Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Introduction. Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP). Methods. A retrospective review of patients aged above 65 years with distal femur fractures (both native and peri-prosthetic) who underwent surgical management between June 2020 and May 2023 was conducted. Patients were divided into three groups based on mode of fixation - single plate or dual plating or nail-plate construct. AO/OTA classification was used for non-periprosthetic, and Unified classification system (UCS) was used for periprosthetic fractures. Data on patient demographics, fracture characteristics, surgical details, postoperative complications, re-operation rate, radiological outcomes and mortality rate were evaluated. Primary objective was to compare re-operation rate and mortality rate between 3 groups at 30 days, 6 months and at 1 year. Results. A cohort of 32 patients with distal femur fractures were included in this study. 91% were females and mean age was 80.97 (range 68–97). 18 (53%) were non-periprosthetic fracture and 14 (47%) were periprosthetic fractures.18 patients underwent single plate fixation (AO/OTA 33A – 8, 33B/C – 2, UCS V3B – 5, V3C – 3),10 patients had dual plate fixation (AO/OTA 33A – 1, 33B/C – 4, UCS V3B – 3, V3C – 2) and 4 patients underwent nail-plate combination fixation (AO/OTA 33A – 4). 70.5% patients had surgery within 36 hours of admission and 90% within 48 hours. Analysis showed no re-operation at 30 days, 6 months in all 3 groups. At 1 year one patient had re-operation in dual-plating periprosthetic group (Distal femur replacement done for failed fixation). Three patients (16%) in single plate group had re-operation at 2 years (2 for peri-implant fracture and 1 for infection). None of the patients treated with Nail-plate combination had re-operation. Mortality rate at 30 days was 0% in among all the 3 groups. At 6 months, it was 16% in single plate group and 0% in DP and NP groups at 6 months and at 1 year mortality rate was 27% in SP group, 10% in DP and 0% in NP group. Combined mortality rate was 0% at 30 days, 9% at 6 months and 18.7% at one year. Conclusion. Our analysis provides insights into fixation methods of distal femur fractures in elderly patients. We conclude that a lower re-operation rate and mortality rate can be achieved with early surgery and rigid fixation with either dual plating or nail-plate construct to allow early mobilisation. Further prospective studies are warranted to confirm these findings and guide the selection of optimal surgical strategies for these challenging fractures

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Ankle fractures in the elderly are common and have a mortality rate of 12% within the first year. Treatment is challenging due to osteoporotic bone and patient co-morbidities. Many patients struggle with non-weight-bearing (NWB) and presently there is no consensus in the literature regarding optimum management of these injuries. We hypothesised that early weight-bearing in frail patients, Clinical Frailty scale (CFS) score of 4 or more will reduce morbidity and allow patients to return to their usual place of residence faster without jeopardising clinical outcome. We conducted a retrospective analysis of 80 patients aged over 65 years managed at Fiona Stanley Hospital for ankle fractures between January 2016 and 2018. Patients were divided into two cohorts: 40 patients managed NWB and 40 who were permitted to weight-bear as tolerated (WBAT). Patients were stratified as fit (CFS 1–3) or frail (CFS 4+). Primary outcomes were one-year mortality, return to primary residence at six weeks and complications. Secondary outcomes included length of acute hospital stay and rehab stay. For frail patients, those managed NWB stayed in rehab for 19 days longer (p=0.03) and had 28% more complications (p=0.03). By 6 weeks, fewer patients returned to full weight-bearing (p=0.03) and fewer patients had returned home (p=0.01). For fit patients, there were no significant differences in primary outcomes between NWB and WBAT. Our novel study categorising patients by CSF demonstrates that early mobilisation in frail patients results in improved outcomes. Currently there is no formal treatment protocol for the management of ankle fractures in the elderly, and we hope that our proposed algorithm will assist surgeons at our institution and elsewhere. Our study suggests that WBAT may benefit frail patients. We propose a protocol to assist in the management of geriatric ankle fracture patients based on clinical frailty scores

Introduction. Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Materials & Methods. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded. Results. There were 32 patients within each arm. Mean age was 78.4 (TTC) and 78.3 (ORIF). The CCI was 5.9 in each group respectively with mean ASA 2.9 (TTC) and 2.8 (ORIF). There were two open fractures within each group. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (TTC) versus 3.3 days (ORIF). There was no statistically significant difference in 30-day, one year or overall mortality at final follow up. Kaplan-Meier survivorship analysis did however demonstrate that of those patients who died post-operatively the mean time to mortality was significantly shorter in those treated with TTC nailing versus ORIF (20.3 months versus 38.2 months, p=0.013). There was no statistical difference in the overall complication rate between the two groups (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in patients treated with TTC nailing however this was not statistically significant. There was no statistical difference in the FADI scores at final follow up, 72.1±12.9 (TTC) versus 67.9±13.9 (ORIF) nor post-operative mobility status. Conclusions. Within our study TTC nailing with an unprepared joint demonstrated broadly equivalent results to ORIF in the management of high-risk ankle fragility fractures; this replicates findings of previous studies. We did however observe that mean survival was significantly shorter in the TTC group than those treated with ORIF. We believe this may have been contributed to by a delay to theatre due to TTC stabilisation being treated as a sub-specialist operation in our unit at the time. We propose that both TTC and ORIF are satisfactory techniques to stabilise the frail ankle fracture however, similarly to the other fragility fractures, the priority should be on an emergent operation in a timely fashion in order to minimise the associated morbidity and mortality. Further randomised control studies are needed within the area to establish definitive results and a working consensus

Introduction. The elbow is the second most common site of non prosthetic joint dislocation. Simple elbow dislocation alone contributes to 11-28% of all elbow injuries. Post-reduction treatment methods include traditional plaster of Paris (POP) immobilisation followed by physiotherapy, sling application followed by early mobilisation and rapid motion. The aim of the study was to evaluate the final outcome and cost-effectiveness of the pop and the sling groups. Study Design. Retrospective cohort study. Methods. We reviewed 42 simple elbow dislocations treated between 1998-2003. 20 patients in POP group and 22 patients in the sling group were assessed at a minimum follow-up of two years. The data collected consisted of age, gender, duration of immobilisation, length of physiotherapy, and return to work. All were assessed using MEPI (Mayo Elbow Performance Index) score and Quick DASH questionnaire. The final outcome was graded as excellent, good, fair and poor. Results. The final functional outcome in the POP group was 10 excellent, 3 good, 4 fair and 3 poor. In the sling group, we had 19 excellent, 1 good and 2 fair results. The mean MEPI scores in the POP and sling group were 89.2 and 98.2 respectively (p<0.05). The mean quick DASH scores in the POP and sling group were 12.8 and 2.7 respectively (p<0.05). The final functional outcome is directly dependent on the length of immobilisation (R=0.91). The mean time to return to work in POP group and sling groups was 6.6 and 3.2 weeks respectively (p<.001). Conclusion. Sling and early mobilisation is a safe and cost-effective method of treatment for simple elbow dislocation. The length of physiotherapy and time taken to return to work were significantly shorter in the sling group. Early mobilisation did not result in redislocation or late instability. The final outcome of the sling and early mobilisation group was significantly better than POP immobilisation group

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Background. Total Hip Arthroplasty (THA) using the Direct Anterior Approach (DAA) is a muscle sparing approach which promotes early mobilisation of patients. It is a technically challenging approach shown to have a high rate of complications, especially during the learning curve. Here we present the results of 157 cases of THA via a DAA on a standard theatre table, with a minimum of 6 months follow-up. Materials & Methods. The authors conducted a prospective study on a group of 149 consecutive patients undergoing 157 cementless primary THAs for coxarthrosis, 8 bilateral. The same surgical technique was used in all patients, performed by the senior author WLW at a single centre. The average age of the patients at time of surgery was 69 years, 78% were female and 57% were right sided. All implants were uncemented, with bearings being ceramic on ceramic or Ceramic on highly cross-linked polyethylene. Patients were assessed clinically and radiographically pre- and post-operatively at 6 weeks, 6 months, 1 and 2 years. Intra-operatively, navigation was used to guide cup position and assess offset and leg length. Results & Discussion. At the time of the latest follow-up, 1 patient had died of unrelated cause and 8 (5%) were lost to follow-up Clinically, the mean Harris Hip Score was 91 points with 88% reporting a good or excellent result, with 5% reporting moderate to severe pain. Radiographically all patients assessed had evidence of stable bony ingrowth. There was subsidence of 2–5mm in 9 stems (6%). Osteolysis was reported adjacent to one cup and one stem. There were no dislocations. The complication rate was 4.5%. This included 2 intra-operative femoral fractures, one a minor greater trochanteric fracture not requiring fixation, the other a calcar fracture treated at time of surgery. There were 3 femoral fractures occurring on average 4 weeks after surgery all requiring revision and one stem subsidence of 10mm following a heavy fall, subsequently requiring revision for leg length discrepancy. Other complications included one non-fatal PE, a haematoma that required evacuation. We report 20 (12%) episodes of lateral femoral cutaneous nerve palsy of any severity, most of which had or were resolving at the 6 month follow-up. Kaplan Mieir survival analysis was 97.2% at minimum 6 months. Patients mobilised day of surgery or day 1 post-op, and were discharged on average day 4 post-op. Neither the intra- or post-operative fractures could be attributed to the learning curve. Similarly episodes of stem subsidence and LFCN palsy occurred spread out over the 3 years of the study. This study supports the existing orthopaedic literature reporting the benefits of the DAA for THA with reduced soft tissue damage, reduced blood loss and early mobilisation with a low incidence of dislocation. Other authors however have reported a high incidence of complications attributing them to the early learning curve. This early study of DAA using a standard theatre table has identified that complications of fracture, stem subsidence and LFCN injury can occur at any time and bear no relationship to a learning curve

Introduction. The primary goal of treatment of an ankle fracture is to obtain a stable anatomic fixation to facilitate early mobilisation and good functional recovery. However, the need for open reduction and internal fixation must be weighed against poor bone quality, compromised soft tissues, patient co-morbidities and potential wound-healing complications. Materials and Methods. We reviewed two matched groups of 18 patients each, who underwent fixation for unstable Weber-B ankle fractures with intramedullary fibular nail (Group 1) and Standard AO semi-tubular plate osteo-synthesis technique (Group 2) to achieve fracture control and early mobilisation. Clinical and radiological fracture union time, and the time at mobilisation with full weight bearing on the ankle were used as outcome measures. Results. The mean age of patients in both the groups was 53.6 yrs and 55.5 yrs respectively. The mean follow-up period was 5.4 months (Group 1) and 6.9 months (Group 2) before discharge. Clinical and radiological union was achieved earlier in patients treated with intramedullary fibular nail (7.3 weeks & 8.7 weeks respectively) compared with plate osteo-synthesis treatment (8.2 weeks & 9.8 weeks respectively) and this was statistically insignificant (p=0.66 & p=0.54 respectively). Patients achieved full weight bearing at 8.4 weeks in nailing group compared to 8.2 weeks in plate osteo-synthesis group (p=0.40). One patient in the plate osteo-synthesis group had wound infection, requiring removal of hardware after fracture union. There were no wound complications in the nailing group. Conclusion. Open reduction and internal fixation with the use of plates and screws based on the AO osteo-synthesis technique remains gold standard for treatment of ankle fracture. Advantages of fibular nail include a minimally invasive procedure with respect to fracture biology, feasibility of its use in compromised soft tissue states and negligible wound healing complications and can be used as a viable alternative

Damage Control Surgery minimises ARDS in trauma. Originally adapted for abdominal trauma, Pape et al extended it for ‘borderline cases’ in Orthopaedics, categorised by narrow parameters such as (ISS) > 40. The rest of the cases are treated by Primary Total Care. ARDS developed due to two ‘hits’ – first, the extent of the trauma, second, the extent and timing of surgery. By manipulating the second hit, better outcomes are obtained. We discuss our usage of Damage Control Orthopaedics (DCO) principles in India. We reviewed 1456 patients operated between January 2002 and June 2005 (mean follow-up 29.5 months). 40 patients with polytrauma (28 male), mean age 39.9 years (range 18-77) and mean ISS 21.65 (range 13-41) satisfed our inclusion criteria (at least 2 long bones fractured or 2 systems injured presenting more than 48 hours after injury). Patients were admitted under the joint care of intensivists and surgeons, and had twice daily physiotherapy with early mobilisation. Fractures awaiting fixation were mobilised with braces and plasters temporarily. Acid-base, nutritional and electrolyte imbalances were corrected on a priority basis. An average of 3.4 procedures was performed on each patient (range 2-7) including 45 long bone nailings. Mean interval between admission and last surgery was 11.1days (range 6-19). 37 patients needed significant pre-operative resuscitation including 5 with ARDS. Post-operatively 39/40 survived and 35/40 returned to normal lives. The only post-operative ARDS died. Furthermore we describe ‘the third hit’ phenomenon which is the collective adverse impact of late presentation of trauma cases, inadequate and incompetent primary care, pre-existing medical conditions, financial, social and infrastructural constraints. Polytrauma patients, even with low ISS, can develop ARDS if they present late to a trauma centre. Appropriate medical therapy and slow but systemic approach to surgery along with aggressive physiotherapy, use of orthosis and early mobilisation saves lives

Multimodal analgesia protocols for pain control following total joint arthroplasty can reduce post-operative pain, allow early mobilisation and early discharge from hospital. This study analyses the achievement of functional milestones, patient satisfaction, length of stay and adverse outcomes using a multimodal analgesia protocol in total joint arthroplasty. All patients planned for elective hip and knee arthroplasty in a NSW teaching hospital under one surgeon between July 2007 and January 2009 were included in this prospective study. Patients undergoing revision surgery, bilateral arthroplasty or total hip arthroplasty for fractures were excluded. Unless contraindicated, all patients followed the multimodal analgesia protocol based on the local infiltration analgesia technique described by Kerr and Kohan. Outcomes measurements included. Patient demographics, post operation milestones, visual analogue pain scores (VAS), narcotic consumption, length of stay, discharge destination, patient satisfaction scores and adverse outcomes. Nineteen patients (13 female and 6 male) with an average age 67 years and BMI 33 had total hip arthroplasty surgery. 84% (16/19) ambulated within six hours post operation. 47% (9/19) of patients were discharged home by day 3 post operation (1/19 on day 1, 5/19 on day 2, 3/19 on day 3). Average day post operation for discharge home was 4.5 days. Thirty-one patients (17 female and 14 male) with an average age 68 years and BMI 33 had total knee arthroplasty surgery. 90% (28/31) ambulated within six hours after surgery. 71% (22/31) of patients were discharged home by day three post operation (6/31 on day 1, 8/31 on day 2 and 8/31 on day 3). Average day post operation for discharge home was four days. Ten patients required morphine in addition to protocol analgesia. VAS scores (1 to 10) averaged 3.2 day one post op and 2.6 prior to discharge. Three patients developed nausea and vomiting and one patient developed urinary retention. No infections, DVTs or other adverse effects occurred in either hip or knee arthroplasty groups. Majority of patients were very satisfied according to 24 hour post op pain management survey and six week post op patient satisfaction survey. Local infiltration analgesia in knee and hip arthroplasty surgery is a safe, well-tolerated and effective form of pain control allowing early mobilisation and early discharge from hospital (1,2). This protocol has been successfully implemented in a public hospital

This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease

Background. The Enhanced Recovery Programme (ERP) is an evidence based initiative aimed at speeding up patient recovery after major surgery and improving their outcomes. The Royal National Orthopaedic Hospital, Stanmore (RNOH) is a specialist orthopaedic and implemented an ERP for primary knee arthroplasties from October 2010. Aims. To analyse the initial results of patients participating in our ERP for primary knee arthroplasty to identify what factors predict their Length of Stay (LoS) and establish where changes can be made to improve outcomes further. Method. We interrogated our prospective ERP database and determined which patients achieved and which ones exceeded the 5-day LoS target. We then performed a further retrospective notes review to gather supplementary information including non-modifiable patient factors to identify factors which influenced their LoS. Results. 261 patients participated in the Knee ERP at the RNOH between October 2010 and December 2011 including patients undergoing complex procedures and bilateral procedures during the same in-patient episode. Mean age was 64 years (32–85 years). Mean LoS was 6.1 days (2–29 days). ASA grade and attendance at the multidisciplinary Joint School all had a positive influence on the LoS, particularly when combined. The day of mobilisation had the greatest correlation with those mobilising early. Mean LoS was 2.8 (Day 0), 4.41 (Day 1), 6.38 (Day 2), 9.23 (Day 3) and 12.95 (Day 4 or later). Conclusion. Identifying and targeting modifiable variables can further improve the outcomes for this particular group of patients. ASA grade and attendance at the multidisciplinary Joint School are among the positive influences on patient LoS. Adjusting analgesia to reduce unwanted effects may facilitate earlier engagement with the physiotherapy service and thus earlier mobilisation. Early results suggest encouraging patients to attend Joint School with subsequently early postoperative mobilisation can positively influence safe return to the home environment

29 cases of complex elbow injuries were reviewed at a mean period of 15 months. Outcome measures included MEPS and DASH score. Patients who had defined early surgery were significantly better than those in whom surgery was delayed. We concluded that Management of complex elbow injuries can be improved by early definitive surgery. The magnitude and type of soft tissue injuries should be identified. MRI scans should be liberally used for this purpose. We believe that early, adequate and appropriate management of soft tissue injuries including use of articulated external fixator for early mobilisation improves the outcome of complex elbow injuries

Introduction. Enhanced Recovery Protocol (ERP) for elective total hip or total knee replacement has become the gold standard. The main principles are to reduce bleeding, both with a tranexamic acid infusion and local injection of adrenaline, and to reduce the risk of postoperative thrombo-embolic complications by early mobilisation, enabled by local anaesthetic infiltration at time of surgery. The aim of this study is to evaluate the impact of the ERP. Methods. A retrospective review was performed including all patients who underwent primary hip or knee arthroplasty surgery between January 2011 and December 2013. The ERP was implemented in our department in August 2012 thus creating two cohorts; the traditional postoperative group and those undergoing ERP. Outcome measurements of length of stay, postoperative transfusion, thrombo-embolic complications and number of re-admissions were assessed. Results. 1262 patients were included. The traditional group contained a total of 632 patients and the ERP group contained 630 patients. The number of patients receiving a blood transfusion postoperatively significantly decreased from 50 (7.9%) to 27 (4.3%) (p value <0.05). There was no statistical difference in postoperative thrombo-embolic events. The length of stay was reduced from 5.5 days to 4.8 days (P value <0.05). There was no difference in the number of re-admissions. Conclusion. ERP has led to a significant decrease in transfusions after elective arthroplasty surgery, without increasing the incidence of thrombo-embolic events. Furthermore it has significantly reduced the length of stay which has obvious cost implications. This study agrees with the current literature in that enhanced recovery should indeed be the gold standard for elective arthroplasty procedures

Management of bone defects is a common surgical challenge encountered following any high energy trauma. Femur fractures with bone loss account for 22% of all the fractures with bone loss/defect, and 5% to 10% of distal femur fractures are open injuries. It was estimated in 2008, that, more than 4.5 million open fractures occur annually in India. In this retrospective study, patients who received bone allograft from our tissue bank between May 2012 and September 2015 were analysed. Of the 553 allografts issued, at that point in time, 26 were used in patients who underwent reconstruction for distal Femur fractures primarily. Fractures with defect or bone loss from 12 cc (1cm) to 144 cc (12cm) were treated with either Internal or External fixation and bone allograft. Morcellised cancellous, or a cortical strut, were used to fill or reconstruct the defect or void. The radiological outcome in terms of fracture union was assessed and Knee society score was used to assess the functional outcome. Complications such as non- union, infection, stiffness and need of revision or additional procedures were also assessed. Osseous consolidation was achieved in all the 26 patients with a Median time of 24 weeks (16 to 60). The Median Functional Knee Society Score was 80, indicating satisfactory functional outcome. Infection was noted in one patient, but it was not attributed to the allograft. Additional minor procedures like bone marrow infiltration, corticotomy for bone lengthening were required in 10 patients. Our studycomprises the largest group of patients treated primarily with Allograft to reconstruct or fill the void of bone loss encountered with distal Femur fracture. Reconstruction of massive bone defects, in patients of distal Femur fractures, with bone allograft, shows encouraging results. The surgeon can achieve the goal of restoring form and function of these difficult injuries in a single stage and the technique will provide the freedom to reconstruct the bony defect up to 150 cc (12 cm length) and recreate the anatomy to near normal. This allows for early mobilisation of patients and restoration of their daily routine at the earliest

Re-positioning osteotomy in the treatment of un-united fracture neck of femur in young patients improves the biomechanical pre-conditions to promote bone union of the Pseudarthrosis. This operative procedure is the method of choice for Pseudarthrosis of the neck of the femur with a viable femoral head. It is also the method of choice in children and in adolescents even if there is avascular necrosis of the femoral head. The operative technique permits exacts planning, stable osteosynthesis both of the un-united fracture of the neck of the femur as well as the osteotomy and allows early mobilisation. In this series of 56 cases, only six (10%) had collapse of the femoral head due to avascular necrosis, six (10%) patients had severe pain in the hip and nine (16%) patients had severe restriction of hip movement. The overall success of the operation in this series was 84%

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation, avoid IR of the femoral and ER of the tibial components, maintain correct joint line position, and achieve symmetrical soft tissue balance. Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilisation of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues. When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure). Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function

The Enhanced Recovery Pathway aims to improve the patient experience as well as expediting discharge. We aim to discharge 85% of patients by day 3. This audit retrospectively looked at primary total hip replacements (THR) and total knee replacements (TKR) patients who had 7 days length of stay and evaluated the factors contributing to the delay. There were 24 patients who stayed 7 days, 12 THR and 12 TKR. There were 15 females and 7 males, the mean age was 77 years (52 to 89). Causes for the delay included patient's reluctance to engage in their rehabilitation (21/24) and Occupational Therapists (OT) identifying difficulties in patient's home circumstances on admission (12/24). Medical problems also delayed early mobilisation, particularly urethral catheterisation (9/24), investigation for venous thromboembolism (6/24) and blood transfusion (3/24). Delay in discharge is multifactorial and requires involvement of MDT. We have identified ways to enhance patient engagement, including a “patient journey” DVD shown preoperatively at “Joint School” and individual white boards for daily goal setting. Fostering greater self-efficacy in patients may improve participation in preoperative discharge planning with OTs. Specific preoperative education may help patients understand the importance of continuing their rehabilitation while medical problems are managed

Introduction. The management of peri-prosthetic distal femur fractures following TKR (Total Knee Replacement) in the elderly remains a challenge with little or no consensus on the best available treatment. Various methods have been described in the management of these complex fractures. Our study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing). Methods. We retrospectively reviewed our database for patients admitted with peri-prosthetic distal femoral fractures between 2005–2013 (n=61). The patients were stratified into 2 groups based on method of management. The Distal Femoral Arthroplasty group (Group A) had 21 patients, with a mean age of 78 years (68–90. The Fixation group (Group B) had 40 patients, with a mean age of 74 years, 23 of those had plating of the fracture, while 17 had a retrograde nail inserted. Pain scores, Length of stay, intra-operative blood loss, and weight bearing status, were compared. Functional outcomes were also assessed using Oxford knee scores, KSS scores, VAS pain assessment and range of motion from last follow up appointment. Minimum follow-up was 2 years. Cost analysis was done for both groups, which included implant costs, consumable costs (man power included), theatre utilisation time and length of hospital stay. The calculation was done based on the PbR (payment by results) system and “best practise tariffs 2010–11” utilised by the NHS (National Health Service) in England. Results. In group A, the average surgical time was 116 minutes with mean blood loss of 400 ml. In group B, the mean surgical time was 123 minutes with average blood loss of 800 ml. The mean length of hospital stay in group A was 9 days whereas in group B was 32 days. All patients were fully weight bearing by day 1.5(range 1–3 days) in group A, compared to a mean of 11 weeks in group B. Mean Oxford score was 28 and KSS score was 70 in group A compared to 27 and 68 in group B. The pain score on VAS was 2 for group A and 1.5 for group B. The mean ROM of the knee was 95° in group A and 85° in group B. We had 4 complications in group A. There were 2 deaths due to medical co-morbidities, 1 superficial infection, and 1 DVT. In the fixation group, there were 6 deaths due to medical co-morbidities, 1 failure of fixation, 6 mal-unions, 1 non-union and 2 infections. Overall, the distal femoral arthroplasty procedure costs approximately £10000, and the fixation group costs were on average of £9800. Discussion & Conclusion. Distal femoral arthroplasty allowed early mobilisation, thus avoiding prolonged hospital stay and reducing the risk of inpatient related morbidity. Complication rates were lower than the fixation group and the overall costs were comparable to that of fixation. Distal femoral arthroplasty appears to be a promising alternative treatment to internal fixation in elderly patients with distal femoral peri-prosthetic fractures. With appropriate patient selection, the prosthesis is likely to survive for the duration of patient's lifetime