Aims. Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres. Methods. mUKAs performed in eight fast-track centres from February 2010 to June 2018 were included from the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Database. All readmissions within 90 days of surgery underwent chart review and readmissions related to the surgical wound or the prosthesis were recorded. Centres were categorized as high-usage centres when using mUKA in ≥ 20% of annual knee arthroplasties. The occurrence of complications between high- and low-usage centres were compared using Fisher’s exact test. Results. We included 3,757 mUKAs: 2,377 mUKAs from high-usage centres and 1,380 mUKAs from low-usage centres. Surgical complications within 90 days occurred in 69 cases (1.8%), 45 (1.9%) in high-usage centres and 24 (1.7%) in low-usage centres (odds ratio (OR) 1.1 (95% confidence interval (CI) 0.65 to 1.8)). The most frequent complications were periprosthetic joint infections (PJIs) (n = 18; 0.48%), wound-related issues (n = 14; 0.37%), and periprosthetic fractures (n = 13; 0.35%). Bearing dislocations (n = 7; 0.19%) occurred primarily in procedures from high-usage centres. In high-usage centres, seven periprosthetic fractures (0.29%) occurred compared to six (0.43%) in low-usage centres (OR 0.68 (95% CI 0.20 to 2.0)). In high-usage centres, nine PJIs (0.38%) occurred compared to nine (0.65%) in low-usage centres (OR 0.58 (95% CI 0.22 to 1.6)). Conclusion. Surgical complications are rare after fast-track mUKA surgery and with no difference in overall occurrence of surgical complications between high- and low-usage centres, although the risk of some specific surgical complications may favour high-usage centres. Cite this article: Bone Jt Open 2023;4(6):457–462

Introduction. Deep venous thrombosis (DVT) is a potentially serious complication after total hip (THA) and knee (TKA) arthroplasty, traditionally justifying aggressive prophylaxis with low molecular weight heparin (LMWH) or direct oral anticoagulants (DOA) at the cost of an increased risk of bleeding. However, fast-track procedures might reduce the DVT risk and decrease the cost-benefit ratio of the current recommendations. The objective of this study was to compare thrombotic and bleeding risk in an unselected population of elective THA and TKA with a fast-track procedure. MATERIAL - METHODS. A series of 1,949 patients were analyzed prospectively. There were 1,136 women and 813 men, with a mean age of 70 years. In particular, 16% were previously treated by antiplatelet agents and 8% by anticoagulants. All patients followed a fast-track procedure including early walking within 24 hours of surgery, and 80% of patients returned home after surgery, with a mean length of stay of 3 days (THA) or 4 days (TKA). The occurrence of a thromboembolic event or hemorrhagic complication has been identified. Results. Out of the 1,110 THAs, 5 thromboembolic events were identified (0.4%): 2 non-fatal pulmonary embolism and 3 DVTs. There was no impact of these complications on the final result. 19 hemorrhagic complications were identified (1.7%): 10 significant haematomas (3 of which were complicated by infection), 9 anemias (with 4 transfusions). Out of the 839 TKAs, 9 thromboembolic events were identified (1.0%): 4 non-fatal pulmonary embolism and 5 DVTs. There was no impact of these complications on the final result. 14 hemorrhagic complications were identified (1.7%): 8 haematomas including 4 reoperations, 6 anemias (with 5 transfusions). Discussion. Thromboembolic complications after elective THA and TKA have virtually disappeared, with a rate of 0.7%. On the other hand, bleeding complications are now more frequent, with a rate of 1.7%. This suggests that the cost-benefit ratio of preventive treatments with LMWH or DOA should be reassessed. Prescribing LMWH or DOA after elective THA and TKA with fast-track procedures exposes the patient to a much higher risk of bleeding than thrombotic risk. The use of aspirin may represent an acceptable compromise in these patients

Fast-track THA and TKA is a dynamic process combining clinical and logistical enhancements to ensure the best outcome for all patients regarding faster early functional recovery and reduced morbidity. Focus is on reducing convalescence by ensuring a smooth pathway with the best available clinical treatment from admission to discharge – and beyond. Main focus areas include pain treatment, mobilization, organizational aspects, traditions, and care principles. Outcome is typically evaluated as: a) length of stay in hospital (LOS), patient satisfaction, and reduced convalescence in the form of earlier achievement of functional milestones; b) safety aspects (reduced morbidity and mortality in the form of complications and readmissions in general and dislocations/manipulations in specific); c) feasibility (can the track be applied to other subgroups of patients, i.e. bilaterals or revisions?); and d) economic savings. Favorable outcomes regarding all these parameters have been documented for fast-track THA and TKA which has also resulted in the development of a Rapid Recovery Programme (Biomet). LOS is now 1–2 days for unselected patients in leading departments with few readmissions, high patient satisfaction and economic savings. In Denmark, the nationwide median LOS is now 4 days and improved logistic features include homogeneous entities, regular staff, high level of continuity, preoperative information including intended LOS, admission on the day of surgery and functional discharge criteria. The improved clinical features include both intraoperative (spinal anesthesia, local infiltration analgesia (LIA), plans for fluid therapy, small standard incisions, no drains, compression bandages and cooling) and postoperative (deep venous thrombosis prophylaxis starting 6–8 hours postoperatively, multimodal opioid-sparing analgesia, early mobilization and discharge when functional criteria are met) facilitating early rehabilitation and discharge. Future challenges include identification of high-pain responders to improve multimodal pain treatment; identification of high-risk patients regarding complications in fast-track set-ups; how to reduce postoperative cognitive dysfunction; how to reduce orthostatic intolerance; and when how and to whom to initiate and give rehabilitation

Purpose. The hip fracture has been increasing as the aging population continues to grow. Hip fracture patients are more susceptible to blood loss and venous thromboembolism (VTE). The objective of this study was to assess the efficacy and safety of tranexamic acid (TXA) in fracture patients undergoing fast-track hemiarthroplasty. Methods. 609 hip fracture patients undergoing hemiarthropalsty from January 2013 to September 2016 were prospectively selected. 289 patients received 15 mg/kg TXA prior to surgery, and the remaining 320 patients received no TXA. All the patients received a fast-track program including nutrition management, blood management, pain management, VTE prophylaxis and early mobilization and early intake. The primary outcome was transfusion requirement, other parameters such as blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay were also compared. Multivariate logistic regression analysis and meta-analysis were also performed to identify the risk factors of transfusion and confirm the results of current study. Results. Transfusion of at least 1U of erythrocyte blood cell occurred in 25 patients (8.65%) in treatment group and in 77 (24.06%, OR=0.299, p<0.001) in control group. The mean level of Hb on POD 1 (111.70±18.40 g/L) and POD 3 (108.16±17.25 g/L) in TXA group were higher than control group (107.29±18.70 g/L, p= 0.008; 104.22±15.16 g/L, p= 0.005 respectively). More patients get off bed to ambulate within 24 hours after surgery in TXA group (37.02% Vs 26.25%, p= 0.004). And the length of hospital stay was shorter (11.82±4.39 Vs 15.96±7.30, p= 0.003). No statistical significance were detected regarding VTE and other adverse events. Logistic regression analysis showed that the relative odds reduction after adjustment for these covariates was 67% (OR= 0.327, 95%CIs= 0.197 to 0.544) in favor of tranexamic acid. Other risk factors included preoperative hemoglobin level, operation time, VTE prophylaxis. Pooling the data showed that tranexamic acid led to a significant reduction in transfusion (OR= 0.33, 95%CIs= 0.25 to 0.43) without sacrificing safety (OR= 0.70, 95%CIs= 0.25 to 1.97). Conclusion. Tranexamic acid was effective and safe to reduce blood loss and transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty

The incidence of hip fractures is rising, and at the same time the patients are getting increasingly frail and elderly. Patients in Europe have a median hospitalization time of as much as 28 days, and the peri-operative morbidity and mortality is high. 1. Most interventional studies have been unimodal with very heterogeneous results and at present, limited data are available from multimodal intervention according to the established principles of fast-track care. 2. This study has very positive results with a reduction in hospitalization from 21 till 11 days. Anaesthesiological intervention in a fast track regimen must be peri-operative in such a high-risk group of patients. Early operation is probably preferable. 3. Pre-operative regional analgesia potentially reduces cardiovascular morbidity, if instituted immediately after arrival. 4. The effect of regional anaesthesia and postoperative regional analgesia on morbidity and mortality in hip fracture patients may be advantageous. 5. . Postoperative epidural analgesia can be provided without restrictions on patient mobility and rehabilitation, provides superior dynamic pain relief and reducing the influence of pain as a restricting factor on physiotherapy. 6. A potential effect of intra-operative volume optimization has been shown, although the effect on morbidity and mortality is unclear. 7. No information exists for postoperative fluid therapy regimens, but fluid excess is probably important to avoid. 8. Hip fracture patients often suffer from malnutrition at the time of admission and protein and energy supplementation potentially reduces mortality and morbidity. 9. Therefore a short perioperative fasting period combined with aggressive peri-operative oral nutrition and anaesthesia and analgesia techniques, that minimizes catabolism and PONV seems rational. Since mortality and morbidity is so high these patients should be treated in close cooperation between surgeons and anaesthesiologists both in the pre and postoperative phase. 10. , as established practice in other high risk patients. Mortality is not the optimal parameter the for success of intervention in this population, as effects are extremely difficult to document, since as much as 50–75 % of the perioperative mortality may be unrelated to the treatment regimen. 11. . The cumulated evidence for the peri-operative care of this patient group is scarce and fast-track rehabilitation regimens should look to other operational procedures for available evidence. 12. Future research should focus on broadening the evidence for relevant pre-operative optimization, the influence of regional analgesia on rehabilitation potential and optimized peri-operative fluid therapy, transfusion and nutrition regimens

Background

Patients with fractured neck of femur have historically received less attention than they deserve and have high morbidity and mortality. Literature suggests that speed to theatre reduces length of in-patient stay and complications.

Purpose

Clinicians need knowledge about early and valid predictors of short-term outcome of patients with hip fracture, to adjust and plan rehabilitation. The concept of multimodal rehabilitation has proven effective. Still, some patients do not regain basic mobility independency in the acute orthopaedic setting. The aim was to examine the predictive value of age, sex, prefracture functional level, mental and health status, and fracture type of in-hospital basic mobility outcome, and discharge destination after hip fracture surgery.

Aims. To investigate the impact of consecutive perioperative care transitions on in-hospital recovery of patients who had primary total knee arthroplasty (TKA) over an 11-year period. Methods. This observational cohort study used electronic health record data from all patients undergoing preoperative screening for primary TKA at a Northern Netherlands hospital between 2009 and 2020. In this timeframe, three perioperative care transitions were divided into four periods: Baseline care (Joint Care, n = 171; May 2009 to August 2010), Function-tailored (n = 404; September 2010 to October 2013), Fast-track (n = 721; November 2013 to May 2018), and Prehabilitation (n = 601; June 2018 to December 2020). In-hospital recovery was measured using inpatient recovery of activities (IROA), length of stay (LOS), and discharge to preoperative living situation (PLS). Multivariable regression models were used to analyze the impact of each perioperative care transition on in-hospital recovery. Results. The four periods analyzed involved 1,853 patients (65.9% female (1,221/1,853); mean age 70.1 years (SD 9.0)). IROA improved significantly with each transition: Function-tailored (0.9 days; p < 0.001 (95% confidence interval (CI) -0.32 to -0.15)), Fast-track (0.6 days; p < 0.001 (95% CI -0.25 to -0.16)), and Prehabilitation (0.4 days; p < 0.001 (95% CI -0.18 to -0.10)). LOS decreased significantly in Function-tailored (1.1 days; p = 0.001 (95% CI -0.30 to -0.06)), Fast-track (0.6 days; p < 0.001 (95% CI -0.21 to -0.05)), and Prehabilitation (0.6 days; p < 0.001 (95%CI -0.27 to -0.11)). Discharge to PLS increased in Function-tailored (77%), Fast-track (91.6%), and Prehabilitation (92.6%). Post-hoc analysis indicated a significant increase after the transition to the Fast-track period (p < 0.001 (95% CI 3.19 to 8.00)). Conclusion. This study highlights the positive impact of different perioperative care procedures on in-hospital recovery of patients undergoing primary TKA. Assessing functional recovery, LOS, and discharge towards PLS consistently, provides hospitals with valuable insights into postoperative recovery. This can potentially aid planning and identifying areas for targeted improvements to optimize patient outcomes. Cite this article: Bone Joint J 2024;106-B(6):573–581

During the last decade primary total hip arthroplasty surgery (THA) has increased with 30% in Sweden. Current law guarantees the patient a right to treatment within 90 days. The public health system has had difficulties meeting the increasing demand. Therefore, in 2012 a systematic review of the patients planned for THA was initiated at Sahlgrenska University Hospital's joint replacement unit. In late 2013 the value-based health care (VBHC) management was introduced in our unit. In 2012 a systematic approach based on the Fast-Track concept was implemented in the joint replacement unit. In 2013 a workgroup consisting of health care professionals involved in the treatment of THA patients was created to improve chosen outcome parameters. During 2011–2016 the number of elective THA has increased from 317 to 486. The cost per patient has decreased from 75,000 SEK to 65,000 SEK. Length of stay has decreased from 5.9 days to 2.5 days. Satisfaction with outcome of surgery one year after THA increased from 76% to 88%. The number of adverse events decreased from 29% to 11%. Number of re-operations within 2 years decreased from 2,7% to 1,9%. Fast-Track and VBHC management was initially received with modest enthusiasm in our unit, and was regarded as means to increase production whilst possibly endanger the well-being of the patients. By using continuous feedback using the data collected it was possible to effectively communicate to patients and caregivers that the patients benefitted from the implementation. VBHC primary aim is to improve patient outcomes and synergetically improve cost and process measurements. This should be appealing to both caregivers and administrators. Focusing on improvement of outcomes after THA combined with VBHC management has contributed to improvement in quality of care and availability of treatment whilst decreasing cost per patient

Background. North America is facing a rising epidemic involving strains of methicillin-resistant Staphylococcus aureus (MRSA) that, instead of being found almost exclusively in hospitals, are community-associated (CA-MRSA). These strains are aggressive, associated with musculoskeletal manifestations including osteomyelitis (OM), and septic arthritis (SA). We aimed to establish novel management algorithms for acute OM and SA in children. We investigated S.aureus susceptibilities to current first-line antimicrobials to determine their local efficacy. Methods. The project was conducted at Nemours Children Hospital in Florida, USA, following approval by the internal review board. A literature review was conducted. An audit of S.aureus antimicrobial sensitivities was completed over three years and compared against national standards. Susceptibilities of clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX) and vancomycin were studied using local resistance ranges. Results. Two algorithms for acute OM and SA management were created adopting a multidisciplinary team approach from admission to discharge whilst differentiating higher risk patients within fast-track pathways. We analysed 532 microbiology results for antibiotic susceptibilities from 2012 to 2014. Overall, 51% of S.aureus infections were MRSA versus 49% methicillin-susceptible S.aureus (MSSA). Surprisingly, clindamycin resistance rates rose compared to 2005 (MRSA 7% in 2005 vs 39% currently, MSSA 20% vs 31% and total S.aureus resistance rate of 8% vs 35%, respectively). MRSA and MSSA isolates were near 100% sensitive to Vancomycin and TMP/SMX. No appropriate national standards existed. Conclusions. Multidisciplinary based algorithms were created for acute OM and SA treatment in children. Possible therapeutic roles for ultrasound guided aspiration and corticosteroids were highlighted in SA. Our audit revealed equal incidence of MSSA to MRSA, supporting national figures on falling MRSA. Interestingly, incresed resistance of MSSA and MRSA was found towards recommended first line clindamycin, raising concern over its efficacy. Level of Evidence. 5

Aim. North America is facing a rising epidemic involving strains of methicillin-resistant Staphylococcus aureus (MRSA) that, instead of being found almost exclusively in hospitals, are community-associated (CA-MRSA). These strains are aggressive, associated with musculoskeletal manifestations including osteomyelitis (OM), and septic arthritis (SA). We aimed to establish novel management algorithms for acute OM and SA in children. We investigated S.aureus susceptibilities to current first-line antimicrobials to determine their local efficacy. Method. The project was conducted at Nemours General Children Hospital in Florida, USA, following approval by the internal review board. A literature review was conducted. An audit of S.aureus antimicrobial sensitivities was completed over three years and compared against national standards. Susceptibilities of clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX) and vancomycin were studied using local resistance ranges. Results. Two algorithms for acute OM and SA management were created adopting a multidisciplinary team approach from admission to discharge whilst differentiating higher risk patients within fast-track pathways. We analysed 532 microbiology results for antibiotic susceptibilities from 2012 to 2014. Overall, 51% of S.aureus infections were MRSA versus 49% methicillin-susceptible S.aureus (MSSA). Surprisingly, clindamycin resistance rates rose compared to 2005 (MRSA 7% in 2005 vs 39% currently, MSSA 20% vs 31% and total S.aureus resistance rate of 8% vs 35%, respectively). MRSA and MSSA isolates were near 100% sensitive to Vancomycin and TMP/SMX. No appropriate national standards existed. Conclusions. Multidisciplinary based algorithms were created for acute OM and SA treatment in children. Possible therapeutic roles for ultrasound guided aspiration and corticosteroids were highlighted in SA. Our audit revealed equal incidence of MSSA to MRSA, supporting national figures on falling MRSA. Interestingly, increased resistance of MSSA and MRSA was found towards recommended first line clindamycin, raising concern over its efficacy

There is an apparent need for easily accessible research data on Periprosthetic hip joint infections (PJI)(1). Administrative discharge registers could be a valuable single-sources for this purpose, and studies originating from such registers have been published(2–4). However, the quality of routinely collected data for administrative purposes may be questionable for use in epidemiological research. The aim of this study was to estimate the positive predictive value of the International Classification of Disease 10th revision (ICD-10) periprosthetic hip joint infection diagnose code T84.5. The study was performed as a cross-sectional study on data extracted from the Danish National Patient Register. Patients with a registration of performed surgical treatment for hip PJI were identified via the ICD-10 code T84.5 (Infection and inflammatory reaction due to internal joint prosthesis) in association with hip-joint associated surgical procedure codes. Medical records of the identified patients (n=283) were verified for the existence of a periprosthetic hip joint infection. Positive predictive values with 95% confidence intervals (95% CI) were calculated. A T84.5 diagnosis code irrespective of the associated surgical procedure code had a positive predictive value of 85 % (95% CI: 80–89). Stratified to T84.5 in combination with an infection-specific surgical procedure code the positive predictive value increased to 86% (95% CI: 80–91), and in combination with a noninfection-specific surgical procedure code decreased to 82% (95% CI: 72–89). This study is the first to evaluate the only discharge diagnose code of prosthesis-related infection in an administrative discharge register. It is apparent, that codes in administrative discharge registers are prone to misclassification on an administrative level, either by wrongful coding by the physician or administrative personal in the registration process. Misclassification must be expected and taken into consideration when using single-source administrative discharge registers for epidemiological research on periprosthetic hip joint infection. We believe that the periprosthetic hip joint infection diagnose code can be of use in single-source register based studies, but preferably should be used in combination with alternate data sources to ensure higher validity(5). This study is funded in part by the Lundbeck foundation Centre for Fast-track Hip and Knee Surgery, Denmark

Eliminating pain and restoring physical activity are the main goals of total hip arthroplasty (THA). Despite the high relevance of activity as a rehabilitation goal of and criterion for discharge, in-hospital activity between operation and discharge has hardly been investigated in orthopaedic patients. Therefore, the aim of this study was to a) measure for reference the level of in-hospital physical activity in patient undergoing a current rapid discharge protocol, b) compare these values to a conventional discharge protocol and c) test correlations with pre-operative activities and self-reported outcomes for possible predictors for rapid recovery and discharge. Patients (n=19, M:F: 5:14, age 65 ±5.7 years) with osteoarthritis treated with an elective primary THA underwent a rapid recovery protocol with discharge on day 3 after surgery (day 0). Physical activity was measured using a 3D accelerometer (64×25×13mm, 18g) worn on laterally on the unaffected upper leg. The signal was analysed using self-developed, validated algorithms (Matlab) calculating: Time on Feet (ToF), steps, sit-stand-transfers (SST), mean cadence (steps/min), walking bouts, longest walk (steps). For the in-hospital period (am: ca. 8–13h; pm: ca. 13–20h) activity was calculated for day 1 (D1) and 2 (D2). Pre-operative activity at home was reported as the daily averages of a 4-day period. Patient self-report included the HOOS, SQUASH (activity) and Forgotten Joint Score (FJS) questionnaires. In-hospital activity of this protocol was compared to previously collected data of an older (2011), standard conventional discharge protocol (day 4/5, n=40, age 71 ±7 years, M:F 16:24). All activity parameters increased continuously between in-hospital days and subsequent am and pm periods. E.g. Time-on-feet increased most steeply and tripled from 21.6 ±14.4min at D1am to 62.6 ±33.4min at D2pm. Mean Steps increased almost as steep from 252 to 655 respectively. SST doubled from 4.9 to 10.5. All these values were sign. higher (+63 to 649%) than the conventional protocol data. Cadence as a qualitative measure only increased slowly (+22%) (34.8 to 42.3steps/min) equalling conventional protocol values. The longest walking bout did not increase during the in-hospital period. Gender, age and BMI had no influence on in-hospital activity. High pre-op activity (ToF, steps) was a predictor for high in-hospital activity for steps and SST's at D2pm (R=0.508 to R=0.723). Pre-op self-report was no predictor for any activity parameter. In-hospital recovery of activity is steep following a cascade of easy (ToF) to demanding (SST) tasks to quality (cadence). High standard deviations show that recovering activity is highly individual possibly demanding personalised support or goals (feedback). Quantitative parameters were all higher in the rapid versus the conventional discharge protocol indicating that fast activation is possible and safe. Equal cadence for both protocols shows that functional capacity cannot be easily accelerated. Pre-op activity is only a weak predictor of in-hospital recovery, indicating that surgical trauma affects patients similarly, but subjects may be identified for personalized physiotherapy or faster discharge. Reference values and correlations from this study can be used to optimize or shorten in-hospital rehabilitation via personalization, pre-hab, fast-track surgery or biofeedback

Introduction/Aim. Flexor tendon injuries of the hand are common with an incidence of over 3000 per annum in the UK. These injuries can affect hand function significantly. Early treatment with optimal repair is crucial to prevent disability. This study aimed at investigating the re-rupture rate following primary flexor tendon repair at our institution and to identify potential risk factors for re-rupture. Methods. 100 flexor tendons' injuries that underwent primary repair over a one-year period were reviewed retrospectively. Data was collected on age, gender, occupation, co morbidities, injured fingers, hand dominance, smoking status, zone of injury, time to surgery, surgeon grade, type of repair and suture, and antibiotic use on included patients. Causes of re-rupture were examined. We compared primary tendon repairs that had a re-rupture to those that did not re-rupture. Univariate and multivariate analysis was undertaken to identify the most significant risk factors for re-rupture. Results. 11 out of 100 (11%) repaired tendons went on to re-rupture. A significantly higher proportion of tendons re-rupture was noted when the repair was performed on the dominant hand (p-value = 0.009), in Zone 2 (0.001), and when a surgical delay of more than 72 hours from the time of injury occurred (0.01). Multivariate regression analysis identified repairs in Zone 2 to be the most significant predictor of re-rupture. Causes of re-rupture included infection in 5, rupture during rehabilitation exercises in 5 and fall in 1 patient. Conclusions. A re-rupture rate of 11% was noted in our study. Patients with Zone 2 injuries, repair on dominant hand and those with a surgical delay of more than 3 days were at higher risk of re-rupture. Careful consideration of these factors especially zone 2 injuries is crucial to reduce this rate. Providing a fast-track pathway for managing these patients can reduce time to surgery

Aims

The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR.

With Lord Darzi’s vision of the future of the NHS, it has become clear that quality of care will be the next focus and the hospitals providing acute orthopaedics and trauma services will have to deliver best and most efficient care for the patients being admitted with fractured neck of femur. This study is aimed at recognizing the changes and organization required at a district general hospital and their initial effect on the quality of services being provided locally. Management of patient with hip fracture involves several specialties within the hospital as well as primary care setup. An audit of A& E waiting time showed significant variation in the delay before transferring the patients to the ward which was addressed by Fast-Track system. In the ward, preoperative assessment was standardized by agreement between orthopaedics and anaesthetics department. Three daytime lists were initiated specifically for hip fracture patients, resulting in increase in the number of patients going to theatre within 48 hours of admission, from 75% to 86%. A protocol was agreed between orthopaedic surgeons and rheumatologists for starting anti-resorptive therapy for these patients in order to decrease the chances of future fragility fractures. Impact of this measure will be assessed in due course. One senior middle grade surgeon was given the charge of managing NOF lists and to coordinate the medical management of these patients. Hospital has also started taking part in National Hip Fracture Database and a HCA has been assigned the duty of uploading the data to NHFD database. A acre pathway is being developed to streamline the whole peri-operative and after discharge management of these patients. With just about a year left before the implementation of healthcare commissioning, it is vital that trusts start working on best and most efficient care for all patients. Hospital will have to publish their quality accounts from next year and their tariffs will be linked to patient reported outcome measures. This study highlights the main issues and the potentially vital role of orthopaedic specialists in developing the required services

Introduction: Increasingly, clinical pathways and fast-track protocols are reducing hospital in-patient stay following elective joint replacement surgery. In order to improve efficiency in our unit, we undertook a prospective observational study to identify pre–and peri-operative factors associated with increased length of stay. Methods: From our prospective primary hip arthroplasty database we analysed data from 2678 consecutive patients over a 9-year period from 1998–2007. Patients were excluded who had bilateral hip replacement, died within 30 post-operative days, or had surgery for a diagnosis other than primary osteoarthritis. This left 2302 patients who were analysed using multiple logistic regression analysis. Results: Length of stay varied from 3 to 58 days, with a mean of 8.1 days, and median 7 days. After multivariate analysis, factors that were found to be significantly associated with shorter length of stay were younger age (p< 0.001), male sex (p< 0.001), more recent year of admission (p=0.008), regular non-steroidal anti-inflammatory medication (p< 0.001), lower Harris Hip Score (p< 0.001), and higher General Health Perception dimension score on SF-36 questionnaire (p< 0.001). In addition, the absence of blood transfusion during admission (p< 0.001) and absence of post-operative urinary catheter (p< 0.001) were also associated with shorter length of stay. The following factors, in particular, were not found to be significantly associated with increased length of stay: obesity, diabetes, smoking, medical comorbidity, other disabling joint condition, use of wound drain post-operatively. Conclusions: We have identified a number of pre-operative factors that predict likely length of stay in a large cohort of patients undergoing primary hip replacement. This data could be used in the future for resource allocation and to improve efficiency in this significant area of healthcare