Aims. As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. Methods. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. Results. In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). Conclusion. Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886–892

Aims. Unicompartmental knee arthroplasty (UKA) and bicompartmental knee arthroplasty (BCA) have been associated with improved functional outcomes compared to total knee arthroplasty (TKA) in suitable patients, although the reason is poorly understood. The aim of this study was to measure how the different arthroplasties affect knee extensor function. Methods. Extensor function was measured for 16 cadaveric knees and then retested following the different arthroplasties. Eight knees underwent medial UKA then BCA, then posterior-cruciate retaining TKA, and eight underwent the lateral equivalents then TKA. Extensor efficiency was calculated for ranges of knee flexion associated with common activities of daily living. Data were analyzed with repeated measures analysis of variance (α = 0.05). Results. Compared to native, there were no reductions in either extension moment or efficiency following UKA. Conversion to BCA resulted in a small decrease in extension moment between 70° and 90° flexion (p < 0.05), but when examined in the context of daily activity ranges of flexion, extensor efficiency was largely unaffected. Following TKA, large decreases in extension moment were measured at low knee flexion angles (p < 0.05), resulting in 12% to 43% reductions in extensor efficiency for the daily activity ranges. Conclusion. This cadaveric study found that TKA resulted in inferior extensor function compared to UKA and BCA. This may, in part, help explain the reported differences in function and satisfaction differences between partial and total knee arthroplasty. Cite this article: Bone Joint Res 2021;10(1):1–9

Aims. Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty. Methods. We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score. Results. Turnover among specific types of operating room staff, including the anaesthesiologist (p = 0.011), circulating nurse (p = 0.027), and scrub nurse (p = 0.006), was significantly associated with increased operative duration. Furthermore, the presence of medical students and nursing students were associated with improved intraoperative efficiency in TKA (p = 0.048) and THA (p = 0.015), respectively. The presence of surgical fellows (p > 0.05), vendor representatives (p > 0.05), and physician assistants (p > 0.05) had no effect on intraoperative efficiency. Finally, the presence of the surgeon’s 'preferred' staff did not significantly shorten operative duration, except in the case of residents (p = 0.043). Conclusion. Our findings suggest that active management of surgical team turnover and composition may provide a means of improving intraoperative efficiency during THA and TKA. Cite this article: Bone Joint J 2021;103-B(2):347–352

Abstract. Objectives. Unicompartmental (UKA) and bicompartmental (BCA) knee arthroplasty are associated with improved functional outcomes compared to Total Knee Arthroplasty (TKA) in suitable patients, although the reason is poorly understood. The aim of this study was to measure how the different arthroplasties affect knee extensor function. Methods. Extensor function was measured for sixteen cadaveric knees and then re-tested following the different arthroplasties. Eight knees underwent medial UKA then BCA, then posterior-cruciate retaining TKA, and eight underwent the lateral equivalents then TKA. Extensor efficiency was calculated for ranges of knee flexion associated with common activities of daily living. Data were analyzed with repeated measures analysis of variance (α=0.05). Results. Compared to native, no differences were detected in either extensor moment or efficiency following UKA. Conversion to BCA resulted in a small drop in extensor moment between 70-90° flexion (p<0.05), but when examined in the context of daily activity ranges of flexion, extensor efficiency was largely unaffected. Following TKA, large decreases in extensor moment were measured at low knee flexion angles (p<0.05), resulting in 8–43% reduction in extensor efficiency for daily activity ranges. Conclusion. This cadaveric study found that TKA is associated with inferior extensor function compared to UKA and BCA. This may, in part, help explain the reported differences in function and satisfaction differences between partial and total knee arthroplasty. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

It has been established that a dedicated orthopaedic trauma room (DOTR) provides significant clinical and organizational benefits to the management of trauma patients. After-hours care is associated with surgeon fatigue, a high risk of patient complications, and increased costs related to staffing. However, hesitation due to concerns of the associated opportunity cost at the hospital leadership level is a major barrier to wide-spread adoption. The primary aim of this study is to determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency. Secondly, we sought to evaluate the associated financial impact of the DOTR, with respect to both after-hours care costs as well as the opportunity cost of displaced elective cases. This was a retrospective cost-analysis study performed at a single academic-affiliated community hospital in Toronto, Canada. All patients that underwent the most frequently performed orthopedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a four-year period from 2016-2019 were included. Patient data acquired for two-years prior and two-years after the implementation of a DOTR were compared, adjusting for the number of cases performed. Surgical duration and number of day-time and after-hours cases was recorded pre- and post-implementation. Cost savings of performing trauma cases during daytime and the opportunity cost of displacing elective cases by performing cases during the day was calculated. A sensitivity analysis accounting for varying overtime costs and hospital elective case profit was also performed. 1960 orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR. After accounting for the total number of each procedure performed, the mean weighted reduction was 31.4% and the mean time saved was 29.6 minutes per surgery. The number of daytime surgical hours increased 21%, while nighttime hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2,476. Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Through the regular scheduling of a DOTR at a single hospital in Canada, the number of surgeries occurring during daytime hours increased while the number of after-hours cases decreased. The same surgeries were also completed nearly one-third faster (30 minutes per case) on average. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Notably, the savings partially stem from decreased OR time as well as decreased nurse overtime. Widespread implementation can improve patient care while still remaining financially favourable

At our tertiary, large, academic healthcare system, we have access to an academic medical center (AMC), a community based, orthopedic friendly, efficient hospital (CBH) and several ambulatory care centers (ASC) which are being prepared to provide same day discharge (SDD) TJA and UKA. We had a near-capacity AMC with an excellent ability to care for medically and technically complicated TJA patients. However, efficiency was less than desired regardless of case complexity with an average effective case time of 4 hours. Concurrently, the orthopaedically, under-utilized community-based hospital (CBH) wanted to increase volume, improve margins, and become a TJA Center of Excellence with the ability to provide an efficient Hospital Outpatient Department (HOPD) and SDD TJA surgery experience. Methods. The CBH had a main operating floor and a separate floor of four OR suites which were repurposed with the goal of utilizing these rooms for TJA four days per week with an average of 3.5 cases per room per day. We preferentially performed primary, uncomplicated TJA, UKA, and minimally invasive TJA at the CBH. Revision surgeries, patients with extensive medical comorbidities, and complex primary surgeries would be performed at the AMC. Our goals were to decrease costs, readmissions, length of stay, and increase margins at the CBH while increasing efficiency, revenue and volume. Protocols were developed to facilitate SDD UKA and THA at both hospitals as well as rapid recovery protocols for TKA at both hospitals with the understanding that the CBH would perform more of these cases but the efficiency could also be implemented at the AMC when possible. We also needed a strategy to deal with TKA and eventually THA being removed from the Inpatient Only (IPO) list. CMS has utilized the “Two-Midnight Rule” to define outpatient status for both THA and TKA. This has distinct financial implications for the facility's reimbursement with outpatient being $10,123 on average versus $12,380 for inpatient status. A protocol-based system was put in place to make both hospitals compliant with the removal of TKA from the IPO List in order to avoid Quality Improvement Organization (QIO) and Recovery Audit Contractor (RAC) after implementation. Results. Comparing FY 2018 to FY 2019, volume increased 26.4% at the CBH. Outpatient case volume rose substantially from 14 cases to 243. Volumes were slightly decreased at the AMC (−4.57%) resulting in a substantial increase in margin contribution for the parent enterprise. Quality metrics at the CBH (surgical site infections (SSI), length of stay (LOS), readmissions, and mortality) were improved. LOS improved from 52% to 71% discharge before 48 hours. The LOS decreased 12% for THA and 8.1% for TKA. CBH readmission rates decreased from 1.38% to 0.9% with no deaths. Surgeon satisfaction is greatly improved as their volume, efficiency, quality metrics, and finances were enhanced. Financial performance was improved in aggregate and per case for the CBH. Although the CBH per-case revenue was 80.3% and 74.4% of the AMC for THA and TKA: the net margins were 3.6% and 18.8% higher for THA and TKA, respectively. The increased efficiency, lower hospital cost and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case. Conclusions. A shifting reimbursement landscape, value-based payment initiatives, and increasing volume have challenged traditional TJA delivery systems. This demonstrates one strategy to help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient settings including ambulatory surgery centers which will be subjected to even further decreases in net revenue per patient

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499

Aims. Tissue adhesives (TAs) are a commonly used adjunct to traditional surgical wound closures. However, TAs must be allowed to dry before application of a surgical dressing, increasing operating time and reducing intraoperative efficiency. The goal of this study is to identify a practical method for decreasing the curing time for TAs. Methods. Six techniques were tested to determine which one resulted in the quickest drying time for 2-octyle cyanoacrylate (Dermabond) skin adhesive. These were nothing (control), fanning with a hand (Fanning), covering with a hand (Covering), bringing operating room lights close (OR Lights), ultraviolet lights (UV Light), or prewarming the TA applicator in a hot water bath (Hot Water Bath). Equal amounts of TA were applied to a reproducible plexiglass surface and allowed to dry while undergoing one of the six techniques. The time to complete dryness was recorded for ten specimens for each of the six techniques. Results. Use of the Covering, OR Lights, and Hot Water Bath techniques were associated with a 25- (p = 0.042), 27- (p = 0.023), and 30-second (p = 0.009) reduction in drying time, respectively, when compared to controls. The UV Light (p = 0.404) and Fanning (p = 1.000) methods had no effect on drying time. Conclusion. Use of the Covering, OR Lights, and Hot Water Bath techniques present a means for reducing overall operating time for surgeons using TA for closure augmentation, which can increase intraoperative efficiency. Further studies are needed to validate this in vivo. Cite this article: Bone Jt Open 2022;3(8):607–610

The need for a better understanding of factors that influence surgical outcome has grown as many complications are thought to be avoidable. One approach proven useful in studying surgical procedures is time-action analysis (TAA), a method which objectively determines the efficiency of individual steps. The aim of this study was to assess the surgical process of total knee arthroplasty using TAA, thus enhancing the insight into the procedure, influence of team members and adverse events, eventually leading to process improvement and reduction of error probability. Methods: In two high output centres and one teaching hospital 37 TKA surgeries were recorded, using 3 different knee systems (NexGen, LCS and Triathlon). The process was analyzed using a fixed taxonomy and the duration, limitations and repetitions were determined using video analysis software. The efficiency of the surgeon was calculated by dividing the time the surgeon spends operating by the time operating plus the time spent talking, thinking or repeating. Results: Although the two high output centres used different knee systems there was no difference in operating time (47min. (95%CI, 43.2 to 50.1) versus 47min. (42.1 to 51.9)). With an inexperienced nurse the waiting time increased in both hospitals during the femoral osteotomy phase (p= 0.01 and p=0.05). Comparing to a training hospital, the tibial alignment phase showed lower surgical efficiency for both the consultant and 6th year residents (80% vs. 95%, p=0.01). Also the nurse waiting time increased during all phases (18min. vs. 2min., p=0.00). In the teaching hospital more problems (communication, instrument and skill) occurred (mean 19 vs. 5 and 2, p=0.00) and twice as much communication problems existed with residents regardless of nurse experience. Surprisingly the number of problems handling instruments increased inversely with nurse experience (p=0.02) as did the waiting time (27min. vs. 15min.) again being highest in the femoral osteotomy phase (p=0.00). Conclusion: The similar results in the high output centres show that TKA is a similar and structured process regardless of the knee system, its efficiency mainly dependent on surgical output. The decrease in resident efficiency is caused by less structured use of instruments and miscommunication with the nurse. For nurses the femoral osteotomy phase is most difficult, requiring high attention due to frequent changing of different pins and cutting blocks. Unfamiliarity with instruments (i.e. low volume) results in higher waiting times. Regardless of the knee system the steps of TKA are similar, therefore a consistent surgeon-nurse (OR tech) verbal interaction is advocated especially with a less experienced team. Training should focus knowledge of instruments using uniform names. Extra attention should be paid by those who do not often place knees to communication with the nurse and clear order of the procedure

Originally used for correction of angular malalignment, 2 hole plate epiphyseodesis has recently gained popularity in paediatric orthopaedic practice for the correction of leg length discrepancy. In this study we aim to assess the efficiency of guided growth plates in correcting leg length discrepancy. Thirty-three children treated for leg length discrepancy with guided growth plates (“8-Plate”, Orthofix, Inc and “I-Plate”, Orthopediatrics) in a tertiary referral centre were retrospectively analysed. Medial and Lateral plates were inserted for symmetrical growth reduction and patients were followed up with clinical and radiological assessment. Thirty patients had distal femoral epiphyseodesis and three had proximal tibial epiphyseodesis. Leg lengths and individual bone lengths were measured from pre and post – operative radiographs. The angle between the screws was measured from radiographs taken intra operatively and at the time of final follow up to assess screw divergence with growth. Efficiency was calculated as the ratio of growth inhibition achieved to the projected discrepancy at maturity if left untreated. At a mean follow up of 17 months (4–30 m) leg length discrepancy improved from a mean of 30 mm (50–15mm) to 13 mm (2.5–39mm) (p < 0.01). The angle between screws increased from 6 degrees to 26 degrees over the follow up period. Efficiency was found to be 66%. There were 5 patients with angular deformity who needed plate removal and 2 patients developed superficial infection that responded to oral antibiotics. Epiphyseodesis using guided growth plates is an effective way to correct leg length discrepancy as it is a reversible procedure. Patients undergoing this treatment should be kept under close follow up to prevent development of angular malalignment. Inserting the screws in a divergent fashion at the outset may increase the effectiveness of this procedure

Introduction and Objective. Almost 60% of the population can expect to experience low back pain (LBP) during their life. Several radiological tools are used to investigate LBP. However, adequate evidence is unavailable to support the use of single photon emission computer tomography (SPECT) in patients with LBP. The objective of this study is to assess the role and efficiency of SPECT in evaluation and management of patients with LBP. Method. Ninety-two patients with LBP were examined and assessed. All the patients received a magnetic resonance imaging (MRI) scan and were referred for a SPECT. We interpreted the modic and degenerative changes found on the MRI and compared it with SPECT tracer uptake. SPECT was used to identify the pain generator and then a surgical plan was made. Data was analyzed for pain improvement in those who underwent surgical treatment to establish the accuracy of CT SPECT in identification of primary pain generator. Results. A total of 184 patients were included in the study who underwent diagnostic CT-SPECT between January 2013 and December 2019. One hundred of them were females and Eighty four males; the mean age was 47.6 years. 111 patients underwent surgery in the form of interbody fusion or posterolateral fusion. 16 patients positive tracer uptake was at asymptomatic level or unrelated. In 3 patients SPECT identified screw sites as pain generator and in all 3 patients screws were removed with good pain relief. Overall axial pain as measured with Numeric rating scale was preoperatively 9.13 ± 0.7 and improved to 4.54 ± 2.3 at 6 months postoperative follow up. MRI changes have been analyzed and correlation studied with relation to SPECT findings. Conclusion. Due to its high precision and sensitivity compared to other radiological modalities, SPECT demonstrated the ability to aid in clinical diagnosis. CT SPECT reveals information that becomes vital in deciding further management. In this study, we exemplified that SPECT scan can give indication for pain generator in axial spine pain and aid in surgical intervention

Introduction. Quadriceps performance following total knee arthroplasty (TKA) is a critical factor in patient satisfaction that can be significantly affected by implant design (Greene, 2008). The objective of this study was to compare quadriceps efficiency (QE) following TKA with a medial-pivot system (EVOLUTION®, MicroPort Orthopedics Inc., Arlington, TN, USA) to non-implanted control measurements. Methods. Five cadaveric leg specimens with no prior surgeries, deformities, or disease were obtained. Each was placed in a custom closed chain device and loaded to simulate a heel-up squat from full-extension to deep flexion (approximately 115°) and back to full extension. Quadriceps force (FQ) and ground reaction force (FZ) were measured, and the ratio of the two was calculated as the quadriceps load factor (QLF). QFLs are inversely related to QE, with higher QFLs representing reduced efficiency. Each specimen was then implanted with a medial-pivot implant by a board certified orthopedic surgeon and force measurements were repeated. Mean pre- (represents control values) and post-implantation QFLs were compared to determine any differences in QE throughout the range of motion. Results. Mean QFLs were not statistically different for pre- and post-implantation measurements throughout loading (Figure 1). QE was increased in the post-implantation measurements compared to pre-implantation between approximately 80° and 115° flexion and reduced between 5° and 80°. The mean peak post-implantation QFL was 5% less than that measured pre-implantation. Discussion. Quadriceps muscles were least efficient during peak flexion (80°–115°) when FQ was highest during both pre- and post-implantation measurements. The similar QE seen between the pre- and post-implantation measurements for most of the range of motion could be a result of the system design, which seeks to mimic the kinematics of the normal knee (Schmidt, 2003). The observed nearly-linear change in the FQ through 75° is likely due to the combination of the medial spherical radius and the conformity of the medial tibial insert socket that provides a constant moment arm on which the extensor mechanism can act. The primary driver of decreasing efficiency of the extensor mechanism is the increasing moment arm of the load with increasing flexion. The second increase in FQ in deep flexion (>110°) for the implanted measurements is likely due to the smaller closing radius on the femoral component in this range. These preliminary data have the potential to be significant clinically in that decreased QE may result in increased quadriceps forces manifesting in anterior knee pain or patient fatigue. Additionally, increased QE may play a role in rehabilitation and return to activities of daily living. The current results show the medial-pivot system may increase QE during peak flexion and does not significantly reduce QE during midflexion when compared to control. In-vivo testing is needed to confirm if these results translate to clinical practice

INTRODUCTION. Adult reconstructive orthopedic surgery in the United States is facing an imminent logjam due to the increasing divergence of the demand for services and the ability for the community to supply those services. In combination with several other factors, a perfect storm is brewing that may leave the system overtaxed and the patient population suffering from either a lack of treatment, or treatment by less qualified providers. A key component to improving the overall efficiency of surgical care is to introduce enabling technologies that can effectively increase the throughput while simultaneously improving the quality of care. One such enabling technology that has proven itself in many industries is robotics, which has recently been introduced in surgery with even more recent applications in orthopedic surgery. A surgeon interactive robotic arm has been developed for partial knee arthroplasty (PKA) and total hip arthroplasty (THA). This study aims to analyse the efficiency of a new robotic technology for use in orthopaedic surgery. METHODS. 18 robotic arm assisted PKA's across 10 sites were recorded to accurately capture the timeline elemental tasks throughout the procedure. Two camera angles were set up to capture both surgical staff group dynamics and individual procedural steps. 17 tasks were identified and measured from video data. (Fig 1) The robotic arm specific tasks were analyzed for correlation to total surgical time (measured as first incision to last suture). The tasks for the surgeons with the shortest and longest total times were compared directly to determine areas of opportunity. RESULTS. Average total time across 18 surgeries was 55 ± 19 min (range: 30–98 min). There was no correlation between bone registration time and total time (p=0.271) and no correlation between femoral burring time and total time (p=0.230). Per task time comparison of the two surgeons exhibited an average time variation of 3.5 min per task (range: 0.7–8.4 min) (Fig 2). The robotic elements of the procedure exhibited an average time variation of 3.3 min per task while the non robotic elements of the procedure (boxed) exhibited an average time variation of 3.8 min per task. CONCLUSION. Our preliminary results indicate that introducing robotic technology in to the OR does not directly lead to an increase in total surgical time. On average, non robotic specific elements of the procedure exhibited a larger opportunity for efficiency gain. This is likely due to the fact that a large population of surgeon users are not only new to the robotic technology, but new to PKA. Further video collection and analysis will lead to an efficiency benchmarking program that aims to establish methods for best practices in achieving efficiency throughout a robotic arm assisted PKA procedure

Summary. Single use instrumentation had a significant reduction on OR Turnover time and instrument setup/clean up time compared to traditional instrumentation. Introduction. Recently, focus has shifted to improving OR efficiency by surgeons and hospital admin. The purpose of this study was to determine the effect of traditional instrumentation vs. single use instrumentation (SUI) on OR efficiency in navigated primary TKA. Methods. This prospective randomized study was conducted at a single center, community hospital by a single surgeon. Patients were split into two groups: Group 1 (Navigated Traditional (n=23)) and Group 2 (Navigated SUI (n=26)). Efficiency was examined by measuring specific time intervals based on milestones in the OR preparation, surgical procedure, and OR cleanup. Results. Instrument set up time was reduced by an average of 8.5 minutes (min) in Group2 vs. Group1 (p=0.00). Patient set up took slightly longer in Group2 (1.47 min) but not statistically significant (p=0.50). Both groups had similar procedure time (p= 0.21) and patient OR Time (120 min for both groups p=0.93). Instrument clean up time was significantly shorter in Group 2 (difference 3.44 min (p=0.01). Overall surgical episode was significantly faster in the Group 2 by 9.57 min (p=0.02). Tourniquet time significantly reduced in the Group 2 by 4.92 min (p=0.02). Overall Instrument set up and clean up was faster by 11.94 min in Group 2 vs. Group 1. Notably, the OR turnover time was reduced by 23.52 min in the Group 2 vs. Group 1. Conclusion. Single-use instruments had a significant reduction on OR Turnover time and instrument setup/cleanup time compared to traditional instrumentation. A larger prospective trial is warranted

We report the effect of padding on the efficiency of the pneumatic tourniquet for the upper limb. Varying thicknesses of two commercially-available types of orthopaedic padding (Cellona and Velband) were applied to the arms of 20 volunteers, with three pressure transducers placed directly beneath the padding. A tourniquet was positioned over the padding and inflated to 220 mmHg. Significant reductions in the transmitted pressure were recorded from the transducers with both padding materials. With eight layers of padding, reductions in pressure of 13% (1% to 26%) and 18% (7% to 35%) were seen with Cellona and Velband, respectively. The reduction in pressure with Velband padding correlated with increasing arm circumference (Pearson’s correlation coefficient 0.711, p < 0.001). Studies to date have examined how arm circumference affects the required tourniquet inflation pressure. Our study is the first to investigate the effect of the padding and the findings suggest that using more than two layers results in a significant reduction in the transmitted pressure

Introduction: Wound Hemearthrosis remains a major concern following TKA. This prospective study evaluates the use of a knotless interlocking suture system and its relationship to wound appearance and OR efficiency. Methods: Two groups of patients undergoing TKA in our institution were evaluated using two different wound closure techniques. Group I consisted of twenty five patients who underwent standard closure using interrupted vicryl for the arthrotomy, deep fascia, superficial fascia, followed by staples. Group II consisted of twenty five patients who underwent closure using three separate running barbed sutures (Quill, Angiotech Inc)– first for the arthrotomy, followed by deep fascia, subcuticular and staples. We compared closure times, drain output and postoperative day to achieve zero wound drainage on the dressings. Results: Closure times for Group II averaged 10 minutes faster than Group I. Drain output was decreased in the barbed suture cohort. Wounds achieved zero drainage, on average, one day sooner in Group II and no patients were returned to the OR for hematoma evacuation or arthrotomy disruption. Conclusions: Use of this new technique for closure of TKA incisions can lead to faster operative times, lower drainage outputs and less immediate postoperative wound drainage. It appears that hemostasis is obtained quicker with the use of this barbed suture system while at the same time while maximizing OR efficiency

Background. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardisation of care on short-term post-operative outcomes and resource utilisation in lower-extremity total joint arthroplasty. Methods. An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first 30 days after discharge. Hierarchical models were used to estimate effects of hospital and surgeon procedure volume and standardisation on individual and combined surgical outcomes and length of stay. Results. After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality and lower risk of readmission and higher likelihood of being discharged home. The impact of process standardisation was substantial; maximising adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume. Conclusion. Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardisation is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established. However, our findings suggest that process standardisation could help providers optimise quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume

The WHO surgical safety checklist was introduced at Derriford Hospital in 2009. Evidence of the effect on efficiency has been slow to appear in the literature. Using a standardised, locally modified WHO surgical safety checklist theatre list capacity, start and finish times as well as time between cases was measured in 4 elective orthopaedic theatres. Data from 3 successive years was analysed retrospectively: prior to checklist introduction, during checklist introduction and routine checklist use. Data was analysed using the One-Way ANOVA with post-hoc Tukey test. The number of cases per list showed a statistical difference from Year 1–2 and this increase was sustained in Year 3. The number of delayed starts showed no difference between Year 1&2, followed by a statistically significant decrease in Year 3. The number of late finishes showed a statistical difference from Year 1–2 and this decrease was sustained in Year 3. However, the number of lost minutes between cases showed no difference between Year 1&2, followed by an increase in Year 3. This study demonstrates that pre-list briefings combined with the WHO surgical checklist can improve theatre list capacity and prompt starts, reduce the number of overruns, however fails to improve turnaround time between cases

Introduction. Total knee arthroplasty (TKA) is a well established treatment option for patients with end stage osteoarthritis. Conventional TKA with manual instruments has been shown to be a cost effective and time efficient surgery. While robotic-assisted operative systems have been shown to have benefits in surgical accuracy, they have also been reported to have longer surgical times. The purpose of this work was to determine surgical time and learning curve for a novel robotic-assisted TKA platform. Methods. Eighty-five subjects underwent robotic-assisted TKA by one of three investigators as part of an FDA and IRB approved Investigational Device Exemption (IDE). All patients received a cruciate retaining total knee implant system. Intra-operative safety, Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Scores (KSS) were collected pre-operatively and at three month follow-up. In addition, surgical times were collected as part of a TKA work flow. To identify activities related to surgical steps required for robotic procedures specific time stamps were determined from the system. Capture of the hip center to final bone cut was used to define case time and identify robotic learning curve. Descriptive statistics were used to analyze results. Results. Surgeon one completed 24 cases, surgeon two completed 32, and surgeon three completed 29 cases in the study. An average surgical time of 44 minutes with standard deviation of 15.7 minutes was recorded. On average surgeons improved in surgical time with increasing cases as indicated by linear regression results. During initial cases, surgeons repeated intra-operative planning steps which decreased with the learning curve. In addition, the average WOMAC score improvement from pre-operative to three months was 33.1 ± 20.04 (p<0.0001). The average KSS Knee score improvement was 46.12 ± 19.68 (p<0.0001). Subjects recovered their pre-operative range of motion by three months post-operative. Conclusion. With cost related pressures in healthcare, hospitals and surgeons focus on improvements in surgical efficiency to stay competitive. The results of this study indicated comparable operative times to conventional TKA cases as reported in literature with the added benefit of optimizing surgical accuracy. Robotic solutions in TKA may become increasingly efficient as surgeons complete a learning curve

The objective of this study was to compare the elution characteristics, antimicrobial activity and mechanical properties of antibiotic-loaded bone cement (ALBC) loaded with powdered antibiotic, powdered antibiotic with inert filler (xylitol), or liquid antibiotic, particularly focusing on vancomycin and amphotericin B. Cement specimens loaded with 2 g of vancomycin or amphotericin B powder (powder group), 2 g of antibiotic powder and 2 g of xylitol (xylitol group) or 12 ml of antibiotic solution containing 2 g of antibiotic (liquid group) were tested. Vancomycin elution was enhanced by 234% in the liquid group and by 12% in the xylitol group compared with the powder group. Amphotericin B elution was enhanced by 265% in the liquid group and by 65% in the xylitol group compared with the powder group. Based on the disk-diffusion assay, the eluate samples of vancomycin-loaded ALBC of the liquid group exhibited a significantly larger inhibitory zone than samples of the powder or the xylitol group. Regarding the ALBCs loaded with amphotericin B, only the eluate samples of the liquid group exhibited a clear inhibitory zone, which was not observed in either the xylitol or the powder groups. The ultimate compressive strength was significantly reduced in specimens containing liquid antibiotics. Adding vancomycin or amphotericin B antibiotic powder in distilled water before mixing with bone cement can significantly improve the efficiency of antibiotic release than can loading ALBC with the same dose of antibiotic powder. This simple and effective method for preparation of ALBCs can significantly improve the efficiency of antibiotic release in ALBCs. We thank H.Y. Hsu for performing the bioassay