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Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_23 | Pages 29 - 29
1 Dec 2016
Parker S Davies L Sanders-Crook L Key T Roberts G Hughes H White S
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Aim. Peri-prosthetic joint infection is a serious and expensive complication of joint arthroplasty. Theatre discipline has infection prevention at its core with multiple studies correlating increased door opening with surgical site infection. The WHO, NICE and Philadelphia Consensus all advocate minimal theatre traffic. The Dutch Health Inspectorate consider >5 door openings per procedure excessive. Method. This prospective observational study over five weeks observed theatre door traffic during hip and knee arthroplasty within the eight laminar flow theatres at our institution. Two students attached to the department collected data. Half way through the study notices reminding people not to enter during arthroplasty were placed on the theatre doors. Results. The students observed 59 knees or hip arthroplasty 32 prior to notice's being placed on the theatre doors. The average number of door openings per case was 67 (25–130) prior to intervention and 70 (34–158) after intervention, although opening rates reduced from 1/min to 0.9/min (p=0.053). Reasons for door opening were drawing up medications, blood tests, delivery surgical equipment, general enquiries, staff breaks and “unknown” entries and exits. Conclusions. The rate of door opening was excessive and remained so after reminders were displayed. This deterioration in theatre discipline potentially has a significant negative impact on theatre hygiene and infection control. Individually wrapped components and screws along with the increasing component choice may have played some role in ‘legitimizing’ door opening. It will be challenging to reverse this behavioural trend but must be achieved


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 42 - 42
1 Apr 2012
Stenning M Hilton A
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It was noted that in our spinal theatre a constant cause of delay was lack of an available radiographer. This work describes our solution to this problem by training theatre staff to operate the imaging equipment for the simple single plane images required in spinal surgery. Under the guidance of the trust's Radiation Protection Advisor to a training program for theatre staff was devised that encompassed the practical aspects of using the imaging equipment and the theoretical elements of radiation safety. All changes in practice complied with the radiation safety regulations IRR 99 and IRMER 2000. The trained staff now work as independent operators in the spinal theatre. They work to a ridge protocol and have to report directly to a Radiation Protection Supervisor (senior radiographer) at the end of each list so that the images taken and radiation dosage can be verified. Since the change of practice, the spinal theatre has been more efficient, performing up to one major case extra per list. The radiology department has benefited by having a radiographer freed to perform more complex procedures elsewhere. The operators have also commented on how they have found the whole process rewarding both professionally and personally. The training of theatre staff to operate the imaging equipment in our spinal theatre has been a successful endeavour and at present the trust is currently planning to expand the program to include other surgical fields such as urology and laparoscopic surgery


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_14 | Pages 40 - 40
1 Mar 2013
Kanyemba S Mjuza A
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Purpose of Study. Discecomy is a common operation peformed for back pain at our hospital. We analysed the theatre register looking at demographic and health data for our patients to shed more light on this cases. Description of Methods. Entries in the spinal unit theatre registers from 2000–2012 were reviewed, and all patients undergoing discectomy for disc herniation recorded analysed regarding demographics and epidemiology. Summary Of Results. A total of 171 patients had operations in our theatres. Of these patients the large majority were females. The age distribution was 45 to 50 years. The lumbar spine was the commonest region operated, especially the lower lumbar spine. We had very low repeat operations from failed surgery or requiring herniation. Conclusion. Surgical registers are an important tool in understanding pathology in the communities we serve. We can track the type of patients treated and then plan appropriate intervention programmes. It also helps to follow-up patients and correlate outcomes, and we can use this data to correlate practices nationally and internationally. NO DISCLOSURES


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 205 - 205
1 Mar 2010
Rackham M Sutherland L Mintz A Cain C Cundy P
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We report the frequency of door-opening (“theatre traffic”) in orthopaedic operations at three metropolitan hospitals with different theatre policies. Published studies have correlated “theatre traffic” with airborne bacteria levels, which have been associated with raised wound infection rates. Hospital A had one scoliosis operation and two hip replacements, Hospital B had one knee revision and one knee replacement. Hospital C had one scoliosis operation. A second scoliosis operation was performed at Hospital C after “theatre traffic” education and door signage discouraging entry. One pair of surgeons performed the scoliosis operations and a different pair did the hips and knees. Hospital A is private and Hospitals B and C are public. The scoliosis operation in Hospital A (private) had an average door opening rate of 0.45/min compared to the same operation in Hospital C (public) with an average door opening rate of 1.0/min. The two hip replacements in Hospital A (private) had an average rate of 0.43/min and 0.51/min while the knee revision and knee replacement in Hospital B (public) had average rates of 0.91/min and 0.77/min respectively. Of concern is the total number of door openings that result from this rate of “theatre traffic”. In the Hospital C (public) operation the total number of door openings equalled 140 over the course of the scoliosis operation. In Hospital B the total number of door openings for the knee revision was 169 and the knee replacement was 72. In contrast, for Hospital A (private) the total number of door openings for the scoliosis operation was 73 and the two hip replacements equalled 30 and 36. The second study at Hospital C after staff education revealed a 35% decrease to 0.65/min. There was a difference in “theatre traffic” between private and public hospitals for the same or similar operations. Staff education and door signage dramatically reduced “theatre traffic” in Hospital C. Surgeons and theatre staff need to be aware of “theatre traffic” and its influence on infection rates


Bone & Joint Open
Vol. 2, Issue 10 | Pages 886 - 892
25 Oct 2021
Jeyaseelan L Sedgwick P El-Daly I Tahmassebi R Pearse M Bhattacharya R Trompeter AJ Bates P

Aims. As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. Methods. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. Results. In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). Conclusion. Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886–892


Bone & Joint Open
Vol. 5, Issue 6 | Pages 452 - 456
1 Jun 2024
Kennedy JW Rooney EJ Ryan PJ Siva S Kennedy MJ Wheelwright B Young D Meek RMD

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_5 | Pages 2 - 2
13 Mar 2023
Hoban K Yacoub L Bidwai R Sadiq Z Cairns D Jariwala A
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The COVID-19 pandemic presented a significant impact on orthopaedic surgical operating. This multi-centre study aimed to ascertain what factors contributed to delays to theatre in patients with shoulder and elbow trauma. A retrospective cohort study of 621 upper limb (shoulder and elbow) trauma patients between 16/03/2020 and 16/09/2021 (18-months) was extracted from trauma lists in NHS Tayside, Highland and Grampian and Picture Archiving and Communication Systems (PACS). Median patient age =51 years (range 2-98), 298 (48%) were male and 323 (52%) female. The commonest operation was olecranon open reduction internal fixation (ORIF) 106/621 cases (17.1%), followed by distal humerus ORIF − 63/621 (10.1%). Median time to surgery was 2 days (range 0-263). 281/621 (45.2%) of patients underwent surgical intervention within 0-1 days and 555/621 patients (89.9%) had an operation within 14 days of sustaining their injury. 66/621 (10.6%) patients waited >14 days for surgery. There were 325/621 (52.3%) patients with documented evidence of delay to surgery; of these 55.6% (181/325) were due to amendable causes. 66/325 (20.3%) of these patients suffered complications; the most common being post-operative stiffness in 48.6% of cases (n=32/66). To our knowledge, this is the first study to specifically explore effect of COVID-19 pandemic on upper limb trauma patients. We suggest delays to theatre may have contributed to higher rates of post-operative stiffness and require more physiotherapy during the rehabilitation phase. In future pandemic planning, we propose dedicated upper-limb trauma lists to prevent delays to theatre and optimise patients’ post-operative outcomes


Bone & Joint Open
Vol. 1, Issue 8 | Pages 494 - 499
18 Aug 2020
Karia M Gupta V Zahra W Dixon J Tayton E

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_19 | Pages 11 - 11
1 Nov 2017
Nicholson J Yapp L Dunstan E
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Increasing demands on our emergency department (ED) has resulted in the reduction of manipulations (MUAs) at the ‘front door’. We hypothesised that MUAs undertaken in theatre is rising with adverse financial implications. We performed a retrospective audit of operating lists in our institution from 2013–2016. Cost estimates were determined by our finance department. We used the NICE guidelines on management of non-complex fractures (NG38 Feb2016) as our audit standard. Data on 1372 cases performed over a three-month representative period during 2013–2016 was analysed. MUAs were 13% of the total theatre workload, with an annual increase in volume noted. Additionally, simple displaced distal radius fractures were routinely receiving a MUA (with or without K-wires) as a primary procedure in theatre. When this workload is combined it makes up 22% of the total theatre workload. Average theatre time was 57 minutes per case. Delays to definite procedure ranged from 8 to 120 hours. Cost of hospital admission and theatre utilisation was approximately £1000 per patient. Conversely, the cost of a MUA in the ED was estimated at £150. Given that we currently undertake around 15 manipulations in theatre a month, performing such work in the ED it would save approximately £153,000 a year to our health board. This audit identifies that MUAs of common orthopaedic injuries undertaken in theatre can lead too significant clinical and financial costs. We have proposed a strong financial argument to management for a twice weekly ‘manipulation list’ in the ED which is currently under review


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_4 | Pages 8 - 8
1 Mar 2021
To K Bartlett J Lawrence J
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Various studies have demonstrated that the necessity for reversal of Warfarin through the use of Vitamin K (Vit K) in neck of femur fracture patients introduces increased duration of stay and poorer outcomes as measured by operative complications and mortality rate. One reason for this delay may be the time latency between admission and the clinicians decision to investigate the INR. In this study we aim to explore the different causes of latency which contribute to a delay to theatre and ascertain whether point of care testing may negate this. We carried out an audit of a cohort of neck of femur fracture patients between 2012 and 2015. Between September 2011 and September 2013, paper notes of 25 patients who were on warfarin at the time of sustaining a Neck of femur fracture (NOF) was obtained within Addenbrookes hospital archives. An additional 80 patients records from the year 2015 were retrieved from EPIC digital records. Time intervals were recorded as follows (from time of A&E assessment by Medical doctor); Interval to orthopaedic specialist assessment, Interval to first INR order, Interval to first INR result seen by specialist, Interval to first Vit K prescribed, Interval to first Vit K given, Interval to Second INR ordered, Interval to second INR seen by specialist, Interval to operation time (as determined by time of team briefing). Analysis of the time intervals as a proportion of total time elapsed between A&E assessment and Time to theatre was performed. Point of care (POC) testing of INR on admission to A&E was introduced and a symmetrical time period was analysed for the same intervals. The latency generated by time taken for a NOF to be assessed by an orthopaedic specialist occupied 8.60% of the total time, the interval between ordering and recording an INR value accounted for 7.96% of time to theatre, the interval between an INR being recorded and subsequently seen by a clinician accounted for 13.4% of time to theatre, the time between orthopaedic specialist assessment and prescription of Vit K took up 7.83% of the total time and the percentage time between Vit K prescription and administration was 12.3%. The time between the first dose of Vit K prescription and arriving at theatre accounted for 76.1% of latency and the time between viewing a second INR and time to theatre occupied 33% of the total time. Following introduction of POC INR testing, there was a statistically significant decrease in time taken for warfarin reversal and consequently a reduction between time of admission to time to theatres. NOF patients who are on warfarin at time of injury introduces complexity to surgical management and planning for theatre. In our audit we demonstrate that causes of delay are distributed throughout the pathway of care and there are several stages. POC INR testing represents an effective method of reducing this latency and improves patient outcome


In patients with hand sepsis does bedside debridement compared to operating theatre debridement have similar clinical outcomes, hospital cost and time to discharge in a District Hospital setting in South Africa?. A case series of 130 adult patients presenting to a district level orthopaedic unit over 1 year with hand sepsis requiring debridement. All included patients were debrided at the bedside (i.e. the emergency room, ward, OPD) under wrist or digital block. Patients excluded from the study included patients with necrotising soft tissue infections that required debridement in theatre. A cost analysis was done based on operating theatre (OT) costs saved as defined by Samuel1 et al. If an average theatre time of 45 min is taken then the cost saved per patient is approximately R1500 and approximately R300000 for the patients included in the case series. This excludes ward and other hospital costs related to a longer hospital admission. The mean time to discharge for the included patients was 24 hours. This study suggests that bedside debridement can be a viable and cost effective option for selected cases of hand sepsis that can avoid the high cost and time associated with operating theatre debridement with similar outcomes. This has implications for the future treatment of hand sepsis in resource constrained settings were operating theatre time is not only very expensive but also very scarce


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_16 | Pages 15 - 15
1 Oct 2017
Lawrence O Moideen AN Topliss C
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Patients who present with a fractured neck of femur (NOF) have a significant rate of morbidity and mortality. In 2011, the National Institute for Health and Care Excellence (NICE) published clinical guidelines in order to improve these rates. Within this guideline NICE state that surgery should be performed on all NOF fractures within 36 hours. Within ABMU Health board the 1000 Lives Campaign goes a step further and aims to operate on 90% of patients within 24 hours. This study investigates the effect of an additional NOF theatre list on compliance to these national guidelines. This retrospective study was performed between October-December 2013 and December-February 2015. The first period of data collection represents a daily trauma list whilst the second period allowed an additional NOF theatre list. Data was collected using the National Hip Fracture Database and the Trauma Theatre List. The number of patients meeting the national guidelines increased with the presence of an additional theatre list (75.19% v 60%). This represents a reduction to the average time to theatre of 4 hours and 30 minutes (29:47 v 34:17). The additional theatre list improved prioritisation of patients with NOF fractures on the list (29.46% v 13.33% listed first on list) and reduced the rate of cancellations (19.38 v 29.17%). During this study Morriston Hospital did not meet national guidelines, however an additional theatre list did significantly improve average time to theatre. This study highlights the significant impact a dedicated NOF fracture theatre list can have. Winner – Best Paper Award


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_9 | Pages 50 - 50
1 May 2017
Roberton A Patel N Hockings M
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Background. Best practice tariff (BPT) for hip fracture was introduced in April 2010, offering financial incentive to encourage trusts to implement best practice and improve quality of care. This equates to £1335. An early indicator of a patient's outcome is the time to operation from admission, with best practice targets of <36hours as a key marker of quality. As well as being detrimental to patient experience, delays in the time to operation have clear links to increased mortality rates. Method. We performed a retrospective audit of neck of femur fracture patients from 01.01.14 for 12 months, investigating time to theatre, other BPT targets, and attainment of BPT. A cost analysis was also performed from financial data. Results. Of 471 patients, 461 operations were performed. Our median time to surgery was 24.9 hours. 140 (30%) of patients were not operated on within 36 hours. 134 of these (96%) would have met the BPT had they been operated on within the 36 hour target i.e. all other BPT targets were met. This equates to a loss of £178,890. Conclusions. We achieved time to theatre target for 70% of patients (compared to 71.7% reported nationally), which is suboptimal. A solution is to dedicate more theatre time to hip fractures on theatre lists or lengthened daily trauma lists. However, at £1200 per hour running theatre, this on its own would not be cost effective. Improved theatre utilisation by 10% can potentially save the trust £3,960,000 in a year. We have put forward plans to audit our current theatre usage, potentially improving utilisation and efficiency (e.g. planned hip fracture first on list from previous day to avoid start delay). Additionally we have introduced a “Time of breach” onto our trauma board to concentrate attention on this part of best practice. Level of Evidence. Level 3


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_12 | Pages 17 - 17
1 Jun 2017
Bloch B Shah A Snape S Boswell T James P
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Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in a temporary operating theatre. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates. A total of 1233 primary hip and knee arthroplasties were performed between August 2012 and June 2013. 44% were performed in temporary theatres. The two groups were matched for age, sex, BMI and ASA grade. The deep infection rate for standard operating theatres was 0/684 (0%); for temporary theatres it was 8/539 (1.5%); p=0.001. Use of a temporary operating theatre for primary hip and knee arthroplasty was associated with an unacceptable increase in deep infection. We do not advocate the use of these theatres for primary joint arthroplasty


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XII | Pages 10 - 10
1 Apr 2012
Riley T Mounsey E Blake S
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It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice. During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for. Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list. Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_32 | Pages 9 - 9
1 Sep 2013
Gill D Bullen N Hill M Metcalfe J
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The WHO surgical safety checklist was introduced at Derriford Hospital in 2009. Evidence of the effect on efficiency has been slow to appear in the literature. Using a standardised, locally modified WHO surgical safety checklist theatre list capacity, start and finish times as well as time between cases was measured in 4 elective orthopaedic theatres. Data from 3 successive years was analysed retrospectively: prior to checklist introduction, during checklist introduction and routine checklist use. Data was analysed using the One-Way ANOVA with post-hoc Tukey test. The number of cases per list showed a statistical difference from Year 1–2 and this increase was sustained in Year 3. The number of delayed starts showed no difference between Year 1&2, followed by a statistically significant decrease in Year 3. The number of late finishes showed a statistical difference from Year 1–2 and this decrease was sustained in Year 3. However, the number of lost minutes between cases showed no difference between Year 1&2, followed by an increase in Year 3. This study demonstrates that pre-list briefings combined with the WHO surgical checklist can improve theatre list capacity and prompt starts, reduce the number of overruns, however fails to improve turnaround time between cases


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_9 | Pages 35 - 35
1 May 2018
Thomas A Wijesinghe C Pralyadi R Alberini F Simmons M
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Introduction. Operating theatre airflow can be measured using pulsed lasers (particle image velocimetry) but the process is difficult to do in 3D. Cup, vane or hot wire anemometers provide only 2D information. 3D measurements enable better understanding of airflow. Patients/Materials & Methods. We used a Windmaster ultrasound 3D anemometer (Skyview systems), which uses three ultrasound transmitters to measure velocity in XYZ planes, with a sampling rate of 32 Hz. Post processing was done using MATLAB. An operating theatre with an Howorth Exflow canopy was studied. Equipment, including lights, was moved. A 50 cm grid was marked, and measurements were made at intervals up to the ceiling. Door opening was observed within the clean zone and the peripheral zone, next to the door and on the opposite side of the room. Anaesthetic screens were studied during operating. Airflow was visualised initially using video of smoke puffs and subsequently measured using the aeronometer. Results. In the upper part of the ultraclean canopy air velocity was 0.34 m/s with a standard deviation of 0.02 m/s, indicating an almost constant velocity. In the periphery there was more turbulence and horizontal air movement. Door opening had no effect on air movements in the clean zone. In the periphery there was an increase in horizontal airflow when the doors are closed. There is a pattern of upward airflow against an anaesthetic screen. This is unlikely to be caused by warming blankets. If the partial wall of the enclosure is lowered this results in a fast washout of air towards the anaesthetist. Discussion. Traditional anaesthetic screens may interfere with airflow. Door opening is a lesser effect. Conclusion. The 3D anemometer enables detailed mapping of airflow within an ultra clean air operating theatre. The data obtained will enable the construction of more accurate computational fluid dynamic models of operating theatres


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_23 | Pages 36 - 36
1 Dec 2016
Fazekas J Shirley R Mcnally M Ramsden A
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Aim. This study aimed to define the increased costs incurred by a return to theatre for cases requiring free tissue transfer for surgical treatment of chronic osteomyelitis. We hypothesised that there would be a significantly greater cost when patients required re-exploration of the free flap. Method. We retrospectively analysed the costs of a consecutive series of sixty patient episodes treated at the Bone Infection Unit in Oxford from 2012 to 2015. Treatment involved excision of osteomyelitis with free tissue transfer for immediate soft tissue cover. We compared the costs of uncomplicated cases with those who returned to theatre and determined the profit/loss for the hospital from remuneration through the UK National Health Service Tariff Structure. Results. Hospital income according to UK HRG tariff was compared to the actual cost of treatment and these 60 cases were significantly underfunded overall (P < 0.005). In just 1 case, the cost to the hospital was completely covered by tariff. Six patients (10%) returned to theatre for urgent flap re-exploration with five flaps salvaged and one failed, requiring another free flap reconstruction (1.7%). These six patient episodes had a significantly higher mean cost compared to the uncomplicated cases. The average financial loss to the hospital for patients who did return to theatre was £18992 (range £8103 to £48380) and in those who did not was £9600 (range – £600 to £23717). The case requiring further free tissue transfer cost a total of £74158, £48380 more than the hospital was paid: the most extreme discrepancy. The overall loss for this group of 60 patients was £590766. Conclusions. Surgery for chronic osteomyelitis is multidisciplinary, complex and therefore expensive. However, this study demonstrates that the hospital currently makes a financial loss on almost all patients but especially if flap complications occur. This study has implications for the long term viability of specialist units treating this important disease


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_10 | Pages 51 - 51
1 Oct 2019
Andrew S Abdelmonem M Kohli S Dabke H
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Background. Various studies have highlighted issues regarding the prevalence of back pain due to lead apron use. The health and safety executive guidelines on personal protection equipment state that an employee should be able to carry the weight of a lead apron without injury (HSE, 2017). It has been suggested that wearing a 15 pound lead apron can place pressures of up to 300 pounds per square inch of the intervertebral discs (Khalil, 1993), ‘interventionalist's disc disease’ has been identified as a confirmed entity (Ross et al. 1997). Aim. To evaluate the prevalence of back pain amongst theatre staff and correlate this to lead apron use. Methods. Data collection (November 2018 – February 2019) involved the distribution of questionnaires to staff using lead aprons on a routine basis at Salisbury District Hospital. Results. A total of 59 members of staff responded to the questionnaire. The results showed that 30% staff had a previous history of back pain, of these 61% felt that their back pain had worsened since wearing lead aprons. 46% of staff who did not have any previous history of back pain developed new back pain since wearing lead aprons. A total of 46% of staff feel that their back pain has been exacerbated or caused by lead apron wearing. Conclusion. The study highlights that a significant proportion of staff had new or worsening back pain due to lead apron use. This can lead to time off work and could lead to unsafe practice around ionising radiation. No Conflicts of interest No funding obtained


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_16 | Pages 10 - 10
1 Oct 2014
Richter P Schicho A Gebhard F
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Minimally invasive placement of iliosacral screws (SI-screw) is becoming the standard surgical procedure for sacrum fractures. Computer navigation seems to increase screw accuracy and reduce intraoperative radiation compared to conventional radiographic placement. In 2012 an interdisciplinary hybrid operating theatre was installed at the University of Ulm. A floor-based robotic flat panel 3D c-arm (Artis zeego, Siemens, Germany) is linked to a navigation system (BrainLab Curve, BrainLab, Germany). With a single intraoperative 3D scan the whole pelvis can be visualised in CT-like quality. The aim of this study was to analyse the accuracy of SI-screws using this hybrid operating theater. 32 SI-screws (30 patients) were included in this study. Indications ranged from bone tumour resection with consecutive stabilisation to pelvic ring fractures. All screws were implanted using the hybrid operating theatre at the University of Ulm. We analysed the intraoperative 3D scan or postoperative computed tomography and classified the grade of perforation of the screws in the neural foramina and the grade of deviation of the screws to the cranial S1 endplate according to Smith et al. Grade 0 stands for no perforation and a deviation of less than 5 °. Grade 1 implies a perforation of less than 2 mm and a deviation of 5–10°, grade 2 a perforation of 2–4 mm and a deviation of 10–15° and grade 3 a perforation of more than 4 mm and a deviation of more than 15°. All patients were tested for intra- and postoperative neurologic complications and infections. The statistical analysis was executed using Microsoft Excel 2010. 32 SI-screws were implanted in the first 20 months after the hybrid operating theatre had been established in 2012. All 30 patients were included in this study (15 men, 15 women). The mean age was 59 years ±23 (13–95 years). 20 patients received a single screw in S1 (66.7%), 1 patient 2 unilateral screws in S1 and S2 (3.3%), one patient 2 bilateral screws in S1 (3.3%) and 8 patients a single screw stabilising both SI-joints (26.7%). 27 screws showed no perforation (84.4%), 1 screw a grade 1 perforation (3.1%) and 4 screws a grade 2 perforation (12.5%). There was no grade 3 perforation. Furthermore there was no perforation of the neural foramina or the ventral cortex in the axial plane of the SI-screws stabilising one SI-joint (24 screws). Only single SI-screws bridging both SI joints showed a perforation of the neural foramina (37% grade 0, 12.5% grade 1, 50% grade 2, 0% grade 3). In the frontal plane 23 screws (71.9%) showed a deviation of less than 5°. In 5 screws a grade 1 deviation (15.6%) and in 4 screws a grade 2 deviation (12.5%) could be found. There was no grade 3 deviation. There were no infections or neurological complications. The high image quality and large field of view in combination with an advanced navigation system is a great benefit for the surgeon. All SI-screws stabilising only one joint showed completely intraosseous placement. Single SI-screws bridging 2 SI-joints intentionally perforated the neural foramina ventrally in 5 cases because of dysmorphic sacral anatomy. This makes image-guided implantation of SI-screws in a hybrid operating theatre a very safe procedure