Aims Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury facilitating early intervention which has a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon directed intra-operative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon directed TcMEP is presented in terms of viability, safety and efficacy. Methods A retrospective review was performed on a single surgeon's prospectively maintained database from 2010 to 2017 where TcMEP monitoring was utilised. The upper limbs were used as the control. A true alert was recorded when there was a 50% or more loss of amplitude of the lower limbs with maintained upper limb signals. Patients with true alerts were identified and their case history analysed. Results Of the 299 cases were reviewed, 279 (93.3%) had acceptable traces throughout and awoke with normal clinical neurological function. No case with normal traces had a post-operative clinical neurological deficit. True alerts occurred in 20 (6.7%) cases. The alert group diagnoses included adolescent idiopathic scoliosis 9 (45%) and congenital scoliosis 6 (30%). The incidence of deterioration based on diagnosis AIS was 9/153 (6%), congenital 6/30 (20%) and TB spine 2/16 (12.5%). Deterioration in congenital is much more common (p=0.02) when compared to AIS. 65% of alerts occurred during rod instrumentation and 15% during decompression of the internal apex in vertebral column resection surgery. 4 (20%) alert cases awoke with clinically detectable neurological compromise Conclusion Surgeon directed TcMEP monitoring has a 100% negative predictive value and allows early identification of physiological cord distress and immediate intervention. In resource constrained environments, surgeon directed TcMEP is a viable and effective method of intra-operative spinal cord monitoring. Clinical relevance • Surgeon directed TcMEP monitoring has a 100% negative predictive value. • In resource constrained environments, surgeon directed TcMEP is viable and effective • Level 3 evidence

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Includes bibliographical references (leaves 45-46). / Thirteen patients seen at Red Cross Children's and Maitland Cottage hospitals have under gone complex treatment for the significant deformities caused by meningococcal septicaemia. These patients underwent 62 surgical procedures between them. These procedures were directed at the treatment of sequelae of growth arrest alone and excluded amputations, contracture releases, skin grafts and flaps. The extent of the surgical problems caused by this disease brought about the realisation that a thorough review of the literature and follow up of these patients was required. This would hopefully be of use in assessing the outcomes of various surgical treatment options employed and in developing guidelines for the future management of physeal arrest in these patients.

During the period July 1994 to September 1998 surgery was carried out on seventy-six hips in seventy-five patients that sustained posterior fracture-dislocation of their hip joints. During my training I was personally involved in thirteen of these cases and was the primary surgeon in seven cases. Because of my personal interest in these patients Dr Siboto provided me the records of all seventy-five patients for my scrutiny. While he has carried out the surgery on all but the seven cases which I operated on, the literature review, the correlating of the data and all of the interpretation is my own personal work. At surgery prospective records were kept of the degree of comminution of the fracture, the presence of marginal impacting and the presence of fragments in the joint. Fractures were then classified according to Thompson and Epstein (1951). The surgical time was recorded as well as the nature of the associated acetabular floor fracture when it occurred. Anatomical reconstruction was always attempted including elevation of marginal impaction and bone grafting where appropriate. Fragments were only discarded when too small and unattached to permit their inclusion in the reconstruction. All patients had neurological assessment preoperatively and their Sciatic nerves were explored and the state of the nerve recorded at surgery. The process of formulating this dissertation took place over a two-year period from September of 1997 until June of 1999. As a result, the number of patients examined in relationship to a specific subject is not constant but alters according to the group under scrutiny at that particular point in time. An initial review of sixty cases in September 1997 was carried out and then an additional fifteen patients up until September 1998 were included where relevant. The aim of carrying out this study was to gain a better understanding of this injury so that we could formulate a management protocol for our patients in Groote Schuur Hospital. First of all, I reviewed the literature to discover exactly what has been written about this pathology. In the process I hoped to gain a better understanding of the problem and attempt to define a more concise approach to the injury by consolidating the broad array of articles written on this subject. Then by reviewing our findings in our large series of patients I aimed to discover whether we were encountering similar problems to the surgeons who had preceded us and whether we had made any new discoveries that might positively contribute to the future management of these patients.

Surgery is a difficult skill to teach and even more difficult to assess. In the context of orthopaedic surgery, the Oxford unicompartmental knee arthroplasty (OUKA) is a commonly performed and technically challenging procedure with a variable and sometimes unsatisfactory revision rate. Thus there is a need to develop methods for optimising performance in this procedure. This thesis aims to use this procedure to explore ways of improving teaching methods and assessment methods, and the use of novel technologies to impact surgical performance. No validated technical skill assessment system currently exists to evaluate surgical performance during OUKA. A consensus-based framework of expert opinion (Delphi methodology) was therefore used to determine the essential technical steps of OUKA to aid development of a technical skill assessment system. A procedure-specific assessment scale named the Oxford Arthroplasty Technical Skill Score (OATSS) was produced. Two clinical studies were conducted to demonstrate the inter-rater reliability and construct validity of OATSS in the real operating theatre. This is the first time that a procedure-specific assessment scale has been developed and validated for a complex orthopaedic procedure. The Delphi methodology was also used to identify important radiographic parameters that could be used to predict clinical outcome following OUKA. Two cohort studies used post-operative radiographs of "failed" and "poorly functioning" OUKA cases (with matched controls) to identify several radiographic parameters that can predict the increased risk of a poor clinical outcome. A virtual reality (VR) based simulator (called ViTAL) was developed to teach the cognitive skills necessary for performing the OUKA procedure. This software-based learning environment was used in a randomised controlled study to assess its training effectiveness. This demonstrated that, when used alongside existing teaching modalities, ViTAL resulted in better acquisition of cognitive skills in novice trainees. A randomised controlled study was subsequently undertaken using anatomic dry-model bones in a surgical skills laboratory to determine the effect of cognitive skills training using the ViTAL simulator on the ability of orthopaedic trainees to perform the OUKA procedure. The previously validated OATSS assessment scale was used to evaluate surgical performance. Results demonstrated that this type of training not only improved acquisition of cognitive skills, but also resulted in better technical skill performance during OUKA procedures. This demonstrates, for the first time, the effectiveness of a purely cognitive VR-based simulator for improving technical skills during arthroplasty surgery. Patient-specific instrumentation (PSI) is a novel and exciting technological development within orthopaedic surgery. A prospective RCT was performed to compare OUKAs implanted using PSI with those implanted using conventional instrumentation. Intra-operative measurements, together with post-operative radiographic analyses, were performed to determine the accuracy of component positioning. With regards to positioning of the femoral component, there was no difference between the accuracy of PSI and conventional instrumentation. However, accuracy of PSI was poor with regards to positioning of the tibial component. Further improvement to the PSI is needed before this can be recommended for routine use. In conclusion, this thesis has demonstrated that improvement of learning and assessment methods is currently the safest and most feasible means of optimising surgical performance during the OUKA procedure. Although it is important to embrace novel training modalities and technological developments in an attempt to enhance surgical performance, they must be scientifically evaluated to ensure that they deliver real clinical improvements.

Aim: To preliminary validate a questionnaire that was developed in this study. The questionnaire was designed to investigate, if patient’s perception of appearance of their Boston corset influences their compliance, in a positive or negative way.   Background: Going through brace treatment brings a lot of feelings for adolescent idiopathic scoliosis patients. Not having a “perfect body” decreases body image and self-esteem. It is highly likely that by changing the patients’ perspective of their brace into liking the appearance of it; the probability of positive compliance will increase in patients.   Method: Mixed method approach was used to develop and validate a new questionnaire. The development and validation were done using literature, expert and patient groups. Qualitative data was evaluated, and quantitative data was analyzed using Pearson’s correlation coefficient and Cronbach alpha.   Result: Preliminary validated questionnaire was created. The group used for validation were all idiopathic scoliosis patients, four boys and four girls, between the age of 6 and 15 years old.   Conclusion and outlook: Further validation of the questionnaire is required before applying on future studies. Preliminary results indicate that patients who like the way they appear in their brace are also compliant. / Syfte: Att preliminär validera ett frågeformulär som utvecklades i denna studie. Frågeformuläret var utformat för att undersöka om patientens uppfattning om deras Boston korsett påverkar deras compliance på ett positivt eller negativt sätt.   Bakgrund: Att genomgå korsettbehandling innebär många känslor för ungdomar med idiopatisk skolios. Att inte ha en "perfekt kropp" minskar kroppsbilden och självkänslan. Det är högst sannolikt att genom att förändra patienternas perspektiv på deras korsett till att tycka om utseendet på den; så ökar sannolikheten för compliance med positiva känslor.   Metod: Mixed Metod användes för att utveckla och validera ett nytt frågeformulär. Utvecklingen och validering gjordes med hjälp av litteratur, expert- och patientgrupper. Kvalitativa data utvärderades och kvantitativa data analyserades med användning av Pearsons korrelationskoefficient och Cronbach alpha.   Resultat: Ett preliminärt validerat frågeformulär skapades. Gruppen som användes för validering var idiopatiska skoliospatienter, fyra pojkar och fyra tjejer, mellan 6 och 15 år gamla.   Slutsats: Ytterligare validering av frågeformuläret krävs före användning i framtida studier. Preliminära resultat indikerar att patienter som tycker om hur de ser ut i deras korsett också följer compliance med positiva känslor

The overall aim was to study outcome following surgery of the injured pelvis with focus on assessment from the patient’s perspective. All adult patients operatively treated for pelvic ring injuries or acetabular fractures at the Department of Orthopaedics, Uppsala University, starting 2003 were prospectively included and followed with quality of life (QoL) instruments for 2 years. The most common trauma mechanism was motor vehicle accident (MVA). Study I included 54 patients with pelvic ring injuries during the three-year period 2003-2005. The two instruments, SF-36 and LiSat-11, were used. In 45 responders lower than normative QoL and life satisfaction prevailed at two years after the injury. Study II included 12 patients with pelvic ring injuries or acetabular fractures sustained following a jump from height in an attempt to commit suicide. At four years all patients were still alive and SCID-interviews performed by a psychiatrist revealed low recurrence of self-destructive behaviour and high QoL in the younger patients. Study III included 136 patients with acetabular fractures where 52 had elementary and 84 associated fracture patterns. Fracture reduction was 0-1 mm in 106 patients and 2 mm or more in 30. QoL was significantly higher in patients with anatomically reduced fractures. Physical SF-36 domains improved with time, albeit QoL was lower than norm. Study IV had the aim to construct a condition-specific outcome instrument for patients with acetabular fractures. Closed and open questions were sent to 127 consecutive acetabular fracture patients at 6, 12 and 24 months following surgery. Responses were validated through factor analysis, scree tests, item reduction and principal component analysis which resulted in a multi-item verbal descriptive scale (VDS) with six condition-specific questions related to “Pain”, “Walking”, “Hip motion”, “Leg numbness”, “Sexual life”, “Operation scar” and a global question concerning impact on daily life activities for acetabular fracture assessment.

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Abstract Introduction Wedged shoe insoles are used as a treatment for different problems in order to change the ground reaction force. They can secondary cause different loading patterns under the foot compared to normal. No previous study has, to the author’s knowledge, clinically evaluated the plantar foot pressure with different full-length wedges in normal persons. Purpose The purpose was to evaluate the plantar pressure with different degrees of full-length wedges in normal persons. Method Twenty persons with normal feet have participated in this single blind study. Wedges were produced clinically in four different shapes, 3° valgus, 0° flat, 3° varus och 6° varus. The test persons were told to walk with the wedges in their comfortable pace in a randomized order. The plantar pressure was measured in the medial and lateral heel as well as in the first and fifth metatarsal head. Results The results show significant increased mean pressure for varus wedges compared to flat as well as valgus wedges, in the area of the medial heel and first metatarsal joint. Also, valgus wedges show significant increased mean pressure compared to flat condition in area of the medial heel. There is no correlation between wedge height and mean pressure for any of the wedge conditions. Conclusion Treatment with wedges leads secondary to increased mean pressure for varus wedges compared to flat as well as valgus wedges, in medial heel and first metatarsal joint. Furthermore, valgus wedges show increased mean pressure compared to flat condition in medial heel. Patients sensitive to high plantar pressures in these areas should be treated with caution.  Further studies are recommended.

Background Stress and burnout in healthcare is a globally occurring problem that has been given attention in both media and research literature. Stress derives partly from a high workload and emotional exhaustion, but ethical and moral factors can also cause stress of conscience which in worst case can lead to burnout.   Objectives There is a lack of studies regarding prosthetists and orthotists experience of stress. By using the validated survey Stress of Conscience Questionnaire (SCQ) the aim is to find out the level of stress in prosthetists and orthotists in Sweden.   Method A web-based survey with the SCQ instrument was sent to prosthetists and orthotists in Sweden and the answers was compiled using SPSS.   Results 68 people answered the survey. The situations that caused the highest stress of conscience for prosthetists and orthotists was when there was a lack of time to provide the care the patient needed, when there were incompatible demands in ones work and when ones work was so demanding that they did not have the energy to devote to their family as they wanted to.   Conclusion The results are similar to results from studies made on other healthcare professions which implicates that stress of conscience is as likely for prosthetists and orthotists. A better understanding for causes of stress for prosthetists and orthotists could trough further studies contribute to a better healthcare-climate for both caregivers and patients. Keywords: conscience, stress, mental illness, prosthetists, orthotists / Bakgrund Stress och utbrändhet inom sjukvården är ett globalt förekommande problem som fått mycket uppmärksamhet inom både medier och forskningsvärlden. Stressen kommer delvis från en hög arbetsbörda och emotionella påfrestningar, men även etiska och moraliska faktorer kan ge upphov till samvetsstress som i värsta fall kan leda till utbrändhet.   Syfte Det finns en brist på studier om ortopedingenjörers upplevelse av stress. Genom att använda den validerade enkäten Stress of Conscience Questionnaire (SCQ) är syftet att ta reda på nivån av stress hos legitimerade ortopedingenjörer i Sverige.   Metod En webenkät med instrumentet SCQ skickades ut till ortopedingenjörer i Sverige och svaren sammanställdes med SPSS.   Resultat 68 personer svarade på enkäten. De situationer som orsakar högst samvetsstress för ortopedingenjörer var då man inte upplevde tillräcklig tid till att ge god vård, då man utsätts för oförenliga krav i sitt arbete och då ens arbete är så krävande att man inte orkar ägna sig åt sina närmaste.   Slutsatser Dessa resultat speglar resultat från studier gjorda på andra sjukvårdsyrken vilket skulle kunna betyda att samvetsstress är lika sannolikt inom ortopedingenjörsbranschen. En ökad förståelse för vad som orsakar stress för ortopedingenjörer kan genom vidare studier bidra till ett bättre vårdklimat för både kliniker och patienter. Nyckelord: samvete, stress, psykisk ohälsa, ortopedingenjörer