Chronic osteomyelitis is a challenging problem and a growing burden for the National Health Service. Conventional method of treatment is 2 stage surgery, with debridement and prolonged courses of antibiotics. Recently single stage treatment of chronic osteomyelitis is gaining popularity due decreased patient morbidity and cost effectiveness. Dead space management in single stage treatment is accomplished by either a muscle / myocutaneous or antibiotic loaded calcium sulphate beads. We analysed the cost effectiveness of two dead space management strategies in single stage treatment of osteomyelitis. Study is designed to analyse the health economics at 2 time points; 45 days post surgery and 2 years post surgery. We report preliminary results at 45 days post surgery. Setting – Level 1 trauma centre and university hospital. Approval – Ethics committee approved study. 10 patients in each group were retrospectively analysed through patient records. Each group was identified for standard demographics, duration of procedure, hospital stay, type and duration of postoperative antibiotics, number of out patient visits in first 45 days and recurrence of infection. Table attached details the results of both groups. In health technology assessment four quadrant model, CSB appears in quadrant II suggesting that it is more cost effective. Based on small data set and on assessment only evaluating cost, at 45 days assessment, antibiotic calcium sulphate beads from a Health Economic Cost Effectiveness Analysis offers a better economic outcome. This is holding constant the morbidity of the patients and effectiveness, assuming both treatments are standards of care, which is best evaluated at 24 months. Acknowledgements. Biocomposites for funding the cost of health economist

Aims

The tibial component of total knee arthroplasty can either be an all-polyethylene (AP) implant or a metal-backed (MB) implant. This study aims to compare the five-year functional outcomes of AP tibial components to MB components in patients aged over 70 years. Secondary aims are to compare quality of life, implant survivorship, and cost-effectiveness.

Aims

The aims of this study were to compare the use of resources, costs, and quality of life outcomes associated with subacromial decompression, arthroscopy only (placebo surgery), and no treatment for subacromial pain in the United Kingdom National Health Service (NHS), and to estimate their cost-effectiveness.

Aims. Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics. Methods. Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system. Results. Four classes were proposed: PR1, where no bone-implant interfaces are affected; PR2, where surgery does not include conversion to total knee arthroplasty, for example, a second partial arthroplasty to a native compartment; PR3, when a standard primary total knee prosthesis is used; and PR4 when revision components are necessary. Round one resulted in 92% inter-rater agreement (Kendall’s W 0.97; p < 0.005), rising to 93% in round two (Kendall’s W 0.98; p < 0.001). Round three demonstrated 97% agreement (Kendall’s W 0.98; p < 0.001), with high intra-rater reliability (interclass correlation coefficient (ICC) 0.99; 95% confidence interval 0.98 to 0.99). Round four resulted in 80% agreement (Kendall’s W 0.92; p < 0.001). Conclusion. The RPKC system accounts for all procedures which may be appropriate following partial knee arthroplasty. It has been shown to be reliable, repeatable and pragmatic. The implications for patient care and health economics are discussed. Cite this article: Bone Jt Open 2021;2(8):638–645

In this review, we discuss the evidence for patients returning to sport after hip arthroplasty. This includes the choices regarding level of sporting activity and revision or complications, the type of implant, fixation and techniques of implantation, and how these choices relate to health economics. It is apparent that despite its success over six decades, hip arthroplasty has now evolved to accommodate and support ever-increasing patient demands and may therefore face new challenges. Cite this article: Bone Joint J 2020;102-B(6):661–663

Abstract. Introduction. There is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR. Methodology. REST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery. Results. 57 patients were randomised and 20 had surgery within the study timelines. All patients allocated the intervention attended an appointment and most engaged with treatment. The intervention group reported improvements in sleep (Sleep Conditions Indicator) and neuropathic pain (painDETECT) scores. Participants found the sleep treatments and study processes to be acceptable. The mean cost of the intervention was estimated at £134.45 per patient. Conclusion. The feasibility study has shown that patient recruitment is feasible, engagement with and adherence to the intervention is high, and the intervention is acceptable to patients and clinicians. Preliminary findings show that the intervention group had improved sleep quality and had reduced levels of pre-operative neuropathic pain. This study has demonstrated that a full RCT is feasible and identified areas for improvement to optimize the trial design

Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence the morbidity and mortality associated is similar to the fractured neck of femur cohort. Despite growing literature, there remains significant controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally surgical fixation and simultaneous THA to allow immediate full weight bearing. £250k NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054). Trial ethical approval (17/EE/0271). After national consultation, 3 arms included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required minimum 12 patients/3 arms to show feasibility, with an optimum 20/arm. Inclusion criteria; patients >60 years & displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma. Primary outcome measure - ability recruit & EQ-5D-5L at 6 months. Secondary outcome measures (9 months); OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics. 11 UK level 1 major trauma centres enrolled into the trial, commenced December 2017. Failure surgical equipoise was identified as an issue regarding recruitment. Full trial recruitment (60 patients) achieved; 333 patients screened. 66% male, median age 76 (range 63–93), median BMI 25 (range 18–37), 87% full mental capacity, 77% admitted from own home. 75% fall from standing height. 60% fractures; anterior column posterior hemi-transverse. Trial feasibility confirmed December 2020. Presented data- secondary outcomes that are statistically significant in improvement from baseline for only the fix and replace arm, with acceptable trial complications. Issues are highlighted with conservative management in this patient cohort. Our unique RCT informs design and sample size calculation for a future RCT. It represents the first opportunity to understand the intricacies of these treatment modalities. This RCT provides clinicians with information on how best to provide management for this medically complex patient cohort

Introduction. Retention and removal of children's orthopaedic metalwork is a contentious issue that has implications for current resource allocation, health economics, complication risks and can impact on future treatments. Understanding how to guide families make informed choices requires an overview of all the relevant evidence to date, and knowledge of where the evidence is lacking. Our aim was to systematically review the literature and provide a meta-analysis where possible, recommending either retention or removal. Materials and Methods. A search of the literature yielded 2420 articles, of which 22 papers were selected for the study analysis. Inclusion criteria: Any paper (evidence level I-IV) assessing the risks or benefits of retaining or removing orthopaedic metalwork in children. Exclusion criteria: Spinal implants; implant number < 40; < 75% recorded follow up; papers including implants in their analysis that always require removal; patients aged >18 years. Results. In total, 4988 patients (6412 implants) were included across all 22 studies. There was a significant amount of heterogenicity between studies. Overall the short term risks of metalwork retention and removal are low, with a few exceptions. In forearm plating re-fracture rates following removal were lower than those seen in studies looking at retained metalwork, provided removal occurred later than 12 months from the initial operation. Forearm re-fracture rates after removal of flexible nails significantly increased if removal was performed before 6 months. Major complications following routine metalwork removal from the proximal femur are relatively rare, with re-fracture rates of 1–5%. The majority of these re-fractures are seen in neuromuscular patients or in patients where removal occurs earlier than 6 months. Routine metalwork removal following SUFE had a complication rate of 30–60%. Conclusions. We found that there are certain subgroups of children that benefit from retention of metalwork and some that benefit from removal. There are several subgroups that we have identified which do not yet have sufficient long term evidence to make a balanced recommendation. We advise that families are made aware of what is known and what is unknown in order to allow for shared decision making

Objectives. Subtotal or total meniscectomy in the medial or lateral compartment of the knee results in a high risk of future osteoarthritis. Meniscal allograft transplantation has been performed for over thirty years with the scientifically plausible hypothesis that it functions in a similar way to a native meniscus. It is thought that a meniscal allograft transplant has a chondroprotective effect, reducing symptoms and the long-term risk of osteoarthritis. However, this hypothesis has never been tested in a high-quality study on human participants. This study aims to address this shortfall by performing a pilot randomised controlled trial within the context of a comprehensive cohort study design. Methods. Patients will be randomised to receive either meniscal transplant or a non-operative, personalised knee therapy program. MRIs will be performed every four months for one year. The primary endpoint is the mean change in cartilage volume in the weight-bearing area of the knee at one year post intervention. Secondary outcome measures include the mean change in cartilage thickness, T2 maps, patient-reported outcome measures, health economics assessment and complications. Results. This study is expected to report its findings in 2016. Cite this article: Bone Joint Res 2015;4:93–8

The NDI is a simple 10-item questionnaire used to assess patients with neck pain. The original validation was performed on 52 patients with neck pain and the test-retest on 17 whiplash patients with a 2-day interval. The SF36 measures functional ability, wellbeing and the overall health of patients. It is used in health economics to assess the health utility, gain and economic impact of medical interventions. Objectives were to independently validate the NDI in patients with neck pain and to draw comparison between the NDI and SF36. 160 patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 34 patients after a period of 1-2 weeks. The internal consistency of the NDI and SF36 was calculated using Cronbach alpha. The test-retest reliability was assessed using the Bland and Altman method and the concurrent validity between the two questionnaires was assessed using Pearson correlation. Both questionnaires showed robust internal consistency: SF36 alpha = 0.878 (se=0.014, 95%CI=0.843 to 0.906) and NDI = 0.864 (se=0.017, 95%CI=0.825 to 0.894). The NDI had significant correlation to all eight domains of the SF36 (p<0.001). The individual scores for each of the ten items had significant correlation with the total disability score (p<0.001). The test-retest reliability of the NDI was acceptable. We have shown irrefutably that the NDI has good reliability and validity and that it stands up well to the SF36

Current health economics forces the clinician to consider the cost of treatment. Currently in Fife Hospitals, all lower limb injuries likely to require operative treatment are admitted from the Accident and Emergency department on the day of injury. The aim of this investigation was to see if non-emergency trauma cases could be managed pre-operatively as outpatients to reduce costs. We prospectively recorded all patients admitted with lower limb trauma excluding neck of femur fractures, requiring operative treatment over an eleven-week period. The senior author reviewed all patients and a clinical judgment was made as to whether the patient could have been safely managed as an outpatient pre-operatively. 61 patients met the inclusion criteria. Average age 41.8 (Range 8-66). The three most common fractures were 23(38%) ankle fractures, 15(25%) tibial fractures and 8(13%) femoral shaft fractures. 28(46%) fractures were deemed safe to have been managed preoperatively on an outpatient basis. 14/23(61%) ankle fractures were deemed safe to be discharged home. The average pre-operative stay was 1.38 nights (Range 1-4 nights). By initiating a simple policy of allowing uncomplicated ankle fracture patients to wait at home and return on the morning of surgery it is possible to reduce inpatient occupancy by 64 nights per year in our department. At a cost of £518 per patient per night, this could result in a saving of around £33,000 in unnecessary overnight inpatient stays. In order to achieve this, clear clinical guidance for admitting doctors is necessary and further prospective research should be conducted into the risk/benefit of implementing this policy

To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ring allograft (FRA). Cost-effectiveness analysis. Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Patients were followed-up for 24 months. Oswestry Disability Index, visual analogue scale, quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. Both treatments produced statistically significant improvements in pain, disability and quality of life at the 24-month follow-up. Costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). The mean incremental cost of IDET was -£3,713 per patient; the mean incremental QALY gain was 0.03. At a threshold of £20,000 per QALY the probability that IDET is cost-effective is 1, and the net health benefit is 0.21 QALY per patient treated. Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative. Ethics approval: Ethics committee COREC. This cost-effectiveness analysis was carried out by the York Health Economics Consortium at the University of York, and was funded by Smith & Nephew. Smith & Nephew had no financial or other involvement in the collection or analysis of the data on which the CEA is based

In Scotland, the number of primary total knee replacements (TKRs) performed annually has been steadily increasing. Data from the Scottish Arthroplasty Project has recently demonstrated that the number of knee replacements performed annually has now outstripped the number of hip replacements. The price of the implant is fixed but the length of hospital stay (LOHS) is variable. An understanding of what currently influences LOHS may therefore be of paramount importance in order that we can influence some of these parameters, with resulting benefit to our patients as well as contributing significantly and favourably towards the health economics of this procedure. This study investigates the influence of intra- and post-operative variables on LOHS. All patients who underwent primary unilateral TKR in the region of Fife, Scotland, United Kingdom, during the period December 1994 to February 2007 were prospectively investigated. The following intra and postoperative details were recorded: length of operation, need for urinary catheterisation, patella resurfacing, lateral release, blood transfusion, the presence of superficial or deep infection, day 1 post-operative haemoglobin and haemoglobin drop (haemoglobin drop between admission haemoglobin and day 1 post-operative haemoglobin). The data was analysed using univariate and multiple linear regression statistical analysis. Data on LOHS was available from a total of 2105 primary unilateral TKRs. The median LOHS was 8.0 days. The highly significant intra and post-operative factors associated with an increased LOHS were lateral release, post-operative haemoglobin, blood transfusion, urinary catheterisation, deep and superficial infection. An awareness and understanding of these factors may enable us to influence them favourably with resulting reduction in the LOHS and, therefore, the associated costs

Early prediction of outcome following hip fracture surgery would save valuable time towards arranging post-op rehabilitation benefiting the patient and health economics. The study aim was to develop a prognostic scoring system for elderly hip fracture patients, which on admission is able to predict rehabilitation needs at discharge based on pre-injury factors. A simple and fast prognostic scoring system was developed based on age, pre-injury level of “independence in activities of daily living” (Katz), medical co-morbidities, cognitive functioning (MMSE) and presence of a caregiver, to predict rehabilitation needs at discharge (0–8 points). Rehabilitation options were direct return to pre-injury living situation (group 1), transfer to an orthopaedic rehabilitation unit for a period shorter than 3 months (group 2), or transfer to a psychogeriatric or orthopaedic rehabilitation unit for a period longer than 3 months (group 3). Rehabilitation needs as predicted and the clinical decision by independent, blinded observers were compared. The score was validated in a prospective study on a consecutive cohort of 77 hip fractured patients. Overall positive predictive value (PPV) of the prognostic score was 0.87 (CI 0.77–0.93), a marked improvement compared to previously published scoring systems with a PPV of 0.68 (CI 0.55–0.79). PPV per group (0.80, 0.92, 0.87) was highest for the most critical groups 2 and 3. In-hospital mortality was 1.3 percent. The average length of hospital stay (LOS) was 11.4 days. Using the score fast and reliable prediction of rehabilitation needs could be made already on admission gaining maximum time for the preparation of adequate discharge destinations improving care and reducing costly LOS

Introduction: The NDI is a simple 10-item questionnaire used to assess patients with neck pain. The original validation was performed on 52 patients with neck pain and the test-retest on 17 whiplash patients with a 2-day interval. The SF36 measures functional ability, wellbeing and the overall health of patients. It is used in health economics to assess the health utility, gain and economic impact of medical interventions. Objectives: (1) Independently validate the NDI in patients with neck pain. (2) Draw comparison of the NDI and SF36. Subjects: 100 patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 30 patients after a period of 1–2 weeks. Statistics: The internal consistency of the NDI and SF36 was calculated using Cronbach alpha. The test-retest reliability and the concurrent validity between the two questionnaire scores were assessed using Pearson correlation. Individual scores for each of the ten items of the NDI were correlated to the total disability score categories. Results: Both questionnaires showed robust internal consistency – alpha for NDI = 0.85 (95% CI = 0.8–0.89) and SF36 = 0.84 (95% CI = 0.79–0.88). The NDI had significant correlation to all eight domains of the SF36 (p< 0.001). The individual scores for each of the ten items had significant correlation with the total disability score (p< 0.001). The test-retest reliability of the NDI was acceptable. Conclusions: We have shown irrefutably that the NDI has good reliability and validity and that it stands up well to the SF36

Enhanced Orthopaedic Recovery (EOR) is an evidence-based, integrated, multi-modal approach to improving recovery following elective orthopaedic surgery. The principles of EOR are to reduce time to functional recovery of postoperative patients safely with subsequent benefits to their length of stay in hospitals, their quality of life and health economics and outcomes. The combination of interventions used has been shown to be effective following major gastro-intestinal surgery but have not been tested in Orthopaedics until now. They aim to reduce the stress response provoked by surgery and the peri-operative catabolic state by optimally managing patient metabolism, post-operative pain, mobility and expectations. Simple interventions along the patients’ journey include pre-operative educational classes, pre-operative carbohydrate loading, a (short) two hour fast ensuring surgery performed on anabolic patients, post operative pain and metabolic optimisation, empowering patients with ownership of their post-operative recovery and proactive post-discharge management. We found that these simple interventions translate well into elective orthopaedic arthroplasty surgery, can be achieved without additional cost and have little impact on intra-operative practice. We conducted a single surgeon, consecutive patient, interventional, cohort study of lower limb primary joint arthroplasty surgery (primary total knee and primary total hip arthroplasty) in a busy district general hospital, 30 bed orthopaedic department. We reviewed the preceding 141 primary joint replacements (75 total hip and 66 total knee arthroplasties) before prospectively assessing the next 50 total hip and 32 total knee arthroplasties. A Mann-Whitney test between the two periods showed a highly statistically significant fall in time to discharge (median hospital stay 6.5 - 4 nights, p< 0.001). We noted no adverse effects as a result implementing EOR. We have shown that by implementing EOR, reduced time to functional recovery and subsequent hospital discharge can be safely achieved with consequent quality of life and health economic benefits

The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration. Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed. Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture]. rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases

Introduction: In Scotland, the number of primary total knee replacements has been steadily increasing since 1992. It has been predicted that the number of total knee replacements performed annually will soon outstrip the number of hip replacements. The price of the implant is fixed but the length of hospital stay, and associated cost, is variable. An understanding of what currently influences length of hospital stay may be of paramount importance in order that we can influence some of these parameters, with resulting benefit to our patients as well as contributing significantly and favourably towards the health economics of this procedure. Materials and Methods: All patients who underwent primary unilateral total knee replacement in the region of Fife, Scotland, UK, during the period December 1994 to February 2007 were prospectively investigated. The following information was gathered: age, sex, body mass index (BMI), year of operation, day of operation, diagnosis, surgeon grade, consultant performing the operation, walking score, walking aids score, stair score, American Knee Society score (pain, stability and range of motion), length of operation, need for lateral release, patella replacement, urinary catheterisation, blood transfusion, presence of deep or superficial infection, pre and post-operative haemoglobin values, haemoglobin drop, and length of hospital stay. All the data was analysed using univariate and multiple linear regression statistical analysis. Results: Data on length of hospital stay was available from a total of 2105 unilateral total knee replacements. Length of stay varied from 4 to 70 days, with a mean of 9.4 and a median of 8.0. There were numerous highly significant predictors of increased length of hospital stay, when considered separately. Many of these independently significant factors remained significant when adjusted for the effects of the others. These included age of the patient, year of admission, consultant performing the operation, use of a walking aid, lateral release, deep and superficial infection, pre and post-operative haemoglobin values, urinary catheterisation and blood transfusion. Of note, the day of operation and high BMI did not influence the length of stay. Conclusion: Prolonged hospital stay following total knee replacement is associated with demographic, preoperative, intra-operative and post-operative factors. An awareness of these factors gives us the opportunity to make attempts to influence them favourably with resulting reduction in length of hospital stay and, therefore, the associated costs

Introduction: Ankle fractures are the most common fracture presenting to any trauma unit in the country with an incidence of 100 per 100,000 in a population. The management and the outcome will very well depend on the mechanism of the injury but there is a window of opportunity of atleast 24hr before the swelling sets in making it technically difficult to operate and hence lengthening the hospital stay with a substantial financial cost. In times where the public health fundings are set to be rolled back and Department of Health been asked to contribute £2.3bn to the Treasury’s £5bn of public spending cuts in2010/1, health economics becomes a vital thread in consideration of treatment planning. Aim: The study was aimed at determining the delay in definitive fixation of the ankle fractures from the time of presentation to the hospital and the reasons entailing the delay with a resultant economic negative resonance of it on the hospital budget spreadsheets and for the patient. Method: A retrospective review of all ankle fracture patients operated during Sept 07 to Aug 08 in this hospital was performed. Electronic records were evaluated to identify the waiting times for the surgery and the reasons thereof. Calculations were performed based upon the days lost and calculated against the national minimum wage of £5.73 an hour for adults (workers aged 22 and over) and £4.77 an hour for workers aged 18 to 21 inclusive (often known as the developmental rate). Cost to the trust because of the extra stay was calculated as well. Results: Total number of patients operated for ankle fracture during the study period was 159. The mean waiting time for surgery was 4.9 days (range 1 to 7.8 days). The mean duration of in-hospital stay for the procedure was 12 days. The commonest cause for the delay of surgery was soft tissue swelling (50%). The total number of patient days lost while waiting for selling to recede was 779.1. Based on the minimum wages considering 8 hours of a working day, the total economic loss to the GDP was approximately £35713.9. With the average cost of hospital stay per day being £ 365 patient the total expenditure to the trust for waiting for the ankle selling to recede was 1788 per patient. Conclusion: Considering the current economic climate, which is set to affect the spending on the health care, its over time that economic consideration is given while considering the promptness of the action with NCEPOD also suggesting that operatic can be done at night if resources available. With European working time directive in play from august 2009 and open reduction and internal fixation considered a index operation it is possible to operate timely by a fresh surgical team

Increasing pressure to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA) is evident in current health care systems for numerous reasons. Patient autonomy and health care economics has challenged the ability of THA implants to maintain functional integrity before achieving bony union. Although collared stems have been shown to provide improved axial stability, it is unclear if this stability correlates with activity levels or results in improved early function to patients compared to collarless stems. This study aims to examine the role of implant design on patient activity and implant fixation. The early follow-up period was examined as the majority of variation between implants is expected during this time-frame. Patients (n=100) with unilateral hip OA who were undergoing primary THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=50) or collarless (n=50) cementless femoral stem. Patients will be seen at nine appointments (pre-operative, < 2 4 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Patients also underwent supine radiostereometric analysis (RSA) imaging < 2 4 hours post-operation prior to leaving the hospital, and at all follow-up appointments. Nineteen collared stem patients and 20 collarless stem patients have been assessed. There were no demographic differences between groups. From < 2 4 hours to two weeks the collared implant subsided 0.90 ± 1.20 mm and the collarless implant subsided 3.32 ± 3.10 mm (p=0.014). From two weeks to three months the collared implant subsided 0.65 ± 1.54 mm and the collarless implant subsided 0.45 ± 0.52 mm (p=0.673). Subsidence following two weeks was lower than prior to two weeks in the collarless group (p=0.02) but not different in the collared group. Step count was reduced at two weeks compared to pre-operatively by 4078 ± 2959 steps for collared patients and 4282 ± 3187 steps for collarless patients (p=0.872). Step count increased from two weeks to three months by 6652 ± 4822 steps for collared patients and 4557 ± 2636 steps for collarless patients (p=0.289). TUG test time was increased at two weeks compared to pre-operatively by 4.71 ± 5.13 s for collared patients and 6.54 ± 10.18 s for collarless patients (p=0.551). TUG test time decreased from two weeks to three months by 7.21 ± 5.56 s for collared patients and 8.38 ± 7.20 s for collarless patients (p=0.685). There was no correlation between subsidence and step count or TUG test time. Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. The presence of a collar on the stem did not affect patient activity and function and these factors were not correlated to subsidence, suggesting that initial fixation is instead primarily related to implant design