Aims. This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification. Methods. We conducted a retrospective analysis of 162 knees (162 patients) that received treatment for PJI post-TKA with combined IV and topical antibiotic infusions at a single academic hospital from 1 January 2010 to 31 December 2022. The incidence of AKI was evaluated using the KDIGO criteria, focussing on the identification of significant predictors and the temporal pattern of AKI development. Results. AKI was identified in 9.26% (15/162) of the cohort, predominantly presenting as stage 1 AKI, which was transient in nature and resolved prior to discharge. The analysis highlighted moderate anaemia and lower baseline serum creatinine levels as significant predictors for the development of AKI. Notably, the study found no instances of severe complications such as wound dehiscence, skin erosion, or the need for haemodialysis following treatment. Conclusion. The findings suggest that the combined use of IV and topical antibiotic therapy in the management of PJIs post-TKA is associated with a low incidence of primarily transient stage 1 AKI. This indicates a potentially favourable renal safety profile, advocating for further research to confirm these outcomes and potentially influence treatment protocols in PJI management. Cite this article: Bone Joint Res 2024;13(10):525–534

Acute Kidney Injury (AKI) formerly known as “acute renal failure” results in rapid reduction in kidney function associated with a failure to maintain fluid, electrolyte and acid-base homeostasis. The UK NCEPOD published a report in 2010 on AKI that revealed many deficiencies in the care of patients with AKI. The UK Renal Association has published the final draft of Clinical Practice Guidelines for Acute Kidney Injury on the 08/01/2011. In our study we determined retrospectively the occurrence of this problem in a District General Hospital and its impact on recovery after lower limb arthroplasty. Data was collected retrospective study over 3 months between Oct to Dec 2010 from theatre registers and the hospital database system. 359 patients were identified. Preoperative (baseline) and postoperative blood investigations included Creatinine, Urea, K+, Na+, GFR, Haemoglobin were analysed. Data collection also included type of anaesthesia, timing of operation, duration of procedure and estimated blood loss. From the hospital database system and clinic letters we collected length of stay and time required for blood results to come back to baseline. A diagnosis of Acute Kidney Injury was based on the International Kidney Disease Improving Global Outcomes (KDIGO) staging classification as recently recommended by UK Renal Association. Stage I Creatinine increase by ≥ 26 μmol/L from baseline, Stage II Creatinine increase by 200-300% and Stage III Creatinine increase ≥ 300%. In our study 11.97% (43/359) of patients developed acute kidney injury following lower limb Arthroplasty. 18 patients (42%) developed Stage I (Cre increase ≥ 26 μmol/L), 17(39%) developed Stage II (Cre increase 200-300%) and 8 patients (19%) developed Stage III (Cre increase ≥ 300%) AKI. Most of these patients were operated during the afternoon session. Patients with acute kidney injury stayed longer in hospital (11.7days) compared to similar age group of patients (6.35days) admitted during the same period. 25% of patients took more than a month for renal parameters to come down to normal. AKI is a new definition and the incidence in our hospital is higher than the 1% expected nationally. Patients with AKI are often complex to treat and specialist timely referral and transfer to renal services if appropriate should be considered. The etiology of Acute Renal Injury is very complex and includes gentamicin antibiotic prophylactic, rapid blood loss in elderly frail patients, non-steroidal pain killers and preexisting cardiac and renal pathology. The need for careful postoperative observation cannot be overemphasised together with judicious blood replacement as required. Acute Kidney Injury following lower limb arthroplasty is a sensitive marker of postoperative care. A successful surgical outcome may not mean a successful renal outcome. Patients with AKI are often complex to treat the new AKI definition and staging system allows an earlier detection and management of this condition. Further prospective audit with large number of patients are required

Acute Kidney Injury (AKI) is an increasingly prevalent complication of lower limb arthroplasty (LLA). Even a transient decrease in kidney function has been shown to be associated with increased mortality and development of subsequent Chronic Kidney Disease (CKD). We set out to determine which perioperative factors are associated with AKI development at our institution through a retrospective cohort methodology. Patients who underwent primary elective LLA from 01/10/16 to 31/09/17 were included, with relevant perioperative data collected from electronic patient records. AKI was classified according to the Acute Kidney Injury Network (AKIN) criteria. Overall 6.6% of 686 patients developed an AKI post-operatively. These individuals had a significantly longer length of stay (Median 7 days vs 5 days for no AKI [p<0.001]). Independent predictors of AKI on multivariate regression analysis included: Diabetes (OR 3.10, 95% CI 1.34 to 7.20; p=0.008) CKD (OR 5.07, 95% CI 2.60 to 9.86; p=<0.001) and male sex (OR female sex 0.33, 95% CI 0.17 to 0.63; p=0.001). A model including any of these three risk factors predicted 82.2% of patients with an AKI. The overall AKI rate for this model was 11.2% compared to 2.3% for those without any of the three criteria. Only 11% of patients had IV fluid continued beyond the recovery room. AKI is a significant problem in LLA. Knowledge of associated risk factors will allow for targeted interventions to decrease AKI incidence. Continuation of IV fluids until the first post-operative morning for high risk individuals may be a simple method of reducing AKI

Abstract. Introduction. Acute kidney injury (AKI) is a common post-operative complication which, in turn, significantly increases risk of other post-operative complications and mortality. This quality improvement project (QIP) aimed to evaluate and implement measures to decrease the incidence of AKI in post-operative Trauma and Orthopaedics (T&O) patients. Methods. Three data collection cycles were conducted using all T&O patients admitted to a single UK West Midlands NHS trust across three six-month periods between December 2018 and December 2020 (n=8215). Patients developing a post-operative AKI were identified using the Acute Kidney Injury Network criteria. Data was collected for these patients including demographic details and AKI risk factors such as ASA grade, hypovolaemia and use of nephrotoxic medications. Results. The percentage of post-operative AKI decreased from 2% (71 patients from 5899 operations) in the first cycles to 1.5% (19 from 1273 operations) by the final cycle. There was a high prevalence of modifiable risk factors for AKI, including post-operative hypovolaemia (50%) and use of nephrotoxic aminoglycosides (81%). Measures implemented between cycles included a pre-operative medication review identifying nephrotoxic medications, early post-operative assessment for consideration of intravenous fluids and junior doctor teaching on fluid therapy. There was a substantial decrease in use of multiple nephrotoxic medications (98% to 59%) and in use of aminoglycosides (88% to 42%) between the final cycles which may explain the reduction in observed AKI incidence. Conclusion. This QIP highlights the benefits of a multifaceted approach in the peri-operative period, through targeting of risk factors in preventing post-operative AKI

BACKGROUND. High-dose antibiotic cement spacers are commonly used to treat prosthetic joint infections following knee arthroplasties. Several clinical studies have shown a high success rate with antibiotic cement spacers, however there is little data on the systemic complications of high-dose antibiotic spacers, particularly acute kidney injury (AKI). This study aims to determine the incidence of AKI and identify risk factors predisposing patients undergoing staged revision arthroplasty with antibiotic cement spacers. METHODS. A single-institution, retrospective review was used to collect and analyze clinical and demographic data for patients who underwent staged revision total knee arthroplasty with placement of an antibiotic-impregnated cement spacer from 2006 to 2016. A search was made through specific procedure (DRG) and diagnostic (CD) codes. Baseline descriptive data were collected for all patients including age, sex, medical comorbidities, type and quantity of antibiotics used in the cement spacer, pre- and postoperative hemoglobin (Hg), BMI, smoking status, peak creatinine levels, and random vancomycin levels. Acute kidney injury was defined as a more than 50% rise in serum creatinine from a preoperative baseline within 90 days postoperatively. RESULTS. A total of 54 staged revision TKA surgeries performed by 5 different surgeons between 2006 and 2016. The total incidence of AKI was 31% (n=17). There was a significant positive association between change in creatinine level and use of oral/intravenous antibiotics (p=0.03, Spearman's rho=0.33) and a significant positive association between AKI and the use of tobramycin cement (p=0.01, Spearman's rho=0.38). Factors that were not significantly associated with AKI include presence of preexisting hypertension (p = 0.26), hyperlipidemia (p = 0.83), coronary artery disease (p = 0.86), chronic kidney disease (p=0.56), and smoking status (p=.35). There was a trend towards increased risk of AKI in patients with diabetes mellitus (p= 0.12), however this was not significant. CONCLUSION. In single staged revision knee arthroplasty there is a significant association between acute kidney injury and type of oral/intravenous antibiotic used in the treatment. Both the use of intravenous vancomycin and tobramycin cement are independently associated with higher rates of AKI. Preexisting medical comorbidities are not independent risk factors for development of AKI. Serum creatinine and measurement of serum aminoglycoside and vancomycin levels should be performed after placement of an aminoglycoside-containing antibiotic cement spacer in a staged revision arthroplasty

Whilst the SIGN Guidelines state that the use of prophylactic antibiotics in surgery unequivocally reduces major morbidity, reduces hospital costs and is likely to decrease overall consumption of antibiotics they state the chosen antibiotics must reflect local, disease-specific information about the common pathogens and their antimicrobial susceptibility. Growing healthcare concern regarding the rates of Clostridium Difficile (C. Diff) within the hospital setting have led to rationalised and better streamlined prescribing practice within the NHS. In NHS Lanarkshire this led to revised guidelines for prophylactic antibiotic use in Orthopaedics in 2010. Routine use of 3. rd. generation Cephalosporin has been replaced by Flucloxacillin 1g and Gentamicin 1mg/kg. Anecdotally the surgeons within our department were concerned that they were recognising more post-operative renal impairment than before 2010. Our study took 902 consecutive cases treated surgically with either Total Hip Replacement, Total Knee Replacement, Dynamic Hip Screw for fracture and Hemiarthroplasty for fracture since the introduction of the new antibiotic policy. We compared this with a similar number of cases treated with the same operations pre-2010. We looked at the pre admission Urea & Electrolystes compared with immediate post-operative results and applied the definition of Acute Kidney Injury (AKI) as defined by the Acute Kidney Injury Network. A. A rapid time course (less than 48 hours) and B. Reduction of kidney function either as an absolute increase in serum creatinine of ≥26.4μmol/l (≥0.3 mg/dl) or a percentage increase in serum creatinine of ≥50%. Based on this definition we found an increased rate of AKI of 13.7% after the introduction of the use of Gentamicin from 9.8% before its routine use. We wish to highlight that the routine widespread use of Gentamicin may be increasing the rate of acute renal dysfunction seen in Orthopaedic patients undergoing major surgery

Aims. There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients. Methods. This cohort study was a secondary analysis of single-centre Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT) trial data. We included patients with a surgically treated appendicular fracture. The primary outcome was drug-induced AKI. The odds of AKI per gram of vancomycin or tobramycin powder were calculated using Bayesian regression models, which adjusted for measured confounders and accounted for the interactive effects of vancomycin and tobramycin. Results. Of the 782 included patients (mean age 48 years (SD 20); 59% male), 83% (n = 648) received at least one vancomycin dose (cumulative range 1 to 12 g). Overall, 45% of the sample received at least one tobramycin dose (cumulative range 1.2 to 9.6 g). Drug-induced AKI occurred in ten patients (1.2%). No association was found between the cumulative dose of vancomycin and drug-induced AKI (odds ratio (OR) 1.08 (95% credible interval (CrI) 0.52 to 2.14)). Additional doses of tobramycin were associated with a three-fold increase in the adjusted odds of drug-induced AKI (OR 3.66 (95% CrI 1.71 to 8.49)). Specifically, the risk of drug-induced AKI rose substantially after 4.8 g of tobramycin powder (7.5% (95% CrI 1.0 to 35.3)). Conclusion. Cumulative doses of vancomycin were not associated with an increased risk of drug-induced AKI among fracture patients. While the risk of drug-induced AKI remains less than 4% with three or fewer 1.2 g tobramycin doses, the estimated risk increases substantially to 8% after four cumulative doses. Level of evidence: Therapeutic Level III. Cite this article: Bone Jt Open 2022;3(4):284–290

INTRO. Two-stage revision arthroplasty for PJI may make use of an antibiotic-loaded cement spacer (ACS), as successful long- term prevention of reinfection have been reported using this technique.[i] However, there is little data on systemic complications of high-dose antibiotic spacers. Acute kidney injury (AKI) is of clinical significance, as the drugs most commonly utilized, vancomycin and aminoglycosides, can be nephrotoxic. We intended to determine the incidence of AKI in patients that underwent staged revision arthroplasty with an ACS, as well as to identify potential predisposing risk factors for the disease. METHODS. Local databases of six different orthopaedic surgeons were retrospectively reviewed for insertion of either a static or articulating antibiotic cement spacer by from 2007–2017. Dose of antibiotic powder implanted, as well as IV antibiotic used, was collected from operative records. Demographics, comorbidities, and preoperative and postoperative creatinine and hemoglobin values were recorded from the EHR. AKI was defined by a more than 50% rise in serum creatinine from preoperative baseline to at least 1.4 mg/dL, as described by Menge et al.[ii] Variables were analyzed for the primary outcome of AKI within the same hospital stay as insertion of the ACS. Categorical variables were analyzed with Chi-Square test, and continuous variables with univariate logistic regression. RESULTS. 75 patients (39 M, 36 F) receiving an ACS were identified, with a mean age of 70.0 (SD=10.6) and a mean BMI of 31.3 (SD=7.3). Incidence of in-hospital AKI was 13.3%. Patients reached AKI at a mean 6.7 days (SD=4.5), during a median length of stay of 13.5 days (IQR=21.8). No significant correlation was found between AKI and the variables of age (p=.430), BMI (p=.569) or gender (p=.181). AKI was also not associated with increased dose of vancomycin (p=.416), tobramycin (p=.440), or gentamycin (p=.846) within the cement spacer, or the comorbidities of hypertension (p=.094), diabetes (p=.146), coronary artery disease (p=1.00) and renal disease (p=.521). However, decreased baseline hemoglobin showed significantly increased risk for AKI (OR=1.67, p =.049), and increased creatinine showed a trend (OR=2.9, p=.059). Percentage of hemoglobin decrease (preoperative to postoperative) did not increase odds for AKI (p=.700). CONCLUSION. The incidence of acute kidney injury in patients that receive antibiotic cement spacers is relatively high when compared to the data reported in primary TKA. ii,[iii]. Our results suggest that patient related risk factors, such as low preoperative hemoglobin, may be involved in the etiology of AKI in this population. Therefore, it may be clinically appropriate to monitor anemic patients for AKI when implanting an ACS

In September 2011 our departmental protocol for peri-operative prophylactic antibiotic administration was altered from cefuroxime to gentamicin/flucloxacillin, in response to reported links between cephalosporin use and Clostridium difficile (C. diff) infection. As both gentamicin and flucloxacillin are known to be nephrotoxic in some patients, we investigated whether the new regimen increases the risk of Acute Kidney Injury (AKI) in patients undergoing elective and trauma hip and knee surgery, classified by severity (AKI Network criteria). The incidence of C. diff was noted. 10 out of 202 (5%) patients receiving cefuroxime (group A) developed AKI, compared with 23 of 210 (11%) patients receiving gentamicin and flucloxacillin (group B) (p=0.012). The severity of the renal injury was higher in the group B patients with 16 sustaining stage II/III AKI, whereas in Group A only one patient sustained a stage II injury and none stage III. The increased AKI rate in group B was observed equally in hip fracture patients and elective hip/knee replacement patients. However, 3 of 80 (4%) patients with hip fractures who received doses of cefuroxime developed C. diff, with none in the other groups (p=0.04). The choice of prophylactic antibiotics depends on a careful assessment of benefits and risks. Our data suggests that whereas hip fracture patients may have benefitted from the protocol change with reduced C. diff incidence, elective hip and knee replacement patients sustained additional harm. Different antibiotic regimens may be appropriate for these two groups

Background. Post-operative acute kidney injury is significant complication following surgery. Patients who develop AKI have an increased risk for progression into chronic kidney disease, end-stage renal failure and increased mortality risk. The patient outcomes following total knee replacement (TKR), who develop AKI has been a topic of interest in recent years as it may have patient and medicolegal implications. Nevertheless, there are no studies looking at the incidence, risk factors and outcomes of AKI following bilateral TKRs at the same sitting. Objectives. To determine the incidence, risk factors and outcomes of post-operative AKI following bilateral TKRs surgery at the same sitting. Methods. This was a retrospective single-centre study performed at the Princess Royal Hospital, which performed a total of 25 BTKR. The incidence, Surgical and patient risk factors were recorded and analysed. Results. The incidence of AKI as defined by NICE guidelines following bilateral TKRs was 20%. 16% (4 patients) had stage 1 and 4% (1 patient) had stage 2 AKI. The mean change in Creatinine between pre- and post-operative blood tests was +19μmol/L. There was a strong significant correlation between CKD and AKI (r=0.75, P<0.05). Furthermore, a moderate correlation was found between higher BMI and pre-operative Charlson index and AKI. AKI did not have an effect on the length of inpatient stay with the mean inpatient length of stay for patients who had an AKI of 10 days compared to 11days for those who did not. All AKIs were resolved within 72 hours. There were no associated mortalities with AKI. Conclusion. The incidence of AKI following bilateral TKR was 20%. Pre-operative chronic kidney disease as well as having a higher BMI were identified as risk factors for developing AKI. Pre-operative CKD optimisation and careful adequate hydration intra-operatively should be considered in these patients. AKI was not associated with an increased length of stay or mortality in our study

In late 2011 there was a change in antimicrobial policy in orthopaedic surgery to reduce the Clostridium difficile (C. diff) rate, this was inducted top down from government, to PCT, to hospital trust. The previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change it was noticed an increased number of patients appeared to suffer from acute kidney injury (AKI). This led us to evaluate the incidence of AKI pre and post antibiotic change and look at the causes behind this. In this retrospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data pulled. The degree of AKI was classified according to the validated RIFILE criteria. Evaluation showed 2–4 fold increase in AKI since antibiotic change. Although mortality was decreased in these patients, the incidence of AKI had increased significantly. However, C. difficile has been obliterated by this change. The investigation highlights potential problems with increased rates of AKI amongst NOF patients, since antibiotic change. Flucloxacillin may have significant impact on this patient group. Dose dependent antibiotics will now be given based on weight and eGFR. Further analysis of this new change needs to be evaluated

In 2011 health policy dictated a reduction in iatrogenic infections, such as Clostridium difficile (C. diff), this resulted in local change to antimicrobial policy in orthopaedic surgery. Previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change an increased number of patients appeared to suffer from acute kidney injury (AKI). We initially evaluated the incidence of AKI pre and post antibiotic change and found a correlation between the Flucloxacillin and AKI. We then made changes to antibiotic policy to mitigate the increased rates of AKI and proceeded to evaluate the outcomes. In this prospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data obtained. The degree of AKI was classified according to the validated RIFILE criteria. Evaluation showed a 4 fold decrease, from 13% to only 3%, in AKI after introduction of the modified antibiotic policy. C.difficile continues to be non-existent since this change. Flucloxacillin obviously had a significant impact on this patient group. However, we have shown that with appropriate changes to antibiotic policy AKI associated morbidity can be significantly reduced. Dose dependent antibiotics will now be given based on weight and eGFR

ERAS (Enhanced recovery after surgery) programs have been widely adopted in elective orthopaedic practice. Early discontinuation of Intravenous (IV) fluids in order to promote mobilisation and subsequent discharge is a key feature of such programs. However concerns have been raised regarding whether such an approach results in an increased risk of acute kidney injury (AKI). We set out to determine the incidence of AKI in patients undergoing hip or knee arthroplasty treated as part of an ERAS program where IV fluids are removed before leaving the recovery room. Investigate whether there is a difference in incidence between patients with a pre-operative eGFR ≥ 60 or < 60 (ml/min/1.73m2). In addition to whether patients who sustain an AKI have a longer post-operative hospital stay. The pre and post-operative blood results of patients undergoing elective total hip and total knee replacements were retrospectively analysed to determine whether they had suffered an AKI during admission. The patient's notes were reviewed for other known causes of peri-operative AKI and the length of their hospital stay. The overall Incidence of AKI was 9.4%. There was a significant association found between pre-operative eGFR and development of an AKI p = 0.002. The incidence of AKI was 5.8% in patients with a pre-operative eGFR ≥ 60 vs 33.3% in those with an eGFR < 60. The development of an AKI was associated with a longer hospital stay p = 0.042. The median length of hospital stay was 7 days for those who suffered an AKI vs 5 days for those who did not. Patients undergoing elective lower limb arthroplasty with a pre-operative eGFR < 60 treated as part of an ERAS program where fluids are discontinued before leaving the recovery room are at high risk of developing an AKI. Further studies are required to ascertain whether a longer duration of IV fluids is effective in reducing the incidence of AKI in this group

Introduction

Renal impairment following major surgery is a formidable complication. There is recent evidence suggesting increasing risk of progression to chronic kidney disease and mortality after transient renal impairment. We aimed to evaluate the impact of pre-operative comorbidities on long-term outcomes of renal-function following hip arthroplasty.

Introduction

Patients with solid organ transplant have been shown to have increased risk of complications following TKA compared to non-transplant patients. The risk of AKI in KTx is reported to be as high as 15.6 % and associated with increased morbidity, and length of stay (LOS). Our aim was to determine the incidence of AKI in KTx undergoing primary and revision TKA and to identify risk factors for its occurrence and its effect on allograft function 1 year postoperatively.

Aims. We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). Methods. This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na. +. ), potassium (K. +. ), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported. Results. The study included 2,721 patients with a mean age of 69 years, of whom 1,266 (46.6%) were male. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥ 65 years), female sex, and ASA grade ≥ III as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dl) and packed cell volume (≤ 0.395 l/l) were noted to be significant risk factors for postoperative anaemia, and potassium (≤ 3.7 mmol/l) was noted to be a significant risk factor for AKI. Conclusion. The costs outweigh the benefits of ordering routine postoperative blood tests in TJR patients. Clinicians should risk-stratify their patients and have a lower threshold for ordering blood tests in patients with abnormal preoperative haemoglobin (≤ 127 g/l), blood loss > 300 ml, chronic kidney disease, ASA grade ≥ III, and clinical concern. Cite this article: Bone Jt Open 2023;4(11):899–905

Aims. This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year. Methods. A single-centre retrospective cohort study was performed at an acute NHS Trust. Hip and distal femur fracture patients admitted within the first month from each of the three starting dates of each national lockdown were included and compared to a control group in March 2019. Data were collected as per the best practice tariff outcomes including additional outcomes as required. Data collection included COVID-19 status, time to theatre, 30-day mortality, presence of acute kidney injury (AKI) and pneumonia, and do not attempt cardiopulmonary resuscitation (DNACPR) status. Data were analyzed using an independent-samples t-test or chi-squared test with Fisher’s exact test where applicable. A p-value of < 0.05 was considered statistically significant. Results. A total of 95 patients during the pandemic were included and 20 were COVID-positive. Patients experienced a statistically significant increase in time to theatre in Lockdown 1 compared to 2019 (p = 0.039) with a decrease with successive lockdown periods by Lockdown 3. The 30-day mortality increased from 8.8% in 2019 to 10.0% to 14.8% in all lockdown periods. COVID-positive patient mortality was 30.0% (p = 0.063, odds ratio (OR) = 4.43 vs 2019). The rates of AKI and pneumonia experienced were higher for patients during the pandemic. The highest rates were experienced in COVID-positive patients, with 45.0% of patients with AKI versus 27.0% in 2019 (p = 0.38, OR = 1.80), and 50.0% of patients diagnosed with pneumonia versus 16.2% in 2019 (p = 0.0012, OR = 5.17). The percentage of patients with a DNACPR increased from 30.0% in 2019 to 60.7% by Lockdown 3 (p = 0.034, OR = 3.61). Conclusion. COVID-positive hip and distal femur fracture patients are at a higher risk of mortality due to AKI and pneumonia. Patient outcomes have improved with successive lockdowns to pre-pandemic levels. Cite this article: Bone Jt Open 2021;2(12):1017–1026

Aims. The efficacy and safety of intrawound vancomycin for preventing surgical site infection in primary hip and knee arthroplasty is uncertain. Methods. A systematic review of the literature was conducted, indexed from inception to March 2020 in PubMed, Web of Science, Cochrane Library, Embase, and Google Scholar databases. All studies evaluating the efficacy and/or safety of intrawound vancomycin in patients who underwent primary hip and knee arthroplasty were included. Incidence of periprosthetic joint infection (PJI), superficial infection, aseptic wound complications, acute kidney injury, anaphylactic reaction, and ototoxicity were meta-analyzed. Results were reported as odds ratios (ORs) and 95% confidence intervals (CIs). The quality of included studies was assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) assessment tool. Results. Nine studies involving 4,607 patients were included. Intrawound vancomycin was associated with lower incidence of PJI (30 patients (1.20%) vs 58 control patients (2.75%); OR 0.44, 95% CI 0.28 to 0.69) and simultaneous acute kidney injury (four patients (0.28%) vs four control patients (0.35%), OR 0.71, 95% CI 0.19 to 2.55). However, it did not reduce risk of superficial infection (four patients (0.67%) vs six control patients (1.60%), OR 0.60, 95% CI 0.17 to 2.12) and was associated with higher incidence of aseptic wound complications (23 patients (2.15%) vs eight in control patients (0.96%), OR 2.39, 95% CI 1.09 to 5.23). Four studies reported no anaphylactic reactions and three studies reported no ototoxicity in any patient group. Conclusion. The current literature suggests that intrawound vancomycin used in primary hip and knee arthroplasty may reduce incidence of PJI, but it may also increase risk of aseptic wound complications. Cite this article: Bone Joint Res 2020;9(11):778–788

Aims. Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients. Methods. All NOF fracture patients presenting between March 2020 and May 2020 were included. Patients were divided into two subgroup: those with or without clinical and/or laboratory diagnosis of COVID-19. Data were collected on patient demographics, pattern of injury, complications, length of stay, and mortality. Results. Overall, 132 patients were included. Of these, 34.8% (n = 46) were diagnosed with COVID-19. Bacterial pneumonia was observed at a significantly higher rate in those patients with COVID-19 (56.5% vs 15.1%; p =< 0.000). Non respiratory complications such as acute kidney injury (30.4% vs 9.3%; p =0.002) and urinary tract infection (10.9% vs 3.5%; p =0.126) were also more common in those patients with COVID-19. Length of stay was increased by a median of 21.5 days in patients diagnosed with COVID-19 (p < 0.000). 30-day mortality was significantly higher in patients with COVID-19 (37.0%) when compared to those without (10.5%; p <0.000). Conclusion. This study has shown that patients with a neck of femur fracture have a high rate of mortality and complications such as bacterial pneumonia and acute kidney injury when diagnosed with COVID-19 within the perioperative period. We have demonstrated the high risk of in hospital transmission of COVID-19 and the association between the infection and an increased length of stay for the patients affected. Cite this article: Bone Joint Open 2020;1-11:669–675

Abstract. Introduction. It is common practice for all patients to have postoperative bloods tests after total knee arthroplasty (TKA). However there have been significant improvement in perioperative care with arthroplasty surgery. As healthcare systems and providers strive towards a more efficient service we must re-consider whether such an intervention is necessary for all patients. Methodology. This retrospective study included all patients who underwent a primary unilateral TKA at a single tertiary arthroplasty centre during a 1 year period. Electronic medical records of 776 patients were reviewed for patient demographics, length of stay and American Society of Anaesthesiologists grade. Blood tests were examined to investigate the incidence of post operative anaemia requiring transfusion, electrolyte abnormalities that required treatment and the incidence of acute kidney injury. Results. Average length of stay in hospital was 4.3 days. Pre-operative (R=-0.22) & post-operative haemoglobin (R=0.2) levels were both negatively correlated with length of stay (p<0.01). There was 1 patient that required a blood transfusion post operatively due to symptomatic anaemia. This patient underwent a complex primary TKA. Significant abnormal post-operative electrolyte levels were found in 100 (12.9%) of patients. 87 of these patients either had abnormal electrolyte levels pre-operatively or were taking a medication that causes the electrolyte abnormality. Medical treatment for abnormal electrolyte levels was required in 32 (4.1%) of all patients. The incidence of acute kidney injury was 4.4%. Conclusion. Routine blood tests after primary total knee arthroplasty is unnecessary for most patients. Blood tests should only be performed in those with identifiable risk factors