Abstract. Background. Post operative radiographs following total joint arthroplasty are requested as part of routine follow up in many institutions. These studies have a significant cost to the local departments, in terms of financial and clinic resources, however, previous research has suggested they may not alter the course of the patients treatment. The purpose of this study was to assess the significance of elective post operative radiographs on changes in management of patients who underwent total joint arthroplasty. Method. All patients who underwent total knee arthroplasty and total hip arthroplasty at a District General Hospital from 2019 to 2020 were included. Data was collected retrospectively from medical records and radiograph requests. Alterations to clinical management based on radiographic findings were reviewed in clinic letters. Results. A total of 227 Total joint arthroplasty were retrieved. With 111(49%) total hip arthroplasty and 116 (51%) total knee arthroplasty. 54 were excluded due to having no clinical follow up and 173 met inclusion criteria. 56 (32%) had their post operative elective radiograph, while 93 (53.8%) patients had none. There were no abnormalities detected from the elective radiographs and none of the patients returned to the theatre. 24 patients (13%) presented with symptoms and had non-elective radiographs, 16 (67%) did not have any interventions and 8 (4.6%) required intervention and were taken to theatre. Discussion: Not performing these radiographs saves time, cost, and prevents unnecessary radiation exposure. In our institution, a 2-view joint radiograph costs £29 and takes roughly 15 minutes. This does not include indirect costs of additional clinic time and patient waiting time. In the larger context, the cost associated with elective radiographs is significant and our data suggests that routine post-operative radiographs are not beneficial as part of standard post-operative protocol for asymptomatic patients. However, performing imaging remains beneficial for patients who re-present with symptoms. Conclusion. Routine elective post-operative joint radiographs did not detect any true abnormalities. Information from elective radiographs has no clinical significance and did not change management. Therefore, this study recommends that there is no rationale requesting elective post-operative joint radiographs. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Revision knee arthroplasty is a complex procedure with the number and cost of knee revision procedures performed per year expected to rise. Few studies have examined adverse events following revision arthroplasty. The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications) and to compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the UK Hospital Episode Statistics. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes including infection (undergoing surgery), pulmonary embolism, myocardial infarction, stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications were included in the elective indications cohort. 939,021 primary knee arthroplasty cases were included of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. These findings highlight the burden of complications associated with revision knee arthroplasty. They will inform shared decision-making for patients considering revision knee arthroplasty for elective indications. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency and an anticipation for increased care requirements

Introduction and Objective. Postoperative pain control in shoulder surgery is challenging even in arthroscopic procedures. Acute postoperative pain can last up to 48hrs despite using multimodal analgesia. Different techniques have been used to control acute pain following shoulder surgery. The most common technique currently used in shoulder surgery at the elective orthopaedic centre in Leeds is a combination of general anaesthetic (GA) and interscalene block (ISB). ISB maybe very effective, however, carries many risks and potential side effects such as brachial plexus injury and paralysis of the vagus and laryngeal recurrent nerves as well as cervical sympathetic nerve and pneumothorax. ISB can also be associated with higher incidence of neurological deficit compared to other peripheral nerve blocks; up to 14% at 10 days in some cases. As such we decided to examine the use of ISB for achieving pain control in our elective unit. Materials and Methods. A prospective consecutive series of 217 patients undergoing shoulder surgery were studied. These were grouped into 10 groups. All procedures were arthroscopic apart from shoulder arthroplasty procedures such as hemiarthroplasty and total shoulder replacements (TSRs). The choice of regional anaesthesia was ISB with GA as standard practice. Visual analogue scores (VAS) at 0hrs, 1hr, 2hrs, 4hrs and 6hrs; and total opiates intake were recorded. A one-way single factor ANOVA was used as preferred statistical analytical method to determine whether there is a difference in VAS scores and total opiates intake amongst the groups. Postoperative analgesics were used for pain relief, although these were not standardised. Results. In total shoulder replacement group, although the RSR group used more morphine on average compared to the ASR group (Mean morphine intake 6.5mg vs 3mg), this was not statistically significant (F<Fcrit; p value= 0.19). When comparing all the arthroplasty groups, the difference in mean morphine intake was also statistically not significant (F<Fcrit; p value=0.24). However, when comparing all 10 groups’ morphine intake there was a statistically significant difference amongst these groups (F>F crit; p value=0.03). Interestingly, there was a statistically significant difference in VAS at 0hrs (F>Fcrit p value=0.01); 1hrs (F>Fcrit; p value=0.00), and at 6hrs (F>Fcrit; p value=0.02) when comparing all 10 groups. Conclusions. ISB is an effective technique in achieving pain control in shoulder surgery; however, there are still variations in analgesic needs amongst groups and the use of alternative techniques should be thus explored. A future prospective study looking at acute pain for a longer period of time after shoulder surgery would explore the effectiveness of ISB in achieving pain control consistent with rehabilitation requirements

There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well. A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions

Background. Patients who undergo elective hip and knee arthroplasty often have multiple risk factors increasing their likelihood of suffering from hyponatraemia post operatively. Consequently suffering from hyponatraemia post elective hip and knee arthroplasty is common. Consequently we wanted to assess the occurrence of hyponatraemia in our elective arthroplasty unit, assess our effectiveness in managing this and importantly assess how its occurrence impacted on length of patient stay. Method. Retrospective analysis of elective hip and knee arthroplasty patients over a five month period. Pre-operative and post-operative sodium levels analysed and their grade measured using NICE reference ranges. In post-operative hyponatraemic patients blood results were analysed up until discharge. Discharge summaries were reviewed to assess communication between primary and secondary care. Length of admission calculated. Formal action plan developed in partnership with the anaesthetic department to improve future management. Results. 103 patients assessed. 24 (23%) suffered from post-operative hyponatraemia. 11 (48%) were discharged with a normalised sodium. 7 (29%) had documentation regarding their hyponatraemia in the discharge summary. 101 (98%) had a sodium drop post-operatively and 2 patients were hyponatraemic pre-operatively. Average length of stay for hyponatraemic hip patients was 5.00 days compared to 4.20 days for patients with normal sodium levels. Hyponatraemic post op knee patients had an average in hospital stay of 5.09 days compared to 4.13 days in knee patients with a normal post-operative sodium level. Conclusion. Hyponatraemia is common in the post-operative arthroplasty patient. In our unit it led to an increase in length of hospital stay. We believe the introduction of a structured post-operative oral rehydration regime with isotonic fluid would be a simple method to reduce occurrence post operatively. We feel standardising intra-operative fluid prescribing will reduce the likelihood of pushing patients into a post-operative hyponatraemic state. Finally we have introduced a hyponatraemia management flowchart to the department so ward based doctors can recognise and effectively manage hyponatraemic patients. If these measures are implemented length of stay in hospital can potentially be reduced

Objectives. We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change. Methods. We retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates. Results. A total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts. Conclusion. We suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design. Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499–505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1

INTRODUCTION. Warfarin remains the treatment of choice for the majority of patients with venous thromboembolism, atrial fibrillation and valvular heart disease or valve replacement unless contraindicated. Poor management of patients on warfarin often leads to delay in surgery, life threatening bleeding during or after operation and unnecessary delay in discharge from hospitals in United Kingdom. METHODS. We carried out a prospective study on patients who were on warfarin and underwent elective and emergency orthopaedic procedures during period of study- August 2007 to April 2008. All patients included in the study were identified from admission notes during period of study. All data regarding indications for warfarin, pre and post procedures INR, elective or emergency orthopaedic procedures and complications were collected using a standard proforma. RESULTS. 18 patients, 12 male and 6 female were included into the study. Patients' age ranged from 47-87 with mean of 76. The indications for warfarin therapy were atrial fibrillation in 12 patients, deep vein thrombosis in 5 patients and left ventricular aneurysm in 1 patient. 18 procedures, 10 elective and 8 emergency orthopaedic procedures were carried out during period of study. Elective procedures - 7 primary joint arthroplasty, 1 revision hip arthroplasty, 1 removal of metalwork and 1 metatarsophalangeal joint fusion. Emergency procedures - 4 hip hemiarthroplasty, 2 dynamic hip screw fixation, 1 external fixator application and 1 open reduction and internal fixation of ankle. All elective admission patients were pre-assessed in clinic prior to admission and were advised to stop warfarin based on their INR level. Patients with INR 2-3 had their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 had their warfarin stopped 5 days prior to surgery. This group of patients had their INR check on admission and ranged from 1.1-1.5. This group of patients had no reversal therapy and no cancellations were made to their operation. 8 emergency admission patients had INR of 1.4-4.7 on admission with mean of 2.7. 5 patients had reversal therapy while 3 patients had no reversal therapy. Pharmacological methods used to reduce the INR were fresh frozen plasma in 1 patient and Vitamin K in 4 other patients. 2 patients that received reversal therapy had operation on day 1, 2 on day 3 and 1 on day 5. 1 patient that had no reversal therapy was operated on day 1, 1 on day 3 and 1 on day 5. Patient that received no reversal therapy and operated on day 5 of admission died post-operatively from medical complications. Mean delay for patient that had reversal therapy was 2.2 days compared to 3 days in patient with no reversal therapy. All patients in this study had prophylactic low molecular weight heparin while off warfarin. Patients were recommenced on their normal dose of warfarin the day after their operation. DISCUSSION & CONCLUSIONS. We conclude that patients on warfarin with INR 2-3 should have their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 should stop their warfarin 5 days prior to elective surgery. Trauma patients on warfarin requiring operation should have their INR reversed on admission to shorten delay in waiting time and improve outcomes

The reinfusion of perioperative cell salvage is one method employed to reduce exposure to donor blood. Data on the safety of this process, however, are scant. Notably, the effect of intraoperative, washed cell salvage reinfusion on prothrombotic markers has not been demonstrated. The risk of postoperative venous thromboembolism following major orthopaedic operations is not insignificant. The study objective was to assess the effect of cell salvage reinfusion on coagulation and platelet activation. Twenty-one patients undergoing elective primary hip operations were recruited. Nine patients received washed cell salvage intraoperatively, and were compared with 12 patients undergoing similar surgery that did not. Two patients in the cell salvage group also received postoperative, unwashed cell salvage. Blood samples were collected pre-operatively, immediately post-operatively, and one day post-operatively for assays of platelet activation markers, P-selectin expression and fibrinogen binding by flow cytometry in diluted whole blood; coagulation activation marker, thrombin-antithrombin complex (TAT); D-dimer by ELISA, thrombin generation by chromogenic assay, and full blood count. Samples of cell salvage material were also analysed for prothrombotic markers. There were no significant differences between the groups preoperatively. Postoperatively haemoglobin levels did not differ significantly between the cell salvage group and controls. Postoperative TAT and D-dimer were significantly higher in the cell salvage group compared with controls (p<0.05). One day postoperatively, there were significantly higher platelet P-selectin expression (p=0.006) and platelet fibrinogen binding (p=0.004) in the cell salvage group compared with controls. The white cell count (WCC) was also significantly higher (p=0.04). In the intraoperative washed cell salvage material, and in postoperative cell salvage, the platelet count was low, but significant proportions of platelets were activated, and levels of D-dimer were elevated compared with venous blood. The postoperative salvage material also contained high levels of TAT. The results from this pilot study show the induction of a prothrombotic state following reinfusion of intraoperative, washed cell salvage in recipients undergoing primary elective hip operations. An inflammatory response to reinfusion is also indicated by the raised WCC. Further investigation into the safety of cell salvage is indicated

Background-. Health care is best delivered face to face, doctor to patient. However, in some places like Scotland, patients can be in remote areas, far from the nearest health care provider. Medical video conferencing (VC) enables patients and doctors to meet for consultations from wherever they may be without the need for travel, and is already used widely in countries like Australia and Canada. Aim-. To do a pilot study of using the existing VC facility at our hospital for surgical pre-assessment of patients for elective foot/ankle and lower limb arthroplasty surgery. Methods- A prospective pilot study was performed at our hospital after approval from our ethics committee. Patient-records were vetted to include/exclude from the study and cases considered as “straightforward” were included. Two separate rooms with VC facility were set up in the orthopaedic outpatients, one with the patient and a trained physiotherapist, while the surgeon used the second room to discuss patient's complaints, do a physical examination, and discuss surgery where appropriate. Results-. 120 patients were included in the study out of which 82 (68 %) patients were seen exclusively through VC. Out of the 82, there were 42 foot/ankle cases and 40 cases for lower limb arthroplasty (TKR/THR). There were 40 cases where the VC consultation had to be converted into a face-to-face consultation mainly because the surgeon (31/40) was not entirely satisfied with the VC consultation (inadequate information in notes, anxious patient, etc). Conclusion-. We found that the VC consultation worked for a large majority of “straightforward” elective foot/ankle and lower limb arthroplasty conditions. We believe that there is certainly a role for VC consultation, especially for patients in rural/remote areas of Scotland, thus bringing down the cost and inconvenience of patient transport considerably

Elective orthopaedic procedures, and particularly total hip arthroplasty (THA), in octogenarians and nonagenarians patients are burdened of several implications. Besides the comorbidities and the anesthesiological issues, legal and ethical implications are present. Some literature data show the clinical improvement of THA in elderly patient but the psychological aspects are not yet evaluated. Aim of this study is to evaluate the clinical aspects and the psychological impact in daily living in octogenarians and nonagenarians patients addressing THA.

We conducted a retrospective evaluation of 81 THA in 81 patients of age more than 85 years with a minimum follow-up of 6 months. Clinical aspects were evaluated using the Hip disability and Osteoarthritis Outcome Score (HOOS). The psychological issues were evaluated with the Short Form 12 (SF-12) using both the Physical Component Summary (PCS) and the Mental Component Summary (MCS). From the starter cohort of 81 patients, 8 patients were died for causes unrelated to surgery, 13 were lost to follow-up, 1 patient was revised for periprosthetic fracture; 59 patients composed the final cohort. Mean HOOS rased from 18,07 ± 17,81 to 92,36 ± 5,74 with statistically significant distribution both in the global score than in all of the different subscales. The PCS raised from 26,81 ± 10,81 to 51,86 ± 4,45 and The MCS raised from 34,84 ± 10,81 to 56,70 ± 5,04, but none of them showed a statistically significant distribution. THA in octogenarians and nonagenarians patients could be a safe procedure with positive results for clinical and psychological aspects.

In this study we aimed to identify which anatomical site was the most effective for methicillin resistant staphylococcus aureus (MRSA) detection within an elective orthopaedic setting. A retrospective review was performed of 13,373 elective orthopaedic patients from pre-assessment and admission screening swabs taken over a five year period (2005-2010). Swabs were taken from the nose, the axilla and either the groin or perineum. MRSA was identified in 136(1.02%) of patients. The nose was found to be positive for MRSA in 89.6% of cases identified. Therefore only 10.4% of the MRSA carriers (0.1% of all admissions) would not have been identified had a single nasal swab been taken. There was no additional benefit in swabbing the axilla. We believe that for the majority of orthopaedic elective admissions a single nasal swab should be sufficient. In hip arthroplasty patients it may be beneficial to additionally swab the groin given the close proximity of the surgical wound

Backgroud: Allogeneic transfusion rates after primary hip and knee arthroplasty are used as quality indicators for hospitals, but hospital comparisons may be hampered by low event rates. Extended hospital stay is often used and may be more suitable as an alternative. This study aims to assess whether transfusion rates and extended hospital stay can be used to reliably rank hospitals. Methods. We used the baseline data from the LISBOA implementation trial, where data on patient characteristics and outcomes were collected in a sample of approximately 100 patients undergoing elective primary total hip or knee arthroplasty for each of the 23 participating hospitals. We calculated the reliability of ranking (Rankability) of transfusion rates and extended hospital stay (> 4 postoperative days), using fixed and random effects logistic regression analysis, by dividing the between-hospital variation to the sum of within and between-hospital variation. Rankability thus shows which part of the hospital differences are true differences and not due to random variation. Results. 1163 total hip and 986 total knee procedures were assessed. After adjustment for patient characteristics the odds ratio (OR) of receiving a transfusion in a hospital after total hip ranged from 0.72 to 1.38 and from 0.30 to 3.30 in total knee. Rankability was 17% for hip and 36% for knee arthroplasty, meaning that only 17% and 36% are true hospital differences. Larger hospital variation was found for extended hospital stay (OR range [0.28–3.51] for hip and [0.10–9.95] for knee arthroplasty), and better rankability. Conclusion. Although allogeneic transfusion rates are useful for monitoring quality within hospitals, they should not be used for ranking hospitals. A large proportion of differences in transfusion rates between hospitals is due to random variation, suggesting that this outcome is not suitable for ranking hospitals contrary to extended hospital stay. Level of evidence. Level 2. Financial disclosure. This study was funded by a grant from The Netherlands Organisation for Health Research and Development and by a grant from Sanquin Blood Supply. Conflict of interest. The authors declare that there are no conflicts of interest. Approval. The Medical Ethical Committee of the Leiden University Medical Center decided that ethical approval was not required under Dutch National law for this type of study

Aim. To investigate the role of websites in enhancing patients' understanding of reason and risk of surgery as a part of informed consent for elective un-instrumented lumbar spine surgery (EULSS). Methodology. This was a National Research Ethical Committee approved RCT study. 63 patients underwent EULSS, out of which 14(29%) declined participation and 14(29%) were excluded. One did not have surgery therefore 34 were randomised to Standard (S) and intervention group (I) using sealed envelope. Standard group were given verbal information & leaflet while the Intervention group were given information on relevant section of . www.eurospine.org. and . www.spinesurgeons.ac.uk. websites. A 13 item Informed Consent Questionnaire (ICQ) was used to collect data. The primary outcomes were patients' perceived understanding of reason and risk of EULSS. Results. Average age was 54 (21–82) years, with similar demographics in both groups. Complete data was available for 20 (13 Standard and 7 Intervention group). No difference (χ. 2. = 0.42, df=1, p= 0.52) was observed on perception of reason and risk of surgery between two groups. Website usage increased from 30% to 50% in intervention group who continued to use the website. Conclusion. Website use appears to be useful to participants. Although support has not been found to accept the experimental hypothesis, valuable information has been gained that will serve to facilitate larger study to further explore the effectiveness of websites in enhancing of EULSS. No Conflict of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Posterior spinal surgery is associated with a significant amount of blood loss. The factors predisposing the patient to excessive bleeding-and therefore transfusion- are not well established nor is the effect of transfusion on the outcomes following spinal surgery. We had two goals in this study. First, we were to investigate any suspected risk factors of transfusion in posterior thoraco-lumbar fusion patients. Second, we wanted to observe the negative impact-if one existed- of transfusion on the outcomes of surgery

All adults undergoing posterior thoraco-lumbar spine fusion in our institution from May 2015 to May 2018 were included. Data collected included demographic data as well as BMI, preoperative hemoglobin, American Society of Anesthesiologists classification (ASA), delta Hemoglobin, estimated blood loss, incidence of transfusion, number of units transfused, number of levels fused, length of stay and re-admission within 30 days. The data was analyzed to correlate these variables with the frequency of transfusion and then to assess the association of adverse outcomes with transfusion.

125 patients were included in the study. Only 6 patients (4.8%) required re-admission within the first 30 days after discharge. Length of stay averaged 8.4 days (3–74). 18 patients (14.4%) required transfusion peri-operatively. When multiple variables were analyzed for any correlation, the number of levels fused, age and BMI had statistically significant correlation with the need for transfusion (P <0.005)

Patients undergoing posterior thoraco-lumbar fusion are more likely to require blood transfusion if they were older, over-weight & obese or had a multi-level fusion. Receiving blood transfusion is associated with increased complication rates.

Abstract

Introduction

Postoperative total shoulder arthroplasty (TSA) blood tests cost the National Health Service in the UK more than £72000 annually without definite evidence of their impact on outcomes. This study aimed to ascertain if these blood tests can be implemented on a per-patient basis.

Hip and knee arthroplasties are very common operations in the UK with over 70000 hip and over 80000 knee arthroplasties taking place in England and Wales in 2011. Fortunately mortality following these operations is rare. However it remains important to understand the incidence and causes of death, in order to manage risk where possible and to inform the consent process.

This study aimed to evaluate the incidence and causes of death within 30 days after undergoing hip or knee arthroplasty in our unit and to highlight possible risk factors.

We looked at 30 day mortality in all patients undergoing hip or knee arthroplasty in our institution between 2005 and 2011. Data on post-operative deaths was derived from the Scottish Arthroplasty Project and correlated with procedural and demographic data from our hospital Patient Administration System (PAS). The notes of all patients who had died within a period of 30 days post-operatively were reviewed to collect data on co-morbid conditions, pre-operative investigations, post-operative thromboprophylaxis and cause of death. All primary and revision knee and hip arthroplasties including bilateral procedures were included. Arthroplasty for trauma was excluded.

A total of 12,243 patients underwent hip or knee arthroplasty within the study period. 59% were female and the mean age was 68 (range 21–91). During this time period the standard protocol was to use aspirin for thromboprophylaxis. Eleven patients died following surgery giving a mortality rate of 0.09%. The most common cause of death was myocardial infarction (7/11 patients).

Our finding of a mortality rate of 0.09% is similar or lower to those found in previous studies. To our knowledge this is the first series of this size looking at mortality from hip and knee arthroplasty within a single centre in the UK.

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. Starting January 2011, our unit has converted from aspirin to Rivaroxaban use routinely following lower-limb arthroplasty for venous thromboembolism (VTE) prophylaxis. The aim of this audit was to retrospectively review its efficacy and the morbidity associated with its use.

All patients undergoing primary and revision lower-limb arthroplasty between February 2011 and July 2011 were reviewed. All patients undergoing total knee replacement surgery and total hip replacement surgery received oral rivaroxaban 10 mg daily post-operatively for 14 days and 35 days respectively. Outcome measures recorded were; investigation for DVT/PE, rate of DVT/PE, wound complications (infection, dehiscence, leaking, bleeding), blood transfusion rate and readmission rate within 6 weeks of surgery.

Of the 162 patients identified, 19 were excluded due to insufficient information or because they did not receive rivaroxaban as VTE prophylaxis. 141 patients (mean age 71.7 years) were included. 69 primary and 5 revision total knee replacements were performed. 60 primary and 7 revision total hip replacements were performed. 9 patients (6.4%) underwent Doppler USS for a painful swollen leg with 1 (0.7%) DVT diagnosed. None were investigated for a pulmonary embolus. 25 (17.7%) patients developed wound complications: 10 superficial infections requiring oral antibiotics, 2 deep infections requiring theatre washout, 1 wound dehiscence, 5 continuously leaking wounds, 5 bleeding wounds/haematomas. 26 (18.4%) patients required post-operative blood transfusion (average 2.2 units). 12 (8.5%) patients were re-admitted within 6 weeks with post-op complications (6 wound complications, 5 painful/swollen limbs, 1 large per-vaginal bleed).

In keeping with previous literature, the rate of VTE following lower-limb arthroplasty using rivaroxaban as prophylaxis is low. However, the rate of morbidity was higher when compared with the use of aspirin in our centre between April and September 2010.

Abstract. There are numerous advantages of discharging patients early after any surgery. Day case arthroplasty in hip and knee is already brought into practice at many centres. We present our journey towards discharging elective shoulder arthroplasty patient on same after their surgery. An initial retrospective study of patients who underwent elective shoulder replacement between 2017 and 2020 were studied. It was identified that a selected group of patients could be discharged on the same of their surgery. The criteria to select a patient for this service was laid down that include ASA 1 or 2, good family support on discharge, personal wishes of patients and early identification of potential patients in the clinic and planning for day case shoulder arthroplasty56 consecutive patients underwent elective arthroplasty of shoulder. Among them 22 patients were discharges on the next day of surgery. The potential patients those could discharged on same were identified to be 11 out of 22 were under ASA 2 and had good family support at home on discharge. Average length of stay after surgery was 2.17 days. We have prospectively discharged 2 patients following the new criteria. This study demonstrates how outpatient elective shoulder could be implemented at other centres. Patient participation and selection with proper planning is key for success here. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

COVID-19 was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. The initial response to the pandemic included the cessation of routine services including elective orthopaedic surgery. There was apprehension among both surgeons and patients about restarting elective surgical services. The high mortality rate in perioperative patients who contract COVID-19 was of particular concern. The aim of this study was to identify the perioperative viral transmission rate in orthopaedic patients at our institution following the restart of elective surgery between August 2020 and November 2020 after the first wave of Covid in the UK. All patients who had their elective Orthopaedic surgeries at our institution from 1st August 2020 to 30th November 2020 were checked whether they were Covid positive or experienced COVID symptoms within 2 weeks after the operation. All patients were advised a 14-day period of comprehensive social distancing, 3 days of self-isolation and had a negative COVID-19 test within 72 hours of surgery and underwent surgery at a COVID free site. The patients were contacted and the hospital database was searched to identify those patients who were Covid positive or had Covid symptoms after the surgery. Baseline patient characteristics were recorded including age, gender, procedure, the subspeciality and admission type. Patients who underwent emergency procedures and trauma operations were excluded. Out of the 499 patients, 315 were contacted over telephone and hospital database was searched for the rest of the patients. We found that none of the patients were positive for COVID or had symptoms of COVID within two weeks of surgery. 5 patients were COVID positive with symptoms few months after the procedure and all of them recovered. There were 144 inpatient admissions and 353 day cases. The development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. Findings of our study confirms that COVID-free elective pathway is an efficient process, and this could be implemented in future elective Orthopaedic surgeries during COVID times. Elective surgery can be safely resumed using dedicated pathways and procedures -Surgeons, hospital staff and patients should remain vigilant