Information graphics, abbreviated to infographics, convey information using visualisations and images. This format of presenting research has been shown to be preferred by 80% of clinicians when compared to text articles. The weekly Journal Club was audited within our institution over a period of 10 weeks. Five weeks of article presentations using plain text abstract displays preceded 5 weeks of infographic display. A multiple-choice questionnaire was constructed weekly so as to test the attendees' recall and comprehension. A total of 1036 multiple-choice questions were answered across the 10 weeks, which included 553 questions (53.4%) based on the standard Journal Club format, and 483 questions (46.6%) on infographic displays. The use of infographics saw significantly improved test results from 42% to 65.8% (p < 0.001). Questions were answered correctly 1.5 times more often following infographic introduction. Infographics were preferred over plain text abstracts by 78% of team members. Infographics enhanced the audience's comprehension and recall of orthopaedic research when used as a presentation tool at the Journal Club. The majority of clinicians preferred infographic displays to plain text abstracts. Research was perceived as being more engaging, and thus more suitable for dissemination, such that key messages could be shared with surgeons, researchers and patients worldwide. (C) 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article: Bone Joint J 2021;103-B(9):1442-1448.

Abstract Introduction Blue Book Guidelines recommend admitting hip fracture patients to an orthopaedic ward within 4 hours of presentation. BOAST guidelines advise early multidisciplinary team management. Since 2018, our Institution has utilised an integrated, multidisciplinary model for referrals of trauma patients in the Emergency Department. We hypothesised that this significantly reduces time to admission. Method We retrospectively reviewed data on all trauma cases admitted over a two-month period in 2017 and 2019 (before and after development of our Integrated Pathway). Our Integrated Pathway is facilitated by a mobile application which is accessed by all ED and Orthopaedic medical staff, including Consultants, allowing instantaneous communication. Results Sixty-six trauma patients were admitted to our Institution between December 2017 and January 2018. Average time taken from triage in ED to admission by the Orthopaedic team was 7hrs 10mins. Sixty-three patients were admitted over the same period in December 2019 and January 2020. Average time taken from triage in ED to admission by the Orthopaedic team was 4hrs 59mins. Conclusions Our Integrated Multidisciplinary mobile application system resulted in a 30.5% decrease in time to admission, which is a significant improvement. We would recommend the introduction of similar systems in other hospitals as part of their Model of Care Pathway.

Dear Sir, On an eerily quiet, urban Dublin street lies an apartment block, it’s balconies chequeredwith identical Irish flags carrying a defiant yet simple, national slogan; ‘You’ll Never Beat the Irish’. It is the brilliance not only of the green–white–orange against the brutalist background that catches the eye but also the boldness, the sheer determination of the silent protest. It is a taunt to the insidious international public enemy that is COVID-19. It first barrelled through Ireland’s door in late February 2020. On March 12, 2020, our Taoiseach Leo Varadkar addressed the nation from Washington, DC, issuing guidance on a nationwide lockdown (Radio Teilifís Éireann, 2020). The virus had not yet gripped the health of the nation, but it was certainly within range of its virulent vice-grip. He urged us to socially distance in order to slow the spread. During times of crisis, we as humans have a natural tendency to seek solace in collectivism and reassurance in joint protection from a threat or crisis (Baumeister & Leary, 1995). Furthermore, our psychobiological response to stress is essential to activate our survival instincts as a species; fight or flight, as it were. But what happens when the one you wish to fight is invisible to the naked eye and thewingspan of your flight is capped by the four walls in which you reside due to social isolation? For those enduring stressful times, anxiety, distress and negative emotions are heightened when we find ourselves separated from those important to us (Baumeister & Leary, 1995). The uncertainty and unpredictability associated with COVID-19 has created a parallel pandemic of fear, anxiety and distress (Ammerman et al., 2020, Yao et al. 2020). Research fromChina has demonstrated heightened rates of psychological distress attributable to COVID-19 (Yao et al. 2020). However, the correlation between epidemics, mental health and suicide is not a new revelation. During the 2003 SARS-2 outbreak, China observed a sharp increase in the rate of suicide among its elderly population (Chan et al. 2006). Furthermore, illness-imposedquarantininghasbeenassociated with detrimental mental-health ramifications for those who must endure it (Brooks et al. 2020). While COVID-19 alone may not be the sole impetus for suicidality, the associated social disconnection, physical isolation and routine disruption may be a pernicious cocktail of risk factors (Ammerman et al. 2020). Suicide is a leading cause of death world-wide (World Health Organisation, 2019). In Ireland, it was estimated that in 2018, one person died per day by suicide (Digital Desk Staff, 2019). According to recent research from the United States, 45% of individuals with suicidal ideation explicitly linked their thoughts to COVID-19 (Ammerman et al. 2020). The same study found that intentional exposure to COVID-19 is being used as a method of suicide (Ammerman et al. 2020). Preliminary data from Ireland’s National Spinal Injuries Unit demonstrate that, over a 2-month period from March to April, the number of admissions attributable to suicide attempts increased from 1.3% in 2019 to 17% in 2020. The psychological impact of COVID-19 serves as a wicked side-kick to its physical manifestations. There is a distinct need to bolster mental-health services around vulnerable populations. Both national and international bodies have published widely on this topic, offering guidance and support for those suffering in the side-lines (Aware, 2020, Mental Heatlh America, 2020). In the words of Thomas Fuller, ‘if it were not for hope, the heart would break’ (Grayling, 2007). Hope is, perhaps, one of the core motivators in our gallant international efforts to overcome the crisis that is COVID-19. A subconscious drive to cling to life, a conscious strive to protect those we love propels our collective efforts in this time of separation. The hope that things will return to some semblance of normality, or, rather a ‘new-normal’, whatever that may come to look like is tangible. It hangs in the air. From the perspective of those who are at the brink of despair and desperation, hope is what may keep them alive; the hope that things may eventually change for the better. In the words of G. K. Chesterton, ‘hope means hoping when everything seems hopeless’ (Chesterton, 1990). The proverbial light in this time of darkness is shining for us all; only, some need help to see it. Our Taoiseach Leo Varadkar bravely and boldly stated, ‘we will prevail’ (Radio Teilifís Éireann, 2020). Indeed, we must.

AimTo quantify the inappropriate bed occupancy amongst patients with traumatic spinal cord injury (TSCI) awaitingtransfer of care from the acute to community.MethodsA prospective audit was carried out, of all newly acquired cases of TSCI in 2017, who progressed through acute careand specialist rehabilitation.ResultsForty-four patients who were audited spent a total of 3915 days occupying a hospital bed, inappropriate for theirphase of care, 78 awaiting admission to specialist acute care, 3126 awaiting admission to rehabilitation and 711awaiting discharge from rehabilitation.ConclusionValuable health-care resources are being wasted because TSCI patients cannot move seamlessly from one phase ofcare to the next. This impacts negatively on the quality of care being delivered to this patient cohort.

Introduction: Cycling has seen a large increase in popularity worldwide over the last number of years. This has been linked to an increase in the number of road traffic accidents involving cyclists. Participation in cycling as part of competitive sport and endurance events has seen particular growth. Aim: To examine patients referred with spinal trauma related to cycling and to assess whether the growing popularity of cycling and particularly competitive cycling is linked to an increase in spinal trauma. Methods: A retrospective analysis was carried out of a prospectively maintained database of referrals to a national referral centre for spinal trauma over a 4-year period (2010-2013). Data were further analysed for years 2012-2013, as there were incomplete data for years 2010-2011. Results: Spinal injuries involving cyclists increased by 200% from 2010 to 2013. In comparison those involving cars only increased by 29% and motorcycles reduced by 68%. From 2012 to 2013 there were 24 cyclist trauma referrals. The most common level injured was cervical spine (71%). Five patients (20.8%) had neurological deficit with 12.5% complete paralysis ASIA A disability score. The spinal fixation rate was 29.1%, 16.6% were managed with a HALO device. In total, 25% of patients were injured whilst training on a racer style bicycle, including all of the patients with complete spinal cord injury. Conclusion: There has been a significant increase in spinal trauma due to cycling accidents over this four year period. Competitive cycling has been a factor in the most severely injured patients. Increased public awareness campaigns for those participating in cycling for sport may be warranted. (C) 2017 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Interventions which may improve neurological outcomes, including time to surgical decompression, in traumatic spinal cord injury (TSCI) evoke much interest. The majority of TSCI patients in Ireland are managed acutely at the National Spinal Injuries Unit (NSIU). A retrospective review of healthcare records of TSCI patients, who had surgical management there, in 2010, 2011, 2012, was performed. From the information gathered, the duration of each stage of the patient pathway was calculated. Median duration between onset of injury and time of arrival at local hospital was 1 hour 25 minutes, between arrival at local hospital and referral to NSIU was 4 hours 17 minutes, between referral to and arrival at NSIU was 6 hours 25 minutes, between onset of injury and arrival at NSIU was 13 hours 7 minutes, between onset of injury and surgical decompression was 27 hours. A number of factors have been identified which could influence these time durations.

AIM: To assess the short and medium-term efficacy and safety of a novel, minimally invasive therapeutic option combining automated percutaneous lumbar discectomy, intradiscal ozone injection, and caudal epidural: ozone-augmented percutaneous discectomy (OPLD).MATERIALS AND METHODS: One hundred and forty-seven patients with a clinical and radiological diagnosis of discogenic sciatica who were refractory to initial therapy were included. Fifty patients underwent OPLD whilst 97 underwent a further caudal epidural. Outcomes were evaluated using McNab's score, improvement in visual analogue score (VAS) pain score, and requirement for further intervention. Follow-up occurred at 1 and 6 months, and comparison was made between groups.RESULTS: OPLD achieved successful outcomes in almost three-quarters of patients in the short and medium term. OPLD achieved superior outcomes at 1 and 6 months compared to caudal epidural. There was a reduced requirement for further intervention in the OPLD group. No significant complications occurred in either group.DISCUSSION: OPLD is a safe and effective treatment for patients with refractory discogenic sciatica in the short and medium term. OPLD has the potential to offer an alternative second-line minimally invasive treatment option that could reduce the requirement for surgery in this patient cohort. (C) 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

It is proposed that the external asymmetric formation of callus tissues that forms naturally about an oblique bone fracture can be predicted computationally. We present an analysis of callus formation for two cases of bone fracture healing: idealised and subject-specific oblique bone fractures. Plane strain finite element (FE) models of the oblique fractures were generated to calculate the compressive strain field experienced by the immature callus tissues due to interfragmentary motion. The external formations of the calluses were phenomenologically simulated using an optimisation style algorithm that iteratively removes tissue that experiences low strains from a large domain. The resultant simulated spatial formation of the healing tissues for the two bone fracture cases showed that the calluses tended to form at an angle equivalent to the angle of the oblique fracture line. The computational results qualitatively correlated with the callus formations found in vivo. Consequently, the proposed methods show potential as a means of predicting callus formation in pre-clinical testing.

Acute cauda equina syndrome secondary to a spinal epidural abscess as a result of a psoas abscess is very uncommon. We report the case of a 64-year old with a 6-day history of left hip pain, which progressively worsened until she presented to the emergency department with systemic infective symptoms and classical acute cauda equina syndrome. A good clinical outcome was achieved by urgent posterior decompression, followed by CT-guided drainage of the psoas abscess and appropriate antibiotic treatment.

The formation of a fracture callus in vivo tends to form in a structurally efficient manner distributing tissues where mechanical stimulus persists. Therefore, it is proposed that the formation of a fracture callus can be modelled in silico by way of an optimisation algorithm. This was tested by generating a finite element model of a transversal bone fracture embedded in a large tissue domain which was subjected to axial, bending and torsional loads. It was found that the relative fragment motion induced a compressive strain field in the early callus tissue which could be utilised to simulate the formation of external callus structures through an iterative optimisation process of tissue maintenance and removal. The phenomenological results showed a high level of congruence with in vivo healing patterns found in the literature. Consequently, the proposed strategy shows potential as a means of predicting spatial bone healing phenomena for pre-clinical testing.

Odontoid fractures currently account for 9-15% of all adult cervical spine fractures, with type II fractures accounting for the majority of these injuries. Despite recent advances in internal fixation techniques, the management of type II fractures still remains controversial with advocates still supporting non-rigid immobilization as the definitive treatment of these injuries. At the NSIU, over an 11-year period between 1 July 1996 and 30 June 2006, 66 patients (n = 66) were treated by external immobilization for type II odontoid fractures. The medical records, radiographs and CT scans of all patients identified were reviewed. Clinical follow-up evaluation was performed using the Cervical Spine Outcomes Questionnaire (CSOQ). The objectives of this study were to evaluate the long-term functional outcome of patients suffering isolated type II odontoid fractures managed non-operatively and to correlate patient age and device type with clinical and functional outcome. Of the 66 patients, there were 42 males and 24 females (M:F = 1.75:1) managed non-operatively for type II odontoid fractures. The mean follow-up time was 66 months. Advancing age was highly correlated with poorer long-term functional outcomes when assessing neck pain (r = 0.19, P = 0.1219), shoulder and arm pain (r = 0.41, P = 0.0007), physical symptoms (r = 0.25, P = 0.472), functional disability (r = 0.24, P = 0.0476) and psychological distress (r = 0.41, P = 0.0007). Patients >65 years displayed a higher rate of pseudoarthrosis (21.43 vs. 1.92%) and established non-union (7.14 vs. 0%) than patients <65 years. The non-operative management of type II odontoid fractures is an effective and satisfactory method of treating type II odontoid fractures, particularly those of a stable nature. However, patients of advancing age have been demonstrated to have significantly poorer functional outcomes in the long term. This may be linked to higher rates of non-union.

It is postulated that there is a causal relationship between mechanical stimulus and the rate of bone healing post fracture. However, despite numerous experimental studies in the literature, no quantifiable relationship has been proposed. It is hypothesized in the present study that the temporal rate of bone fracture healing, measured in terms of callus stiffening per week, can be described mathematically based on the relative motions between bone fragments at the initial stage of the healing process. To test this, a comparative reanalysis of experimental data found in the literature was conducted. These individual data sets described a relationship between an initial intermittently applied peak interfragmentary strain and the change in interfragmentary motion or the increase in callus stiffness over time. The data were converted into a relative increase in stiffness, which normalised the results and reduced inter-study variability. The rates of healing for the various initial strains were compared, and based on this a mathematical phenomenological model was derived. Error analyses were then performed, which showed a high level of congruence between the in-vivo and simulated rates of healing. The results of the comparative analysis revealed that there is a positive correlation between the rate of callus stiffening and interfragmentary strain. Finally, the proposed model has shown for the first time that a quantifiable cause-and-effect relationship exists between the rate of bone healing and mechanical stimulus.