysplasia of the Hip. Conclusions: The results will help guide clinicians, researchers and funding bodies to focus research towards important topics and improve the evidence for practice in paediatric orthopaedic surgery. We hope that this study will encourage the development of collaborative international studies to improve care in paediatric orthopaedics. Level of evidence: Level V – decision analysis.

Background: Femoral neck fractures (FNF) have high mortality rates. Surgical delay likely contributes. Dynamic hip screw (DHS) fixation is common for FNF, and the tip–apex distance (TAD) measures screw position in the femoral head. A TAD >20–25 mm is considered a risk factor for screw cut-out. This study investigated the association between (1) surgical delay and complication/mortality rates within two years post-surgery and (2) TAD and postoperative complications following DHS in FNF. Methods: This retrospective study included 325 FNF patients who underwent DHS osteosynthesis at Regional Hospital Randers, Denmark from 2015–2021. The primary composite outcome included complications measured on radiographs (e.g., screw cut-out, avascular necrosis), reoperation, or death within 2 years. Radiographs were evaluated for TAD and postoperative complications/reoperations. Surgical delay was defined as the time from the diagnostic radiograph to the start of the operation. TAD was measured based on radiographs. Electronic patient journals and national SSN registers were used to assess reoperation and death rates. Results: The mortality rate was 16% within 1 year and 26% within 2 years. The complication rate was 16% within 2 years. The median surgical delay was 7.9 h (IQR 5; 14). Surgical delay was significantly associated with the 1-year mortality rate (p < 0.01), but not with the 1-year complication rate (p = 0.77). Surgical delay was associated with complication rates 2 years post-surgery only for undisplaced fractures, p = 0.046. The median TAD was 16.3 mm (13.8; 18.7); no association with complications p = 0.56) or 20 mm, six of whom had complications, and 6/59 with TAD >25 mm, none of whom had complications. Conclusions: We report a significant association between surgical delay and mortality rates in FNF, despite surgical delays <24 h. Additionally, there was a significant association between surgical delay and risk of complication/reoperation 2 years post-surgery for undisplaced fractures. No association was found between TAD and complication rates following DHS fixation for FNF; however, only a few TAD outliers were observed.

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Background/Objectives: Distal radius fractures (DRFs) are among the most common fractures in the elderly, with increasing incidence due to population aging. Recent evidence questions the benefits of operative treatment, particularly in elderly patients. The present study aimed to assess post-traumatic osteoarthritis (OA) and patient-reported outcome measures (PROMs) after a minimum of two years of follow-up of the previously published VOLCON randomized controlled trial (RCT), which compared operative and non-operative treatments of unstable DRFs in patients aged ≥ 65 years. Methods: This study presents a minimum two-year follow-up of a single-center, assessor-blinded RCT. A total of 100 patients with unstable DRFs were randomized to either operative treatment with volar locking plating or non-operative treatment with cast immobilization. The primary outcome was post-traumatic OA, assessed using the Knirk and Jupiter classification. Secondary outcomes included PROMs (Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH)) and Patient-Rated Wrist/Hand Evaluation (PRWHE), complications, pain, grip strength, and range of motion (ROM). Statistical analyses were performed using two-way ANOVA. Results: After a median follow-up of 3.0 years, 60 patients (28 non-operative and 32 operative) were available for analysis. There was no significant difference in OA between the groups (p = 0.57). PROMs (Quick-DASH, PRWHE), pain, grip strength, and ROM were time-dependent (p < 0.001) but not treatment-dependent. Complications were more frequent in the operative group, including hardware-related issues requiring reoperation. Conclusions: At a minimum of two years of follow-up, no correlation was found between treatment choice and post-traumatic OA. Functional outcomes were similar between groups, suggesting that non-operative treatment remains a viable option for elderly patients with unstable DRFs.