Background. In surgeon controlled bundled payment and service models, the goal is to reduce cost but preserve quality. The surgeon not only takes on risk for the surgery, but all costs during 90 days after the procedure. If savings are achieved over a previous target price, the surgeon can receive a monetary bonus. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with cardiology consultation at their discretion, and without dictating specific testing. Our participation in the Bundled Payments for Care Improvement (BPCI) program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having costly readmissions for cardiac events. Objective. To determine the medical effectiveness and cost savings of instituting a new innovative cardiac screening program (Preventive Cardio-Orthopaedics) for total hip and knee replacement patients in the BPCI program and to compare result to those managed in the more traditional fashion. Methods. The new screening program was instituted on 11/1/17 directed by an advanced cardiac imaging cardiologist (EH). Testing included an electrocardiogram, echocardiogram, carotid and abdominal ultrasound, and coronary computed tomography angiography (CCTA). If needed, a 3 day cardiac rhythm monitor was also performed. Four of the ten physicians in our group performing hip and knee replacement surgeries participated. Charts of readmitted patients were reviewed to determine past medical history, method of cardiac clearance, length and cost of readmission. Results. 2,459 patients had total hip or knee replacement in the BPCI program between 1/1/15 and 10/31/17 prior to instituting the new program. All had complete 90 day postoperative readmission data supplied by the CMS, with 25 (1%) of these patients having readmissions for cardiac events for a total cost of readmissions of %149,686. 14 of 25 had a preoperative clearance by a cardiologist. In 19 of the 25 patients, the only preoperative cardiac screening tool performed was an electrocardiogram. Since instituting the new program, 842 additional surgeries were performed, 463 by the four surgeons involved. 126 patients were agreeable to be evaluated through the Preventive Cardio-Orthopaedics program. 4 patients of the four physicians still screened via the traditional cardiac program had a cardiac event readmission. The average readmission hospital stay was 3.33 days at a total cost of %42,321. 2 patients of the four physicians evaluated by the Preventive Cardio-Orthopaedics program had a cardiac related readmission, at an average hospital stay of 2 days, and at a total cost of %10,091. Conclusions. Risk sharing programs have forced surgeons to take a more active role in optimizing their patients medically; otherwise they will be penalized with a decreased reimbursement. Traditionally, we have abdicated this responsibility to primary care and cardiology physicians but have noted a high cardiac readmission risk. In response, we have begun using a unique cardiac screening model. Our preliminary experience predicts fewer cardiac readmissions thereby improving care, and at a lower cost

Background. The Bundled Payments for Care Improvement (BPCI) was developed by the US Center for Medicare and Medicaid (CMS) to evaluate a payment and service delivery model to reduce cost but preserve quality. 90 day postoperative expenditures are reconciled against a target price, allowing for a monetary bonus to the provider if savings were achieved. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative cardiovascular readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with or without additional cardiology consultation, without dictating specific testing. Typical screening includes an EKG, occasionally an echocardiogram and nuclear stress test, and rarely a cardiac catheterization. Our participation in the BPCI program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having readmissions for cardiac events. Objective. To determine the medical effectiveness and cost savings of instituting a new innovative cardiac screening program (Preventive Cardio-Orthopaedics) for total hip and knee replacement patients in the BPCI program and to compare result to those managed in the more traditional fashion. Methods. The new screening program was instituted on 11/1/17 directed by an advanced cardiac imaging cardiologist (EH). Testing included an electrocardiogram, echocardiogram, carotid and abdominal ultrasound, and coronary computed tomography angiography (CCTA). If needed, a 3 day cardiac rhythm monitor was also performed. Four of the ten physicians in our group performing hip and knee replacement surgeries participated. Charts of readmitted patients were reviewed to determine past medical history, method of cardiac clearance, length and cost of readmission. Results. 1,361 patients had total hip or knee replacement in the BPCI program between 1/1/15 and 1/28/18 and all had complete 90 day postoperative readmission data supplied by the CMS, with 25 of these patients evaluated through the Preventive Cardio- Orthopaedics program. 12 (0.90%) screened via the traditional cardiac program had a cardiac event readmission. The average readmission hospital stay was 3.67 days at a total cost of $69,378. 7 of 12 had a preoperative clearance by a cardiologist. In 9 of the 12 patients, the only preoperative cardiac screening tool performed was an electrocardiogram. None of these 25 patients evaluated through the new program has been readmitted. 84 more patients have been evaluated in this program since 1/28/18, but 90 day readmission data is still incomplete. Preliminary data suggests that the highest risk in these patients is not severe coronary artery disease, but atrial fibrillation, hypertension with left ventricular hypertrophy, and cardiac plaques with ulceration. Conclusions. Risk sharing programs have forced joint replacement surgeons to take a more active role in optimizing their patients medically; otherwise they will be penalized with a decreased reimbursement. Traditionally, we have abdicated this responsibility to primary care and cardiology physicians but have noted a high readmission risk with a cardiac event. In response, we have begun using a unique cardiac screening model. Our preliminary experience predicts fewer cardiac readmissions thereby improving care, and at a lower cost

The incidence of hip fractures is rising worldwide. Hip fracture patients with a cardiac murmur have an echocardiogram pre-operatively in our unit. We assessed the impact of obtaining a pre-operative echocardiogram on treatment of such patients, using National Confidential Enquiry into Patient Outcome and death (NCEPOD) report 2001 as gold standard. We undertook a retrospective audit of hip fracture patients (N=349) between 01/06/08 and 01/06/09. 29 patients had pre-operative echocardiogram (echo group). A computer generated randomised sample of 40 patients was generated from N, ‘non-echo’ group. Data was obtained from medical records and the Hospital Information Support System. The groups were compared using Student's t test. Age and gender distribution were similar in both groups. 29 patients had pre-operative echo. The indication for requesting an echocardiogram pre-operatively was an acute cardiac abnormality in 4 cases. 25 patients had echocardiogram for no new cardiac problem. In the latter group, the reason for requesting an echo was a cardiac murmur in 23 patients and extensive cardiac history in 2 cases. A specialist input from the cardiologist was sought in 5 cases. Most patients with aortic valve abnormality had surgery under general anaesthetic. No patient required cardiac surgery or balloon angioplasty pre-operatively. There was a significant delay to surgery in the patients who had a pre-operative echo (average 2.7 days, range 0–6 days) compared to ‘non-echo’ group (average 1.1 days, range 0–3 days), (P< 0.001). There was no significant difference in length of stay and mortality at 28 days between the two groups. We are now developing departmental guidelines for requesting echo in hip fracture patients with cardiac murmur to prevent unnecessary avoidable delay. We are developing a link with the cardiology department to expedite echocardiogram requests in hip fracture patients

Pre-operative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on pre-operative age, sex and body mass index (BMI). There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P<0.001). Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P<0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 - 21.7 with a cardiac history compared to 4.8 - 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, nor did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA. The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history. This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors

Introduction. Cardiac events have been found to occur with increased frequency in total joint arthroplasty (TJA) patients >65 y/o without known coronary artery disease (CAD). Avoidance of readmissions for cardiac events is paramount with bundled payment programs. It has been thought that many of these patients may have undiagnosed CAD because of sedentary life styles brought on by chronic osteoarthritis. The purpose of this study is to assess with Coronary Computed Tomographic Angiography (CCTA) the prevalence and severity of CAD in patients >65 y/o for elective TJA. Methods. 126 elective patients that were part of a total hip and knee bundled payment program were referred for cardiac evaluation with CCTA if they were >65 but <70 y/o with a history of heart disease or 2 risk factors or were >70 y/o. CCTA was acquired on all patients unless they had a history of a severe allergic reaction to contrast, GFR <50 ml/min., the presence of atrial fibrillation, or declined the test. All images were evaluated by an experienced reader. Arterial narrowing of 70% diameter or greater was classified as significant CAD. Intermediate lesions <70% were reclassified as significant if CT-FFR (Functional flow reserve) was < or = 0.80. Results. Excluding the 12 patients with known CAD who had stents or coronary artery bypass graft (CABG), the remaining 114 patients were classified into three groups. 34/114 (29.8%) had no CAD (Group A). 75/114 (65.8%) had (Group B). 5/114 (4.4%) had > or = 70% stenosis. Group C included one patient who had <70% stenosis but had CT-FFR <80%. Of 17 patients with known CAD with >70% or heart CT-FFR <80%, or prior stents/CABG, one patient was predicted to be high risk of a cardiac event because of a complex plaque with an ulcer, history of suppressed paroxysmal atrial fibrillation, and withdrawal from apixaban. He was nurse navigated throughout his hospital course and post discharge only to be recalled to the hospital to be rescued with cardiac stenting. Conclusion. Patients >65 y/o having TJA without a cardiac history were found to have a 4.4% prevalence of significant CAD. When added to the patients with known CAD, the overall prevalence was 13.5%. One patient had complex plaque predictive of a cardiac event. As the US population ages and TJA becomes more prevalent with greater pressure to reduce costs by bundling and shifting to outpatient surgery, further data needs to be collected to better understand CAD in TJA patients >65 y/o

Aim. Prosthetic joint infections (PJI) and fracture related infections (FRI) are the most challenging complications in orthopaedic surgery. An interdisciplinary approach is mandatory not only to correctly diagnose and treat major musculoskeletal infections but also to address the comorbidities and impairments these patients are not rarely suffering from. Since, little data exists on cardiac complications following PJI and FRI revision surgery, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality. Method. We prospectively included consecutive patients at high cardiovascular risk (defined as expected postoperative hospital stay of >24 hours PLUS age >45 years with pre-existing coronary, peripheral or cerebrovascular artery disease OR age >65 years) undergoing major orthopaedic surgery between 2014 and 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T (hs-cTnT). All-cause mortality was assessed at 30 days and one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery (for PJI/FRI) and patients receiving aseptic major bone and joint surgery. Results. In total 911 consecutive patients, with an overall PMI rate of 15.4% (n=140) were included. The PMI incidence in patients undergoing septic revision surgery was significantly higher compared to aseptic orthopaedic surgeries (29.2% vs 14.3%, p=0.001), also after multivariable adjustment (odds ratio 2.1, p=0.02). Mortality was higher at one year (16.9% vs. 8.3%, p=0.037) and numerically at 30 days (6.2% vs. 2.4%, p=0.085) in patients undergoing septic revision surgery. Virulence of the disease-causing pathogen showed no significant relationship with PMI incidence or mortality. Conclusions. Patients undergoing revision surgery for PJI or FRI were at a distinct higher risk of PMI and death compared to matched non-septic patients. In major bone and joint infections screening for PMI and treatment in specialized multidisciplinary units should be considered

Aim. Swedish guidelines on antibiotic prophylaxis in arthroplasty surgery recommend cloxacillin in fixed doses that pay little attention to the patient's renal function and weight. Nevertheless, there are no studies on whether the resulting free prophylactic cloxacillin in vivo concentrations are optimal. We aimed to evaluate whether the current recommended prophylactic dosage of cloxacillin is adequate. Method. We performed a prospective two-centre study, measuring the free (active) cloxacillin concentrations in plasma throughout surgery, in patients subject to primary hip and knee prosthetic joint replacements, aiming at 100 patients per centre. To account for plasma-bone exposure differences, concentrations were considered adequate if twice the epidemiological cut-off value for cloxacillin concerning wild type Staphylococcus aureus whereas two-three times were labelled threshold values. The two enrolling hospitals are acute care hospitals in central Sweden, also performing 600 - 1200 primary hip and knee joint arthroplasties annually. All patients scheduled for elective primary hip or knee replacements from January 2022 to April 2024 were eligible for participation. Exclusion criteria were allergy towards penicillins, cognitive disorders leading to inability to sign informed consent, and an absence of interpreter in case of a patient not speaking Swedish or English. Results. We present results from the first 49 patients included. Four patients had free cloxacillin concentrations below cut-off (8.2%). These four cases had prolonged surgeries of 77-100 minutes. An additional 5/49 (10.2%) had threshold values. Conversely 5/49 (10.2%) cases had concentrations exceeding 15 times the needed. No cases with threshold or low cloxacillin concentrations were attributable to a lack of concerning timing and dosing of cloxacillin. All concentrations were above or equal to our cut-off at the start of surgery. Eighteen percent of patients were of normal of weight (BMI 18.5- 25). Of the rest 4% were morbidly obese (BMI >40), 41% obese (BMI 30-40) and 37% overweight (BMI 25-30). Twenty seven percent (43/159) had diabetes and 45% suffered cardiac disease. Conclusions. Some patients in our cohort had insufficient active cloxacillin levels at the end of prosthetic joint surgery. Previous studies indicate that insufficient prophylactic antibiotic concentrations might lead to an enhanced risk of prosthetic joint infections. Other patients were massively overdosed, leading to unnecessary ecological effects and potentially adverse reactions. As inadequate cloxacillin concentrations were not associated with a lack of compliance to current guidelines a change in practise might be needed. Our final results may help to determine how dosing should be adjusted

There is limited literature on the effects of socioeconomic factors on outcomes after total ankle arthroplasty (TAA). In the setting of hip or knee arthroplasty, patients of a lower socioeconomic status demonstrate poorer post-operative satisfaction, longer lengths of stay, and larger functional limitations. It is important to ascertain whether this phenomenon is present in ankle arthritis patients. This is the first study to address the weight of potential socioeconomic factors in affecting various socioeconomic classes, in terms of how they benefit from ankle arthroplasty. This is retrospective cohort study of 447 patients who underwent a TAA. Primary outcomes included pre-operative and final follow-up AAOS pain, AAOS disability, and SF-36 scores. We then used postal codes to determine median household income using Canadian 2015 census data. Incomes were divided into five groups based on equal amounts over the range of incomes. This method has been used to study medical conditions such as COPD and cardiac disease. These income groups were then compared for differences in outcome measures. Statistical analysis was done using unpaired t-test. A total of 447 patients were divided into quintiles by income. From lowest income to highest income, the groups had 54, 207, 86, 64, and 36 patients, respectively. The average time from surgery to final follow up was 85.6 months. Interestingly, we found that patients within the middle household income groups had significantly lower AAOS disability scores compared to the lowest income groups at final follow-up (26.41 vs 35.70, p=0.035). Furthermore, there was a trend towards middle income households and lower post-operative AAOS pain scores compared to the lowest income group (19.57 vs 26.65, p=0.063). There was also a trend toward poorer AAOS disability scores when comparing middle income groups to high income groups post-operatively (26.41 vs 32.27, p=0.058). Pre-operatively, patients within the middle-income group had more pain, compared to the lowest and the highest income groups. No significant differences in SF-36 scores were observed. There were no significant differences seen in middle income groups compared to the highest income group for AAOS pain post-operatively. There were no significant differences found in pre-operative AAOS disability score between income groups. Patients from middle income groups who have undergone TAA demonstrate poorer function and possibly more pain, compared to lower and higher income groups. This suggests that TAA is a viable option for lower socioeconomic groups and should not be a source of discouragement for surgeons. In this circumstance there is no real disparity between the rich and the poor. Further investigation is needed to explore reasons for diminished performance in middle class patients

Aim. Daptomycin plus fosfomycin combination therapy is a valuable strategy for treating staphylococcal osteoarticular infections. Considernig that each gram of fosfomycin contains 330 mg of sodium, electrolytic imbalance due to sodium overload could pose safety issues, especially in the cardiopatic patients and/or in the frail elderly. The aim of this study was to compare the efficacy of using reduced vs. standard daily dose fosfomycin in combination with daptomycin in a cohort of patients with osteoarticular infections. Method. This analysis included adult patients with osteoarticular infections admitted to the Infectious Diseases Unit of our University hospital in the period Nov 2022 – Feb 2024 and who were treated with daptomycin (8-10 mg/kg/daily) plus 24h-continuous infusion (CI) fosfomycin at the standard-dose of 16 g daily (standard-dose group) or at the reduced-dose of 8-12 g daily (reduced-dose group). All the patients underwent therapeutic drug monitoring (TDM) of fosfomycin for granting a pharmacodynamic target attainment of 24h-area under the concentration-time curve over minimum inhibitory concentration (AUC24h/MIC) >95 against Staphylococcus aureus with an MIC value up to 32 mg/L and of 70%t>MIC. Estimated glomerular filtration rate (eGFR) was assessed at each TDM session. Patient clinical outcome was assessed. Results. The standard- and the reduced-dose groups included 43 (29 males, 67.4%) and 21 (11 males, 52.4%) patients, respectively. No differences in median age (54 vs. 63 years, p=36), weight (80 vs. 76 kg, p=0.13) and type of diagnosis [prosthetic joint infections (16 vs. 29, p=0.38), osteomyelitis (2 vs. 9, p=0.72), septic arthritis (3 vs. 3, p=0.39) and spondilodiscitis (0 vs. 2, p=1.0)] were observed between the two groups. Median eGFR was similar in the standard vs. the reduced-dose group (109 vs. 98 mL/min/1.73m2, p=0.004). In the reduced-dose group, CI fosfomycin was administerd at 8 and 12 g/daily in 12 and 9 patients, respectively. There was no difference between the standard- and reduced-dose groups in attainment of the pharmacodynamic targets of AUC24h/MIC>95 (41/43 vs. 20/21, p=1.0), of 70%t>MIC (43/43 vs. 21/21 p=1.0) and of clinical cure (39/43 vs. 19/21, p=1.0). Conclusions. Combination therapy of 8-10 mg/kg/daily daptomycin plus 8-12 g/daily CI fosfomycin may be as effective as that of 8-10 mg/kg/daily daptomycin plus 16 g/daily CI fosfomycin. The fosfomycin reduced-dose strategy allows to decrease the daily sodium load by 25-50% compared to the standard dose, thus reducing the risk of cardiac adverse events. TDM may be a valuable strategy for individualizing fosfomycin dose in patients with osteoarticular infections

Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk and identify cardiac abnormalities. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare mortality, surgical wait times, length of stay (LOS), and health care costs for similar hip fracture patients managed with and without preoperative echocardiograms. A population based, retrospective cohort study of all hip fracture patients (>age 45) in Ontario, Canada was conducted. The primary exposure was pre-operative echocardiography (between hospital admission and surgery). Patients receiving preoperative echocardiograms were matched to those without using a propensity score incorporating patient demographic information, comorbidity status, and provider information. Mortality rates, surgical wait times, post-operative length of stay (LOS), and medical costs (expressed as 2013$ CAN) up to 1-year post-operatively were assessed after matching. There were 2354 (∼5.6%) of 42,230 eligible hip fracture patients that received a preoperative echocardiogram during the study period. After successfully matching 2298 (∼97.6%) patients, echocardiography was associated with significant increases in mortality at 90 days (20.1% vs. 16.8%, p=0.004) and 1 year (32.9% vs. 27.8%, p < 0 .001), but not 30-days (11.4% vs. 9.8%, p=0.084). Patients with echocardiography also had an increased (mean ± SD) delay (in hours) from presentation to surgery (68.80 ± 44.23 hours vs. 39.69 ± 27.09 hours, p < 0 .001) and only 38.1% of patients had surgery within 48 hours. Total LOS (in days) (mean 19.49 ± 25.39 days vs. 15.94 ± 22.48 days, p < 0 .001) and total healthcare costs at 1 year (mean: $51,714.69 ± 54,675.28 vs. $41,861.47 ± 50,854.12, p < 0 .001) were also increased. There was wide variability in echocardiography ordering practice in Ontario, with a range of 0% to 22.97% of hip fracture patients undergoing preoperative echocardiography at different hospital sites. Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality. It is also associated with increased surgical delay, post-operative LOS, and total health care costs at 1 year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay, and further research is necessary to clarify indications for this common preoperative investigation

Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk and identify cardiac abnormalities. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare mortality, surgical wait times, length of stay (LOS), and health care costs for similar hip fracture patients managed with and without preoperative echocardiography. A population based, retrospective cohort study of all hip fracture patients (>age 45) in Ontario, Canada was conducted. The primary exposure was pre-operative echocardiography (between hospital admission and surgery). Patients receiving preoperative echocardiography were matched to those without using a propensity score incorporating patient demographic information, comorbidity status, and provider information. Mortality rates, surgical wait times, post-operative length of stay (LOS), and medical costs (expressed as 2013$ CAN) up to one year post-operatively were assessed after matching. There were 2354 (∼5.6%) of 42,230 eligible hip fracture patients that received preoperative echocardiograghy during the study period. After successfully matching 2298 (∼97.6%) patients, echocardiography was associated with significant increases in mortality at 90 days (20.1% vs. 16.8%, p=0.004) and one year (32.9% vs. 27.8%, p < 0 .001), but not 30-days (11.4% vs. 9.8%, p=0.084). Patients with echocardiography also had an increased (mean ± SD) delay (in hours) from presentation to surgery (68.80 ± 44.23 hours vs. 39.69 ± 27.09 hours, p < 0 .001) and only 38.1% of patients had surgery within 48 hours. Total LOS (in days) (mean 19.49 ± 25.39 days vs. 15.94 ± 22.48 days, p < 0 .001) and total healthcare costs at one year (mean: $51,714.69 ± 54,675.28 vs. $41,861.47 ± 50,854.12, p < 0 .001) were also increased. There was wide variability in echocardiography ordering practice in Ontario, with a range of 0% to 22.97% of hip fracture patients undergoing preoperative echocardiography at different hospital sites. Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality. It is also associated with increased surgical delay, post-operative LOS, and total health care costs at one year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay, and further research is necessary to clarify indications for this common preoperative investigation

Abstract. In the pediatric population, scoliosis is classified into congenital, syndromic, idiopathic, and neuromuscular in aetiology. Syndromic scoliosis represents a wide range of systemic anomalies associated with scoliosis. The primary challenge for a clinician is to think beyond the scoliotic curve, as the underlying pathology is multisystemic. The aim of this review is to identify the systemic anomalies, associated with syndromic scoliosis. MEDLINE, EMBASE, and CINAHL databases were searched, dating from 1990–2020, relevant to the purpose of our study. Keywords used: “scoliosis”+ “syndrome” + “genetic”. Retrospective, prospective studies were included. Case reports that had fewer than 4 patients were not included. Delineating 60 articles, we found a total of 41 syndromes to be associated with scoliosis. Thoracic region was the most common level of scoliosis curve, being noted in 28 syndromes. Mental retardation, seizures, and ataxia were the commonly noticed CNS anomalies. VSD, ASD, and TGA were the anomalies associated with CVS; Hypotonia, rib and vertebral malformations were the most identified neuromuscular anomalies; pulmonary hypoplasia, renal agenesis, and strabismus were other associations. A multidisciplinary approach, involving spinal surgeons, paediatricians, geneticists, anesthesiologists, and allied health professionals, is vital for the best care of patients with syndromic scoliosis. The location of the scoliotic curve reflects the associated anomalies, as thoracic curvature is more closely linked with cardiac anomalies, while lumbosacral curvature is seen to be often linked with genitourinary anomalies. We hope that this article provides a clear overview of the systemic associations in syndromic scoliosis and thus, facilitates and streamlines the management protocol

Background of study. There has been an exponential increase in the use of direct thrombin (DT) and factor Xa inhibitors (FXI) in patients with cardiovascular problems. Premature cessation of DT/FXI in patients with cardiac conditions can increase the risk of coronary events. Our aim was to ascertain whether it is necessary to stop DT and FXI preoperatively to avoid postoperative complications following hip fracture surgery. Materials and Methods. Prospective data was collected from 189 patients with ongoing DT/FXI therapy and patients not on DT/FXI who underwent hip fracture surgery. Statistical comparison on pre- and postoperative haemoglobin (Hb), ASA grades, comorbidities, operative times, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rates between the two groups was undertaken. Results. There were 91 patients in the DT/FXI group (DTX) and 88 in the non-DTX group (NDTX). Mean age was 81.9 years. There was no difference in ASA grade, number of comorbidities (except cardiac comorbidities), age, gender and operation times between the groups. Mean preoperative Hb was 12.9 g/dl and 13.5 g/dl respectively in the DTX and NDTX. 4 and 2 patients respectively required transfusions postoperatively in the DTX and NDTX (p= 0.17). We found no difference with respect to LOS, wound infection, haematoma and reoperation rates between the two groups postoperatively. Conclusions. Our study suggests that maintaining DT and FXI therapy throughout the perioperative period in high risk patients with femoral neck fractures is not associated with an increased risk of bleeding or complications following hip fracture surgery

Introduction. Methoxyflurane can cause hepatotoxicity and nephrotoxicity at anaesthetic doses but has excellent analgesic properties and no nephrotoxic effects in patients without preexisting disease. Approved for use in the UK and Ireland in 2015, it is currently being used in emergency departments for analgesia during fracture reduction. During the Covid emergency, with theatre access severely restricted and many patients unwilling to use inhaled Nitrous oxide, Penthrox had the potential to provide adequate pain relief to aid frame removals and minor procedures in the clinic. Materials and Methods. Patients presenting to the Limb Reconstruction Unit Elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme inducing drugs were excluded. Verbal consent was obtained, the risks and benefits explained and the procedure was done in a side room in the clinic. Besides patient and procedure details, the Visual Analog Score and Richmond Agitation Scale was noted and patient's satisfaction documented. The results were presented as numbers, means and averages. Results. A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had Hexapod Removals, 9 had heel rings removed and 3 others had an ex fix removed. Eleven patients required/ requested extra pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient had a wire jam during removal and required a GA for removal. Conclusions. Patient satisfaction was very high (>95%) with good results and allowed frame removals and minor procedures to be done in the clinic during the Covid pandemic. It also cut expenses and has potential for regular future use

There is currently wide variation in the management of patients who are anticoagulated with Warfarin and require urgent orthopaedic surgery. These form an important and significant group of patients, in terms of real numbers (at least 5,600 per annum in the UK). A study was initiated with an audit of 34 patients presenting to the West Wales unit who were warfarinised at admission and required trauma surgery. Observations were recorded about their pre-operative management and the delay this caused in taking the patient to theatre. 6 months later, a similar group of patients were re-audited. The mean delay to surgery in those patients in whom the INR was left to fall spontaneously was 5.5 days. Following administration of 1mg i.v. Vitamin K in those patients without cardiac valves, re-audit showed the mean delay reduced to 2.2 days. Representations from at least 6 major specialties were considered and a consensus statement was derived. Standardised protocols, which hinge on whether or not the patient has or does not have a cardiac valve were devised. Vitamin K should not be given to those patients with a cardiac valve and early consultation with cardiology and anaesthetics is recommended, with consideration of referral to a specialist cardiothoracic unit. For those patients without a cardiac valve, 1mg of Vitamin K may be administered, repeated as necessary until the INR is less than 1.8. Intravenous Heparin should be provided in the interim whilst the patient is waiting for surgery. This is discontinued the morning of surgery and subcutaneous Heparin reinstated post-operatively. These recommendations have been trialled in the two units involved in the study and have been relatively safe and easy to implement

Introduction:. The safety of simultaneous bilateral knee replacement (BTKA) remains controversial. Some studies have proposed a higher incidence of serious complications, even death, following BTKA whilst others refute the latter. The objective of this meta-analysis was to evaluate the safety of BTKA. Methods:. A computerised literature search was conducted to identify all citations, between 1966 to 2005, concerning BTKA. All the English-language abstracts were obtained. A multistage assessment was then used to identify articles fulfilling the inclusion criteria for the study. All randomised, prospective studies reporting the outcome of BTKA were included. Details of any reported data were extracted and extensive analysis of relevant variables carried out. Results:. 150 published articles pertaining to BTKA were identified of which 18 papers on 27,807 patients (44,684 knees) were included in the meta-analysis. 10,734 cases were unilateral TKA, 16,378 were simultaneous BTKA and 458 were staged bilateral TKA with at least 3 months’ time duration between the surgical procedures. The complications analyzed were DVT, PE, cardiac events and mortality. The incidence of PE (OR=1.8), cardiac complications (OR=2.4), and mortality (OR=2.24) were higher after simultaneous BTKA. The incidence of DVT was LOWER in the group with simultaneous BTKA. Discussion:. Based on the findings of this meta-analysis, simultaneous BTKA seems to carry a higher risk of serious cardiac complications, pulmonary complications, and mortality. This procedure should be reserved for the healthy and young patients

Introduction. The safety of simultaneous bilateral knee replacement (BTKA) remains controversial. Some studies have proposed a higher incidence of serious complications, even death, following BTKA whilst others refute the latter. The objective of this meta-analysis was to evaluate the safety of BTKA. Methods. A computerised literature search was conducted to identify all citations, between 1966 to 2005, concerning BTKA. All the English-language abstracts were obtained. A multistage assessment was then used to identify articles fulfilling the inclusion criteria for the study. All randomised, prospective studies reporting the outcome of BTKA were included. Details of any reported data were extracted and extensive analysis of relevant variables carried out. Results. 150 published articles pertaining to BTKA were identified of which 18 papers on 27,807 patients (44,684 knees) were included in the meta-analysis. 10,734 cases were unilateral TKA, 16,378 were simultaneous BTKA and 458 were staged bilateral TKA with at least 3 months time duration between the surgical procedures. The complications analysed were DVT, PE, cardiac events and mortality. The incidence of PE (OR=1.8), cardiac complications (OR=2.4), and mortality (OR=2.24) were higher after simultaneous BTKA. The incidence of DVT was LOWER in the group with simultaneous BTKA. Discussion. Based on the findings of this meta-analysis, simultaneous BTKA seems to carry a higher risk of serious cardiac complications, pulmonary complications, and mortality. This procedure should be reserved for the healthy and young patients

Blood conservation is an essential aspect of total hip arthroplasty (THA). As recently as 10 years ago, it was standard practice across North America for patients to undergo pre-operative autologous blood donation (PAD) prior to an elective TJA. Though the cost of PAD is about the same as allogenic blood transfusion, it has fallen out of favor due to mixed results. Instead, most surgeons have implemented a practice of obtaining pre-operative hemoglobin levels. If anemia is diagnosed, the patient should be worked up for the underlying cause. In cases of pre-operative anemia where a specific deficiency cannot be elucidated, consideration can be given to the use of erythropoietin (EPO). The routine use of tranexamic acid (TXA) has become the standard of care at most institutions since it is safe, inexpensive, easy to administer, and very effective at minimizing peri-operative blood transfusion. Intravenous TXA can be administered effectively in a variety of different ways and a number of different protocols are described. The popularised Mayo Clinic protocol is to administer TXA once prior to incision (1g IV in 50mL of normal saline) and once during wound closure. Acute normovolemic hemodilution is a technique utilised just before or after the induction of anesthesia in which whole blood is removed while keeping the patient normovolemic with acellular fluids (i.e. crystalloids or colloids). This technique is rarely used. Hypotensive anesthesia is a technique utilised to keep mean arterial pressures (MAP) at a level around 50mm Hg. It appears to be most effective with the use of epidural anesthesia. Certain patients may not be good candidates for hypotensive anesthesia (high cardiac risk factors), but it can be an effective corollary to other intra-operative measures. Historically, many surgeons practiced reflexive transfusion protocols rather than treating patients on an individual basis. Current practice has adopted a more pragmatic approach to transfusion. Specifically, patients are assessed for signs of anemia and are often allowed to drift well below 8g/dL as long as they remain asymptomatic and have a suitable cardiac risk

Background. In the United Kingdom, over 1 million elective surgeries were cancelled due to COVID-19, resulting in over 1.9 million people now waiting more than 4 months for their procedure – 3x the number last year. To address this backlog, the healthcare service has been asked to develop locally-designed ‘COVID-light’ facilities. In our local system, 822 patients awaited orthopaedic surgery when elective surgery was permitted to resume. The phased return of service required a careful and pragmatic prioritisation of patients, to protect resources, patients, and healthcare workers. Aims. We aim to describe how the COVID-19 Algorithm for Resuming Elective Surgery (CARES) was used to consider 1) Which type of operation and patient should be prioritised? and 2) Which patients are safe to undergo surgery? The central tenets to this were patient safety, predicted efficacy of the surgery, and delivering compassionate care by considering biopsychosocial factors. Methods. Orthopaedic surgeons were provided with details of patients on their waiting list. They prioritised patients into those for surgery within 1 month (. Urgent. : e.g. arthroplasty for rapid deterioration from avascular necrosis or infection, or in the lowest quartile of Oxford Hip/Knee/Shoulder scores), < 3 months (. Soon. : e.g. revision or second-stage arthroplasty), and > 3 months (arthroplasty for end-stage arthrosis). The surgeon-led stratification was then reviewed by a multidisciplinary surgical prioritisation team, including anaesthetists and operating theatre managers, to consider medical history, the need for additional intraoperative services (such as cardiac physiologists, or specialist equipment requiring industry ‘reps’), and the risk of postoperative deterioration requiring HDU/ICU. The MDT also reviewed what the impact of disease and further delay may have on a patient's mental health, ability to work, or ability to care for dependents. The CARES protocol created an aggregate score for efficacy, compassion, safety and surgical risk to equitably rank patients. Results. The implementation of CARES stratified the waiting list into 122 (14.8%) patients requiring urgent surgery, with high likely health-gain or biopsychosocial gain, of whom 76 were low-risk and 46 were high-risk – medically moribund or complex. There were 232 (28.2%) patients required surgery within 3 months, and 468 (57.1%) patients were deemed safe to delay for > 3months. Alongside i) staff- and patient-screening, ii) adequate personal protective equipment, and iii) increased used of regional anaesthesia, the healthcare system was reconfigured, to create two surgical pathways. ‘Green Well’ patients were scheduled for surgery at a clean site – an elective surgical centre with no on-site HDU/ICU. ‘Green High-Risk’ patients underwent surgery at the general hospital (with on-site HDU/ICU) in operating rooms (ORs) which were physically segregated from ‘Red’ ORs reserved for COVID-19+ or trauma patients. In 6 weeks, 164 patients underwent surgery with no transmission of COVID-19 between patients or staff. Conclusion. Our healthcare system safely resumed elective surgery as early as the top 2% of hospitals nationally. This was facilitated by CARES stratification (which factors safety, efficacy, and compassion), MDT-led decisions, and surgical pathway reconfiguration. This generalisable, validated approach could be widely applied to facilitate restarts globally

INTRODUCTION. Shoulder arthroplasty (SA) is an effective procedure for managing patients with shoulder pain secondary to degenerative joint disease or end stage arthritis that has failed conservative treatment. Insurance status has been shown to be an indicator of patient morbidity and mortality. The objective of the current study is to evaluate the effect of patient insurance status on outcomes following shoulder replacement surgery. METHODS. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing shoulder arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical and surgical complications occurring during the same hospitalization with secondary analysis of mortality. Pearson's chi¬squared test and multivariate regression were performed. RESULTS. A data inquiry identified 103,290 patients (68,578 Medicare, 27,159 private insurance, 3,544 Medicaid/uninsured, 4,009 Other) undergoing partial, total and reverse total shoulder replacements. The total number of complications was 17,810 (17.24%), and the top three complications included acute cardiac events (8,165), urinary tract infections (3,154), and pneumonia (1,635). The highest complication rate was observed in the Medicare population (20.3%), followed by the Medicaid/uninsured (16.9%), other (11.1%), and the privately-insured cohort (10.5%). Multivariate regression analysis indicated that having Medicare insurance, white race, increasing age, higher comorbidity, and urgent or emergent admissions was associated with medical complications. Black patients, increasing age and comorbities was associated with surgical complications. Overall mortality was 0.20% and was more common in total shoulder arthroplasty and surgeries done on emergent or urgent admissions. DISCUSSION. This data reveals that patients with Medicare, Medicaid or no insurance were more likely to have medical complications, most commonly cardiac complications, UTIs and pneumonia. Primary insurance payer status can be considered as an independent risk factor during preoperative risk stratification and planning