OpenPredictor, a machine learning-enabled clinical decision aid, has been developed to manage backlogs in elective surgeries. It aims to optimise the use of high volume, low complexity surgical pathways by accurately stratifying patient risk, thereby facilitating the allocation of patients to the most suitable surgical sites. The tool augments elective surgical pathways by providing automated secondary opinions for perioperative risk assessments, enhancing decision-making. Its primary application is in elective sites utilising lighter pre-assessment methods, identifying patients with minimal complication risks and those high-risk individuals who may benefit from early pre-assessment. The Phase 1 clinical evaluation of OpenPredictor entailed a prospective analysis of 156 patient records from elective hip and knee joint replacement surgeries. Using a polynomial logistic regression model, patients were categorised into high, moderate, and low-risk groups. This categorisation incorporated data from various sources, including patient demographics, co-morbidities, blood tests, and overall health status. In identifying patients at risk of postoperative complications, OpenPredictor demonstrated parity with consultant-led preoperative assessments. It accurately flagged 70% of patients who later experienced complications as moderate or high risk. The tool's efficiency in risk prediction was evidenced by its balanced accuracy (75.6%), sensitivity (70% with a 95% confidence interval of 62.05% to 76.91%), and a high negative predictive value (96.7%). OpenPredictor presents a scalable and consistent solution for managing elective surgery pathways, comparable in performance to secondary consultant opinions. Its integration into pre-assessment workflows assists in efficient patient categorisation, reduces late surgery cancellations, and optimises resource allocation. The Phase 1 evaluation of OpenPredictor underscores its potential for broader clinical application and highlights the need for ongoing data refinement and system integration to enhance its performance

Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the National Health Service, which have been further lengthened by the onset of the SARS-CoV-19 global pandemic in March 2020. The Department of Health (DoH) in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to Total Hip Arthroplasty (THA). Waiting list information was obtained via a Freedom of Information request to the DoH (May 2021) and National Joint Registry data was used to determine baseline operative numbers. Mathematical modelling was undertaken to calculate the time taken to meet the ECF target and also to determine the time to clear the waiting lists for THA using the number of patients currently on the waiting list and percentage operating capacity relative to pre-Covid-19 capacity to determine future projections. As of May 2021, there were 3,757 patients awaiting primary THA in Northern Ireland. Prior to April 2020, there were a mean 2,346 patients/annum added to the waiting list for primary THA and there were a mean 1,624 primary THAs performed per annum. The ECF targets for THA will only be achieved in 2026 if operating capacity is 200% of pre COVID-19 pandemic capacity and will be achieved in 2030 if capacity is 170%. Surgical capacity must exceed pre-Covid capacity by at least 30% to meet ongoing demand. THA capacity was significantly reduced following resumption of elective orthopaedics post-COVID-19 (22% of pre-COVID-19 capacity – 355 THAs/annum post-COVID-19 versus 1,624/annum pre-COVID-19). This modelling demonstrates that, in the absence of major funding and reorganisation of elective orthopaedic care, the targets set out in the ECF will not be achieved with regards to hip arthroplasty. Waiting times for THA surgery in the NHS in Northern Ireland are likely to remain greater than 52 weeks for most of this decade

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

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Clinical Excellence (NICE) has altered their prophylaxis guidance in the setting of total hip arthroplasty (THA). The aim of this study was to present the VTE incidence in 8,890 patients who underwent total hip arthroplasty between January 1997 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Analysis of prospective data collection from consecutive patients undergoing THA was performed with the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within 6 months of the index operation as the primary outcome measure. 90-day all-cause mortality of this cohort of patients was also analysed. 8890 patients were reviewed. This included 7235 primary, 224 complex primary and 1431 revision cases. The incidence of DVT was 0.64% after elective THA and the incidence of PE was 0.54%. There was no difference in the incidence between primary and revision cases. The 90-day all-cause mortality was 0.88%. Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to VTE. Our results support the use of aspirin as an effective form of prophylaxis against VTE following THA. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other attractive advantages of using aspirin for VTE prophylaxis

The early revision rate in elective Total Hip Arthroplasty (THA) three years after surgery in elderly patients over 80 years is significantly lower for cemented stems in the German Arthroplasty Register (EPRD): cemented 3,1% (3.0 – 3.2) vs. uncemented 4.2% (4.1 – 4.3; p < 0.001). However, the mortality rate in elderly patients is elevated for cemented fixation. This study presents a detailed analysis of the influence of stem type and fixation on revision and mortality rate in this patient cohort. Elective primary THA cases for primary Coxarthrosis using uncemented cups from the EPRD data base were analysed (n. 0. = 37,183). Four stem type groups were compared: cementless, cementless with collar, cementless short, and cemented. Stems with at least 300 cases at risk three years after surgery were analysed individually. The reference stem was determined as the stem with the lowest revision rate and at least 1000 cases under surveillance 3 years after surgery (n. 3. = 28,637). The revision rate for cemented stems (2.5% [2.2–1.81] was lower than for uncemented (4.5% [4.2–4.9]; p<0.001) and uncemented short stems (4.2% [3.1–5.7]; p=0.002). The revision rate of uncemented collared stems (2.3% [1.5–3.6]) was similar to cemented stems (p=0.89) and lower than for uncemented stems (p=0.02). One year mortality showed no sig. differences between the groups (p>0.17): cemented 3.2% [2.9–3.6], uncemented 3.4% [3.1–3.7], uncemented short 3.5% [2.5–4.9], uncemented collar 2.0% [1.2–3.2]. “Cementless” and “cementless short” stems should not be used in patients over 80 years due to the higher revision risk. If cementing should be avoided, “cementless collared” stems seem to be a good alternative combined with a tendency for a lower one year mortality rate

Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration. Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI). 102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA. TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA

Aims. We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion. Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77

Aims. The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime. Patients and Methods. A prospective audit database was used to identify patients who had died within 42 and 90 days of surgery respectively between April 2000 and December 2012. A case note review was performed to ascertain the causes of death. Results. During this period 7983 THAs were performed. The rate of mortality was 0.43% and 0.58% at 42 and 90 days respectively. The groups comprised 1571 patients (19.7%) on warfarin, 1838 (23.0%) on LMWH and 4574 (57.3%) on aspirin. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. The higher mortality rate for LMWH was significant (p < 0.05). There were six fatal pulmonary emboli (PEs) (0.08%). A total of three occurred within 42 days, all in the LMWH group. A total of three occurred between 42 and 90 days; one on warfarin, two on LMWH. The leading causes of death in all three groups were lower respiratory tract infections and myocardial infarction. Conclusion. We confirmed that fatal PE following elective THA with a multi-modal prophylaxis regime is rare. We further found that LMWH conferred no benefit over aspirin in this context, and is associated with a higher all-cause rate of mortality. Take home message: This study proposes that aspirin may be an appropriate thromboprophylaxis agent when used as part of a multi-modal regimen, suggesting current guidelines should be reviewed. Cite this article: Bone Joint J 2016;98-B:585–8

Whilst total hip replacement (THR) is generally safe and effective, pre-existing medical conditions, particularly those requiring inpatient admission, may increase the risk of post-operative mortality. Delaying elective surgery may reduce the risk, but it is unclear how long a delay is sufficient. We analysed 958,145 primary THRs performed for solely osteoarthritis April 2003-December 2018, in the NJR linked to Hospital Episodes Statistics to identify inpatient admissions prior to elective THR for 17 conditions making up the Charlson index including myocardial infarction, congestive heart failure, cerebrovascular disease and diabetes. Crude analyses used Kaplan-Meier and adjusted analyses used Cox modelling. Patients were categorised for each co-morbidity into one of four groups: not recorded in previous five-years, recorded between five-years and six-months before THR, recorded six-months to three-months before THR, and recorded between three-months and day before surgery. 90-day mortality was 0.34% (95%CI: 0.33–0.35). In the 432 patients who had an acute MI in the three months before THR, this figure increased to 18.1% (95%CI 14.8, 22.0). Cox models observed 63 times increased hazard of death within 90-days if patients had an acute MI in the 3-months before their THR, compared to patients who had not had an MI in the five years before their THR (HR 63.6 (95%CI 50.8, 79.7)) This association reduced as the time between acute MI and THR increased. For congestive cardiac failure, the hazard in the same scenario was 18-times higher with a similar protective effect of delaying surgery. Linked NJR and HES data demonstrate an association between inpatient admission for acute medical co-morbidities and death within 90-days of THR. This association is greatest in MI, congestive cardiac failure and cerebrovascular disease with smaller associations observed in several other conditions including diabetes. The hazard reduces when longer delays are seen between the admission for acute medical conditions and THR in all diagnoses. This information will help patients with previous medical admissions and surgeons to determine optimal timing for surgery

Implants in total hip replacement (THR) are associated with different clinical and cost-effectiveness profiles,. We estimate the costs and outcomes for NHS patients in the year after THR associated with implant bearing materials using linked routinely collected data. We linked NJR primary elective THR patients for osteoarthritis to HES and National PROMs. We estimated health care costs, health-related quality of life indices, and revision risks, in the year after primary and revision THRs overall. We used generalised linear models adjusting for patient and hospital characteristics and estimated 10-year cumulative probability of revision. We imputed utilities using chained equations for half the sample with missing PROMS. We linked 577,973 elective primary THRs and 11,812 subsequent revisions. One year after primary THR, patients with the cemented THRs using cobalt chrome or stainless steel head with HCLPE liner/cup cost the NHS, on average, £13,101 (95%CI £13,080,£13,122), had an average quality-of-life score of 0.788 (95%CI 0.787,0.788), and a 10-year revision probability of 1.9% (95%CI 1.6,2.3). Compared to the reference, patients receiving a cemented THR with delta ceramic head and HCLPE liner/cup, hybrid THR with delta ceramic head and HCLPE liner/cup, and hybrid THR with alumina head and HCLPE liner/cup had lower 1-year costs (-£572 \[95% CI -£775,-£385\], -£346 \[-£501,-£192\], -£371 \[-£574,-£168\] respectively), better quality of life (0.007 \[95% CI 0.003,0.011\], 0.013 \[0.010,0.016\], 0.009 \[0.005,0.013\] respectively), and lower 10-year revision probabilities (1.4% \[1.03,2.0\], 1.5 \[1.3,1.7\], 1.6%\[1.2,2.1\] respectively). Implant bearing materials are associated with varying mean costs and health outcomes after primary THR. Ours is the first study to derive costs and health outcomes from large, linked databases using multiple imputation methods to deal with bias. Our findings are useful for commissioning and procurement decisions and to inform a subsequent cost-effectiveness model with more granular detail on THR implant types

Introduction. In the United States, cementless femoral fixation remains the dominant mode of fixation for femoral neck fractures, despite strong worldwide registry data that supports cemented fixation. The reason for this discrepancy remains unknown, controversial and often difficult to compare due to multiple variables. The purpose of this study was to evaluate a matched cohort of patients undergoing arthroplasty for femoral neck fractures and assess outcomes of revisions, periprosthetic fractures and mortality. Methods. This is an exact matched cohort study. Cemented fixation cases were exact matched to cementless fixation cases in a 1:1 fashion based on age, sex and Charlson Comorbidity Index (CCI). Outcome variables included: revision for periprosthetic fracture; all cause revision and mortality at any time point; all cause revision and mortality within 1-year and within 90-days. The primary independent variable was femoral fixation (cemented, cementless) and covariates included race (black, white, other), ethnicity (hispanic, non-hispanic), teaching status (minor, major, nonteaching) and bedsize (1–99, 100–399, >=400). Chi-square tests and multivariable logistic regression models were used for statistical analysis. Results. A total of 64,283 femoral neck fractures were evaluated. 17,138 cementless femoral stems were matched exactly to cemented femoral stems based on age, gender and Charleston comorbidity index (CCI). In the multivariate logistic regression analysis, compared to cementless femoral fixation, cemented fixation was associated with a 20% reduction in overall revision (OR 0.796, 0.675–0.939), a 30% reduction in revision at 1 year (OR: 0.709, 0.589–0.854) and a 86% reduction in revision for periprosthetic fracture (OR: 0.144, 0.07–0.294). However, cemented stem fixation was associated with a 23% (OR: 1.33, 1.134–1.338) and 16% (OR: 1.232, 1.134–1.338) increase in mortality at 90 days and 1 year post op respectively. Conclusions. In this exact matched cohort study, risk of early revision and revision for PPFx was dramatically reduced at all time points with the use of cemented stem fixation for elective THA and FNF. However, the increased risk of 90d and 1 year mortality following cemented stem fixation in the elective population warrants further investigation

Thromboprophylaxis after elective orthopaedic surgery remains controversial. Recent guidelines from the National Institute for Clinical Excellence (NICE) have suggested that low molecular weight heparin should be given to all patients undergoing total hip replacement. The British Orthopaedic Association is currently debating this guideline with NICE, as it is not clear whether published evidence supports this view. We present the early mortality in our unit after total hip replacement using aspirin as chemical thromboprophylaxis. The 30-day and 90-day mortality after primary total hip arthroplasty was zero. We compare this with that reported previously from our unit without using chemical thromboprophylaxis. With the introduction of routine aspirin thromboprophylaxis, deaths from cardiovascular causes have dropped from 0.75% to zero. These results demonstrate that there is a strong argument for the routine administration of aspirin after elective total hip replacement

During the last decade primary total hip arthroplasty surgery (THA) has increased with 30% in Sweden. Current law guarantees the patient a right to treatment within 90 days. The public health system has had difficulties meeting the increasing demand. Therefore, in 2012 a systematic review of the patients planned for THA was initiated at Sahlgrenska University Hospital's joint replacement unit. In late 2013 the value-based health care (VBHC) management was introduced in our unit. In 2012 a systematic approach based on the Fast-Track concept was implemented in the joint replacement unit. In 2013 a workgroup consisting of health care professionals involved in the treatment of THA patients was created to improve chosen outcome parameters. During 2011–2016 the number of elective THA has increased from 317 to 486. The cost per patient has decreased from 75,000 SEK to 65,000 SEK. Length of stay has decreased from 5.9 days to 2.5 days. Satisfaction with outcome of surgery one year after THA increased from 76% to 88%. The number of adverse events decreased from 29% to 11%. Number of re-operations within 2 years decreased from 2,7% to 1,9%. Fast-Track and VBHC management was initially received with modest enthusiasm in our unit, and was regarded as means to increase production whilst possibly endanger the well-being of the patients. By using continuous feedback using the data collected it was possible to effectively communicate to patients and caregivers that the patients benefitted from the implementation. VBHC primary aim is to improve patient outcomes and synergetically improve cost and process measurements. This should be appealing to both caregivers and administrators. Focusing on improvement of outcomes after THA combined with VBHC management has contributed to improvement in quality of care and availability of treatment whilst decreasing cost per patient

Background

Orthopedic surgeons have relied heavily on opiates after total hip replacement (THR) despite no clear evidence of benefit and a rapidly growing abuse epidemic. Multimodal analgesia may reduce or even obviate the need for opiates after elective surgery.

Background

Total hip replacement (THR) is clinically and cost-effective. The surgical approach influences outcomes, however there is little generalisable and robust evidence to guide practice. We assessed the effect of surgical approach on THR outcomes.

Introduction

Previous systematic reviews have shown that patients experience low physical activity levels following total hip replacement (THR). However no previous systematic reviews have examined the changes between pre- and post-operative physical activity levels.

Litigation costs are significant and increasing annually within the National Health Service (NHS) in England.

The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action.

A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed.

The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465.

Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims.

Total hip replacement (THR) is one of the most common and cost-effective elective surgical procedures. In the National Health Service (NHS) of England and Wales a myriad of implants for THR are offered at a variety of locally negotiated prices. This study aims to estimate the total burden of elective THR to the NHS, expenditure on implants, and different scenarios of cost changes if implant selection changed for different patient groups. Using National Joint Registry (NJR) data and NHS reference costs, we estimated the number and expenditure of NHS funded primary and revision THR in the 10-year period 2008–2017 and forecasted the number and expenditure on THR over the next decade. Using NJR average NHS Trust prices for the different implant combinations we estimated the average cost of implants used in THRs and estimated the budget impact on NHS providers from switching to alternative implants. The NHS spent over £4.76 billion performing 702,381 THRs between 2008–2017. The average cost of implants was £1,260 per surgery, almost a fifth of the cost of primary THR. Providing cemented implant combinations in primary elective THRs may potentially save up to £281 million over the next 10 years, whilst keeping 10-year revision risks low. The NHS is likely to spend over £5.6 billion providing primary elective THR over the next decade. There are efficiency savings to realise in the NHS by switching to more cost-effective implant combinations available for patients undergoing primary elective THR surgery, but these will need to be balanced against the risks inherent to a change in selection of implants and surgical practice. The HIPPY programme will be conducting practice surveys, discrete choice experiments and a large randomised controlled trial of cemented, uncemented and hybrid fixation in THR for patients under 70 to answer uncertainties

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

Aims. Total hip arthroplasty (THA) is one of the most successful surgical procedures. The objectives of this study were to define whether there is a correlation between socioeconomic status (SES) and surgical complications after elective primary unilateral THA, and investigate whether access to elective THA differs within SES groups. Methods. We conducted a retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, over a 17-year period. Patients were divided into income quintiles based on postal codes as a proxy for personal economic status. Multivariable logistic regression models were then used to primarily assess the relationship between SES and surgical complications within one year of index THA. Results. Of 111,359 patients who underwent elective primary THA, those in the lower SES groups had statistically significantly more comorbidities and statistically significantly more postoperative complications. While there was no increase in readmission rates within 90 days, there was a statistically significant difference in the primary and secondary outcomes including all revisions due (with a subset of deep wound infection and dislocation). Results showed that those in the higher SES groups had proportionally more cases performed than those in lower groups. Compared to the highest SES quintile, the lower groups had 61% of the number of hip arthroplasties performed. Conclusion. Patients in lower socioeconomic groups have more comorbidities, fewer absolute number of cases performed, have their procedures performed in lower-volume centres, and ultimately have higher rates of complications. This lack of access and higher rates of complications is a “double hit” to those in lower SES groups, and indicates that we should be concentrating efforts to improve access to surgeons and hospitals where arthroplasty is routinely performed in high numbers. Even in a universal healthcare system where there are no penalties for complications such as readmission, there seems to be an inequality in the access to THA. Cite this article: Bone Joint J 2022;104-B(5):589–597