Aims

This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices.

Aims

The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system.

While obesity is associated with an increased risk of complications after total hip arthroplasty (THA) the relationship between body mass index (BMI) and the risk of early postoperative complications has not been fully characterized. This study sought to describe the relationship between BMI and the risk of early postoperative complications, including periprosthetic joint infection (PJI), composite surgical, and composite medical complications. Primary, elective THAs performed from 2016–2021 were identified using the Premier Healthcare Database (PHD). The study's primary outcome was the diagnosis of PJI within 90 days of THA. Using BMI as a continuous variable, logistic regression was used to develop restricted cubic splines (RCSs) to determine the impact of BMI on PJI risk. Bootstrap simulation was used to identify an inflection point in the final RCS model. The same technique was used to characterize the effects of BMI on composite medical and surgical complications. We found that PJI risk increased exponentially beyond a BMI cutpoint of 37.4 kg/m. 2. Relative to the cutpoint, patients with a BMI of 40 or 50 kg/m. 2. were at a 1.22- and 2.55-fold increased risk of developing PJI, respectively. Surgical complications increased at a BMI of 32 kg/m. 2. and medical complications increased at a BMI of 39 kg/m. 2. Relative to these cutpoints, patients with a BMI of 50 kg/m. 2. were at a 1.36- and 2.07-fold increased risk of developing medical and surgical complications, respectively. The results of this study indicate a non-linear relationship between patient BMI and early postoperative risk of PJI, composite medical complications, and composite surgical complications following THA. The identified cutpoints with associated odds ratios can serve as tools to help risk-stratify and counsel patients seeking primary THA

An intra-articular steroid injection can be a useful diagnostic tool in patients presenting with debilitating hip pain and radiographically mild osteoarthritis. The clinical and patient reported outcomes associated with patients who have radiographically mild osteoarthritis and undergo total hip arthroplasty (THA) remain poorly studied. Patients undergoing primary, elective THA at a single academic medical center by a fellowship-trained adult reconstruction surgeon between 2017–2023 were identified. Only those patients who underwent an intra-articular corticosteroid injection into the operative hip within one year of surgery were included. Patients were divided into two cohorts based on the severity of their osteoarthritis as determined by preoperative radiographs; those with Kellgren-Lawrence (KL) grade I-II arthritis were classified as “mild” whereas those with KL grade III-IV arthritis were classified as “severe”. Clinical and patient reported outcomes at final follow-up were compared between cohorts. The final cohorts included 25 and 224 patients with radiographically mild and severe osteoarthritis, respectively. There were no baseline differences in age, gender or time between intra-articular corticosteroid injection and THA between cohorts. There were no significant differences in the preoperative or postoperative HOOS JR values between patients with mild or severe arthritis (all p>0.05). There were no significant differences in the change in HOOS JR scores from the preoperative to final follow-up timepoints between cohorts. There were no significant differences in the percentage of patients who achieved the minimal clinically important difference (MCID) on the HOOS JR questionnaire between cohorts. Patients with radiographically mild osteoarthritis who feel relief of their hip pain following an intra-articular corticosteroid injection report similar preoperative debility and demonstrate similar improvements in patient reported outcome scores following THA compared to patients with radiographically severe osteoarthritis

We report the impact of implementing a new short-stay hip and knee arthroplasty pathway in a National Health Service (NHS) hospital. This was enacted due to existing concerns with a long length of stay (LOS) and reduced elective operating capacity each winter due to emergency bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimise readmission rates and generate financial savings, all combining to facilitate full elective activity during the winter. We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It includes rigorous preoperative optimisation, specific anaesthetic protocols and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, including the initial six months post implementation of the short-stay pathway. LOS data was collected for the full period and data was compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected. There was an immediate and significant decrease in median LOS from 4 days pre-implementation to 1 day post-implementation. Patient satisfaction was high, and the 30-day readmission rate was unchanged (5.95%), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial cost savings due to reduced LOS and the elimination of routine post-operative blood tests, estimated at over £1.6m per year. Elective activity over winter was significantly higher (79%) than in the same time period in the previous year. An acute introduction of a carefully planned and coordinated short-stay hip and knee pathway is safe, cost-effective and popular with patients, but also contributes to increased efficiency in the delivery of elective healthcare in the context of increasing demand and financial constraints in the NHS

Most hip replacements are performed in an in-patient setting; however, there has been a shift in recent years in Canada towards doing more on an outpatient basis. In 2021–2022, 15.6% of hip replacements were performed as day surgeries compared to 0.7% in 2018–2019. This analysis will assess patient reported outcome measures of patients who had inpatient versus outpatient hip replacement surgery between 2018 and 2021. We analysed a retrospective sample of 4917 adult patients who had an elective primary unilateral hip replacement. Preoperative and three-month postoperative PROMs were completed - the Oxford Hip Score, EQD5L and patient satisfaction with the outcome were recorded. Patients who had an outpatient procedure were matched 1:1 with patients who are admitted to hospital for surgery based on age, sex and pre-COVID versus the COVID (March 15, 2020 as the start). Preoperative PROMs and Charlson Comorbidity Index were collected. T-tests and chi-square tests were used to assess the differences. The inpatient group on average was older, female and had a lower preoperative PROMs score and more comorbidities than the outpatient group. With cohort matching the sample consisted of 1244 patients. The inpatient and outpatient groups have similar Oxford scores, postoperative EQ-5D-5L scores and the proportion satisfied with their surgical results. The Oxford postoperative score was slightly higher in the outpatient group compared to the inpatient group; however, this is not clinically significant. We observed that outpatient protocols have no difference in patient satisfaction, self-reported functional outcomes and self-reported health-related quality of life three months after a hip replacement. Day surgery protocols represented potential solution to the challenges caused by the expected increase in demand for hip replacements. Our results demonstrated that patients do well clinically with day surgery procedures and there does not appear to be any detrimental effect on PROMs

Background. Over 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques. Methods. PRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios. Results. Differences in the primary outcome at 24 hours will be estimated by mixed-effects linear regression modelling, with fixed effects for randomisation factors and other important prognostic variables, and random effects for centre, using the as-randomised population. Treatment effects with 95% confidence intervals will be presented. Conclusion. The study is due to open in May 2024 and complete in 2026. Conflicts of Interest. No conflicts of interest declared. Sources of Funding. NIHR Health Technology Award – grant number NIHR153170. Trial presentations so far. APOMP 2023 and 2024; RCOA conference, York, November 2023; Faculty of Pain Management training day, London, February 2024

The August 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Comparing augmented and nonaugmented locking-plate fixation for proximal humeral fractures in the elderly; Elevated five-year mortality following shoulder arthroplasty for fracture; Total intravenous anaesthesia with propofol reduces discharge times compared with inhaled general anaesthesia in shoulder arthroscopy: a randomized controlled trial; The influence of obesity on outcomes following arthroscopic rotator cuff repair; Humeral component version has no effect on outcomes following reverse total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial; What is a meaningful improvement after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex?; The safety of corticosteroid injection prior to shoulder arthroplasty: a systematic review; Mortality and subsequent fractures of patients with olecranon fractures compared to other upper limb osteoporotic fractures.

The August 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Antibiotic prophylaxis and infection rates in paediatric supracondylar humerus fractures; Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK; Health-related quality of life in idiopathic toe walkers: a multicentre prospective cross-sectional study; Children with spinal dysraphism: a systematic review of reported outcomes; No delay in age of crawling, standing, or walking with Pavlik harness treatment: a prospective cohort study; No value found with routine early postoperative radiographs after implant removal in paediatric patients; What do we know about the natural history of spastic hip dysplasia and pain in total-involvement cerebral palsy?; Evaluating the efficacy and safety of preoperative gallows traction for hip open reduction in infants

The August 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Understanding perceived leg length discrepancy post-total hip arthroplasty: the role of pelvic obliquity; Influence of femoral stem design on revision rates in total hip arthroplasty; Outcomes of arthroscopic labral treatment of femoroacetabular impingement in adolescents; Characteristics and quality of online searches for direct anterior versus posterior approach for total hip arthroplasty; Rapid return to braking after anterior and posterior approach total hip arthroplasty; How much protection does a collar provide?; Timing matters: reducing infection risk in total hip arthroplasty with corticosteroid injection intervals; Identifying pain recovery patterns in total hip arthroplasty using PROMIS data.

Aims

The COVID-19 pandemic has disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. This study aimed to quantify the backlog, analyze national trends, and predict time to recovery.

Aims

Total knee arthroplasty (TKA) with a highly congruent condylar-stabilized (CS) articulation may be advantageous due to increased stability versus cruciate-retaining (CR) designs, while mitigating the limitations of a posterior-stabilized construct. The aim was to assess ten-year implant survival and functional outcomes of a cemented single-radius TKA with a CS insert, performed without posterior cruciate ligament sacrifice.

Periprosthetic joint infections (PJIs) and osteosynthesis-associated infections (OSIs) present significant challenges in trauma and orthopaedic surgery, substantially impacting patient morbidity, mortality, and economic burden. This concern is heightened in patients with pre-existing comorbidities, such as diabetes mellitus, which are not always modifiable at presentation. A novel intraoperative strategy to prevent these infections is the use of Defensive Antibacterial Coating (DAC), a bio-absorbable antibiotic-containing hydrogel applied to implant surfaces at implantation, acting as a physical barrier to prevent infection. The purpose of this study is to assess the use of a commercially available hydrogel (DAC), highlighting its characteristics that make it suitable for managing PJIs and OSIs in orthopaedics and traumatology. Twenty-five patients who underwent complex orthopaedic procedures with intraoperative application of DAC between March 2022 and April 2023 at a single hospital site were included. Post-operative assessment encompassed clinical, laboratory, and radiographic examinations. In this study, 25 patients were included, with a mean age of 70 ± 14.77 years and an average ASA grade of 2.46 ± 0.78. The cohort presented an average Charleston Comorbidity score of 5.45 ± 2.24. The procedures included 8 periprosthetic fractures, 8 foot and ankle surgeries, 5 upper limb surgeries, and 4 elective hip and knee surgeries. Follow-up assessments at 6 weeks and 6 months revealed no evidence of PJI or OSI in any patients, nor were any treatments for PJI or OSI required during the interim period. DAC demonstrated efficacy in preventing infections in high-risk patients undergoing complex orthopaedic procedures. Our findings warrant further investigation into the use of DAC in complex hosts with randomized control trials

Shoulder replacement surgery is a well-established orthopaedic procedure designed to significantly enhance patients’ quality of life. However, the prevailing preoperative admission practices within our tertiary shoulder surgery unit involve a two-stage group and save testing process, necessitating an admission on the evening before surgery. This protocol may unnecessarily prolong hospital stays without yielding substantial clinical benefits. The principal aim of our study is to assess the necessity of conducting two preoperative group and save blood tests and to evaluate the requirement for blood transfusions in shoulder arthroplasty surgeries. A secondary objective is to reduce hospital stay durations and the associated admission costs for patients undergoing shoulder arthroplasty. We conducted a retrospective observational study covering the period from 1st January 2023 to 31st August 2023, collecting data from shoulder arthroplasty procedures across three hospitals within the Aneurin Bevan University Health Board. Our analysis included 21 total shoulder replacement cases and 13 reverse shoulder replacement cases. Notably, none of the patients required postoperative blood transfusions. The mean haemoglobin drop observed was 14 g/L for total shoulder replacements and 15 g/L for reverse shoulder replacements. The mean elective admission duration was 2.4 nights for total shoulder replacements and 2 nights for reverse shoulder replacements. Our data indicated that hospital stays were extended by one night primarily due to the preoperative group and save blood tests. In light of these findings, we propose a more streamlined admission process for elective shoulder replacement surgery, eliminating the need for the evening-before-surgery group and save testing. Hospital admissions in these units incur a cost of approximately £500 per night, while the group and save blood tests cost around £30 each. This revised admission procedure is expected to optimise the use of healthcare resources and improve patient satisfaction without compromising clinical care

Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population. The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded. The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively. We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture

Aims

Weightbearing instructions after musculoskeletal injury or orthopaedic surgery are a key aspect of the rehabilitation pathway and prescription. The terminology used to describe the weightbearing status of the patient is variable; many different terms are used, and there is recognition and evidence that the lack of standardized terminology contributes to confusion in practice.

Aims. Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion. Methods. All patients who underwent elective THA were analyzed retrospectively in this single-centre study from 2020 to 2021. A total of 2,892 patients were included. Transfusion-related parameters were evaluated. A multiple logistic regression was performed to determine whether age, BMI, American Society of Anesthesiologists (ASA) grade, sex, or preoperative haemoglobin (Hb) could predict the need for transfusion within the examined patient population. Results. The overall transfusion rate was 1.2%. Compared to the group of patients without blood transfusion, the transfused group was on average older (aged 73.8 years (SD 9.7) vs 68.6 years (SD 10.1); p = 0.020) and was mostly female (p = 0.003), but showed no significant differences in terms of BMI (28.3 kg/m. 2. (SD 5.9) vs 28.7 kg/m. 2. (SD 5.2); p = 0.720) or ASA grade (2.2 (SD 0.5) vs 2.1 (SD 0.4); p = 0.378). The regression model identified a cutoff Hb level of < 7.6 mmol/l (< 12.2 g/dl), aged > 73 years, and a BMI of 35.4 kg/m² or higher as the three most reliable predictors associated with postoperative transfusion in THA. Conclusion. The possibility of transfusion is predictable based on preoperatively available parameters. The proposed thresholds for preoperative Hb level, age, and BMI can help identify patients and take preventive measures if necessary. Cite this article: Bone Jt Open 2024;5(7):560–564

Aims. Shoulder arthroplasty is effective in the management of end-stage glenohumeral joint arthritis. However, it is major surgery and patients must balance multiple factors when considering the procedure. An understanding of patients’ decision-making processes may facilitate greater support of those considering shoulder arthroplasty and inform the outcomes of future research. Methods. Participants were recruited from waiting lists of three consultant upper limb surgeons across two NHS hospitals. Semi-structured interviews were conducted with 12 participants who were awaiting elective shoulder arthroplasty. Transcribed interviews were analyzed using a grounded theory approach. Systematic coding was performed; initial codes were categorized and further developed into summary narratives through a process of discussion and refinement. Data collection and analyses continued until thematic saturation was reached. Results. Two overall categories emerged: the motivations to consider surgery, and the information participants used to inform their decision-making. Motivations were, broadly, the relief of pain and the opportunity to get on with life and regain independence. When participants’ symptoms and restrictions prevented them enjoying life to a sufficient extent, this provided the motivation to proceed with surgery. Younger participants tended to focus on maintaining employment and recreational activities, and older patients were eager to make the most of their remaining lifetime. Participants gathered information from a range of sources and were keen to optimize their recovery where possible. An important factor for participants was whether they trusted their surgeon and were prepared to delegate responsibility for elements of their care. Conclusion. Relief of pain and the opportunity to get on with life were the primary reasons to undergo shoulder arthroplasty. Participants highlighted the importance of the patient-surgeon relationship and the need for accurate information in an accessible format which is relevant to people of different ages and functional demands. Cite this article: Bone Jt Open 2024;5(7):543–549

Aims

Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF).

Aims

To examine whether natural language processing (NLP) using a clinically based large language model (LLM) could be used to predict patient selection for total hip or total knee arthroplasty (THA/TKA) from routinely available free-text radiology reports.