The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to free hand orthopaedic operation notes.

A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to free hand operation notes.

97 cases were identified, of which 74 were free hand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes vs 0 (0%) in the free hand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the free hand op-note group (templated median 14, range 12-14, vs. free hand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by Registrars or Consultants identified Registrars as more likely to document the antibiotic prophylaxis given (p = 0.025).

Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations.

Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance.

Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores.

A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37)

Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year.

The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures.

Tranexamic Acid (TXA) is widely used to decrease bleeding by its antifibrinolytic mechanism. Its use is widespread within orthopaedic surgery, with level one evidence for its efficacy in total hip and knee replacement surgery; significantly reducing transfusion rates without increased thromboembolic disease. There is limited evidence for its use during hip fracture surgery, and we therefore sought to investigate its effects with a prospective cohort study.

We recorded intra-operative blood loss, pre and post-operative haemoglobin and creatinine levels, post-operative complications and mortality in all hip fracture patients over a six month period. During this time, we introduced one gram of TXA into our standardised hip fracture theatre checklist. It was subsequently given to all patients unless contra-indicated.

A total of 99 patients were included. 90-day mortality in the control group was 16%, there was no mortality in the TXA group (p<0.05). 14 patients required a transfusion in the control group and 3 in the TXA group (19% vs 11% transfusion rate, 0.36 units RCC vs 0.22 per patient respectively) Mean blood loss was 338 vs 235mls, Haemoglobin drop 23 vs 18g/dl control and TXA groups respectively.

We have demonstrated a significantly lower mortality rate with TXA. We have also shown lower rates of transfusion, blood loss and recorded haemoglobin drop with the use of TXA. We intend to continue this study to demonstrate this significantly, and fully clarify the safety profile of TXA in this frail cohort of patients.