Abstract

The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines.

Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively.

Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time.

Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK.

In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated.

Telemedicine is the delivery of healthcare from a remote location using integrated computer/communication technology. This systematic review aims to explore evidence for telemedicine in orthopaedics to determine its advantages, validity, effectiveness and utilisation particularly during our current pandemic where patient contact is limited.

Databases of PubMed, Scopus and CINHAL were systematically searched and articles were included if they involved any form of telephone or video consultation in an orthopaedic population. Findings were synthesised into four themes: patient/clinician satisfaction, accuracy and validity of examination, safety and patient outcomes and cost effectiveness. Quality assessment was undertaken using Cochrane and Joanna Briggs Institute appraisal tools.

Twenty studies were included consisting of nine RCTs across numerous orthopaedic subspecialties including fracture care, elective orthopaedics and oncology. Studies revealed high patient satisfaction with telemedicine for convenience, less waiting and travelling time. Telemedicine was cost effective particularly if patients had to travel long distances, required hospital transport or time off work. No clinically significant differences were found in patient examination nor measurement of patient reported outcome measures. Telemedicine was reported to be a safe method of consultation. However, studies were of variable methodological quality with selection bias.

In conclusion, evidence suggests that telemedicine in orthopaedics can be safe, cost effective, valid in clinical assessment with high patient/clinician satisfaction. Further work with high quality RCTs is required to elucidate long term outcomes. This systematic review presents up-to-date evidence on the use of telemedicine and provides data for organisations considering its use in the current COVID-19 pandemic and beyond.

Introduction

Periacetabular osteotomy has been described as an effective way of treating symptomatic hip dysplasia. We describe a new minimally invasive technique using a modification of the Smith Peterson approach.

Introduction

‘VTE disease is the new MRSA’, with much attention received in the media and the political world. Following the 2010 NICE guidelines all patients admitted to hospital should have VTE prophylaxis considered and a formal VTE risk assessment done with documentation and review in a 24 hour period. We carried out a completed audit cycle to identify our adherence to these guidelines and introduced a novel method to ensure compliance.

An anaesthetist recently remarked that orthopaedic surgeons are ‘twice as strong as an ox but half as smart’. We set out to ascertain if this had any evidence basis by conducting an observational study.

We compared 36 male orthopaedic surgeons to 40 male anaesthetists across 3 hospitals to ascertain if there was a significant difference between the two groups in terms of Intelligence Quotient (IQ) and strength. We tested the IQ of each doctor using an official MENSA IQ test. We assessed the strength as reflected by the grip strength using a hand-grip dynamometer. Un-paired t-tests were used to assess statistical significance.

Orthopaedic surgeons had a significantly greater mean grip strength 47.25Kg (SD=6.95) compared to anaesthetists 43.83Kg (SD=7.57) (p=0.04). The mean IQ of orthopaedic surgeons was also significantly greater at 105.19 (SD=10.85) than anaesthetists at 98.38 (SD=14.45) (p=0.02). Furthermore, the IQ of orthopaedic surgeons seems to increase with increasing age and seniority (an IQ jump of 5 IQ points from Registrar to Consultant).

We have concluded that this proverb should be revised to orthopaedic surgeons are as strong as an ox and twice as smart, although further studies are advocated to ascertain the IQ of Ox.

We present the 12 month data on the relatively novel drug Dabigatran Etexilate (Pradaxa), a new oral anticoagulant which was introduced to combat the risk of post operative venous-thromboembolic disease (VTED) in orthopaedic surgery. This drug was introduced at our hospital in March 2010 and we present our modified protocol of: using 5000u subcutaneous Dalteparin whilst in hospital and giving Dabigatran only on discharge, and at a lower dose (150mg compared to 220mg).

We carried out a retrospective analysis of the notes and imaging of every patient who underwent elective hip and knee arthroplasty over 12 months since the drug was introduced. We evaluated the rate of VTED complications and the rate of transfusion and bleeding post operatively.

The case series of 370 patients showed a 1% risk of deep vein thrombosis with no pulmonary emboli and 1 death due to an unrelated cause. There was a transfusion rate of 11% with 0.5% patients taken back to theatre for evacuation of haematomas. There were no reported adverse effects of Dabigatran.

We argue that our modified protocol for this novel drug should be followed as it is both safe and effective for postoperative anticoagulation.

Despite a lack of evidence, the UK's Department of Health introduced a policy of ‘Bare below the elbows’ attire to try to reduce the incidence of nosocomial infection. This study investigates the link between attire and hand contamination. A prospective observational study of doctors working in a District General Hospital was performed. The fingertips were imprinted on culture medium, and the resulting growth assessed for number of colony forming units, presence of clinically significant pathogens and multiply resistant organisms. These findings were correlated with attire, grade, gender and specialty. 92 doctors were recruited of which 49 were ‘Bare below the elbows’ compliant and 43 were not. There was no statistically significant difference between those doctors who were ‘bare below the elbows’ and those that were not for either the number of colony forming units (p=1.0), or the presence of significant organisms (p=0.77). No multiply resistant organisms were cultured from doctors' hands. ‘Bare below the elbows’ attire is not related to the degree of contamination on doctors' fingertips or the presence of clinically significant pathogens. Further studies are required to establish whether investment in doctor's uniforms and patient education campaigns are worthwhile.

Introduction

The Rapid Recovery Program (RRP) is a holistic perioperative accelerated discharge process that aims to improve efficiency and quality of care, improve patient education, standardise protocols and pathways and encourage early mobilisation & discharge.