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

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

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.

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

Telemedicine is the delivery of healthcare from a remote location using integrated computer/communication technology. This systematic review aims to explore evidence for telemedicine in orthopaedics to determine its advantages, validity, effectiveness and utilisation particularly during our current pandemic where patient contact is limited. Databases of PubMed, Scopus and CINHAL were systematically searched and articles were included if they involved any form of telephone or video consultation in an orthopaedic population. Findings were synthesised into four themes: patient/clinician satisfaction, accuracy and validity of examination, safety and patient outcomes and cost effectiveness. Quality assessment was undertaken using Cochrane and Joanna Briggs Institute appraisal tools. Twenty studies were included consisting of nine RCTs across numerous orthopaedic subspecialties including fracture care, elective orthopaedics and oncology. Studies revealed high patient satisfaction with telemedicine for convenience, less waiting and travelling time. Telemedicine was cost effective particularly if patients had to travel long distances, required hospital transport or time off work. No clinically significant differences were found in patient examination nor measurement of patient reported outcome measures. Telemedicine was reported to be a safe method of consultation. However, studies were of variable methodological quality with selection bias. In conclusion, evidence suggests that telemedicine in orthopaedics can be safe, cost effective, valid in clinical assessment with high patient/clinician satisfaction. Further work with high quality RCTs is required to elucidate long term outcomes. This systematic review presents up-to-date evidence on the use of telemedicine and provides data for organisations considering its use in the current COVID-19 pandemic and beyond

The treatment of massive chronic tears is problematic. The re-tear rate following surgery for extensive cuff tears remains high, and there is little consensus regarding optimum treatment. To investigate the outcome of a cohort of patients who had open repair of an extensive cuff tear using the Leeds Kuff patch as an augment. A retrospective cohort study of consecutive patients with a massive cuff tear who had surgery in our regional elective orthopaedic centre over a two year period from January 2015 to Dec 2016. All patients followed identical rehabilitation protocols, supervised by physiotherapists with an interest in the shoulder. Outcomes assessment was undertaken at a minimum of 12 months by a registrar or physiotherapist who was not part of the treating team. Pre-op data collection included; range of motion, pain score, Oxford shoulder score (OSS), assessment of muscle atrophy on MRI. Data collection was completed in 15 patients. The mean age was 62 yrs (56 – 75). The mean pre-op OSS was 22, improving to a mean of 43. The range of motion and pain score improved. There were no intra-operative complications. One patient required a second surgery for evacuation of a haematoma at 10 days post op. One patient had an obvious re-tear at 4 months. Open rotator cuff repair with synthetic Kuff patch augmentation for chronic degenerative tears appears worthwhile when assessed at 12 months and they continuous to improve even at 18 months. This treatment method may be a useful option for patients > 70 years old

Background. In the United Kingdom (UK), the fastest growing population demographic is the over 85 years of age, but despite this, outcomes achieved in the octogenarian population with a Unicompartmental Knee Replacement (UKR) are underrepresented in the literature. The Elective Orthopaedic Centre, Epsom, has an established patient reported outcome measures (PROMs) programme into which all patients are routinely enrolled. We aim to investigate the outcome of medial UKR using the oxford phase 3 implant in octogenarians. Methods. We retrospectively reviewed our database for patients aged 60–89 years, who underwent a medial unicompartmental Knee Replacement (UKR) using the oxford phase 3 implant, between June 2007-December 2012 (N=395). The patients were stratified into 3 groups based on age, 60–69 (N=188), 70–79(N=149), and 80–89(N=58). Oxford Knee Scores (OKS), Euro-quol (EQ-5D) scores, revision rates, and mortality were compared. Results. We found that the octogenarian group achieved considerable improvement at 1 year with a mean OKS of 39.2 (+/−7.193) and EQ-5D score of 0.791(+/−0.241). And this improvement remained significant at 2 years. There was no difference in functional outcome when the 3 groups were compared. Revision rates for the 3 groups from youngest to oldest were, 8.5%, 4.5%, and 6.9% respectively. Odds ratio and survival analysis showed no significant difference between the groups. Conclusion. In conclusion, we found that octogenarians over a 2 year period achieved similar functional outcome as their younger counterparts. Level of Evidence. IV

Background and Aims. Daily senior review is of paramount importance to provide optimal clinical care and facilitate timely discharge. Also, the General Medical Council state in Good Medical Practice 2013 that “work should be recorded clearly, accurately and legibly…containing relevant clinical findings, decisions made and actions agreed”. This audit aims to evaluate whether all trauma and elective Orthopaedic patients at one unit receive a daily senior review, which is fully documented in the case-notes, and whether a Comprehensive Unit-based Safety Programme (CUSP) toolkit can better facilitate this?. Methods. Case-notes for all patients admitted under Trauma and Orthopaedics on three separate non-consecutive days during a two-week period were scrutinized, examining them for the presence of CUSP toolkits and whether these were adequately completed. Results. 71 case-notes containing 291 CUSP toolkits were analysed. 46.4% had a completed toolkit for everyday since admission; however for those that did not, over half (55.2%) did not have a senior review documented elsewhere for the missing days. Only 1.4% of case-notes had a full complement of up-to-date CUSP toolkits completed entirely correctly. For patients on Orthopaedic wards, most common errors were failure to document date and time (69.7% incorrect), ward and bed number (30.7% incorrect), patient alerts (70.7% incorrect) and overall compliance in documentation of required parameters such as MRSA status, investigations, observation and fluid charts (23% incorrect). Conclusion. In conclusion, better education for clinical staff is needed to improve compliance both with daily senior review, CUSP toolkits and overall documentation to provide optimum patient care

Background. Tourniquets are routinely used in total knee arthroplasty (TKA) with an estimated use by up to 93% of surgeons. Advantages include the ability to provide a bloodless field of view to facilitate cement application and increase the success of the procedure. Overall reduction in blood loss is another perceived advantage, however recent research has demonstrated no measurable reduction and conversely a substantial increase in complications such as deep vein thrombosis and systemic emboli. Given the significant complications of tourniquet use we aim to identify patients’ views on tourniquets and of emphasis their awareness of the possible risks involved prior to the procedure. Method. A questionnaire-based study was carried out on 35 patients attending an elective orthopaedic centre for TKA surgery. Ethical approval was granted by NRES committee – East of England (REC Ref: 14/EE/1265). Patients were provided with an information sheet detailing the reasons for the tourniquet use and the associated risks and benefits. They were then provided with a questionnaire to ascertain their views and previous understanding of the subject. Simple statistical measures were implemented to analyse the data. Results. Only 32% of patients were aware of the use of tourniquets during the operation. 19% were aware of the benefits prior to reading the information sheet provided with 29% understanding the risks involved prior to their procedure. Finally we found 97% of patients would like more information on the use of tourniquets preoperatively. Conclusion. Tourniquets are widely used in TKA surgery, however, they carry significant risks which are not clearly relayed preoperatively to all patients. Given that 91,000 TKA operations are performed per year we believe it is of paramount importance that all patients are appropriately counselled on the risks and benefits of its use and fully informed consent, including risks of tourniquet use, should be obtained prior to the procedure. Level of Evidence. Level 3

Background. Tourniquets are routinely used in total knee arthroplasty (TKA) with an estimated use by up to 93% of surgeons. Advantages include the ability to provide a bloodless field of view to facilitate cement application and increase the success of the procedure. Overall reduction in blood loss is another perceived advantage, however recent research has demonstrated no measurable reduction and conversely a substantial increase in complications such as deep vein thrombosis and systemic emboli. Given the significant complications of tourniquet use we aim to identify patients' views on tourniquets and of emphasis their awareness of the possible risks involved prior to the procedure. Method. A questionnaire-based study was carried out on 35 patients attending an elective orthopaedic centre for TKA surgery. Ethical approval was granted by NRES committee – East of England (REC Ref: 14/EE/1265). Patients were provided with an information sheet detailing the reasons for the tourniquet use and the associated risks and benefits. They were then provided with a questionnaire to ascertain their views and previous understanding of the subject. Simple statistical measures were implemented to analyse the data. Results. Only 32% of patients were aware of the use of tourniquets during the operation. 19% were aware of the benefits prior to reading the information sheet provided with 29% understanding the risks involved prior to their procedure. Finally we found 97% of patients would like more information on the use of tourniquets preoperatively. Conclusion. Tourniquets are widely used in TKA surgery, however, they carry significant risks which are not clearly relayed preoperatively to all patients. Given that 91,000 TKA operations are performed per year we believe it is of paramount importance that all patients are appropriately counselled on the risks and benefits of its use and fully informed consent, including risks of tourniquet use, should be obtained prior to the procedure. Level of Evidence. Level 3

Background. Despite an ageing population and a rise in the number of joint replacements being performed, the mean age of patients undergoing surgery remains static. One explanation for this is continued concern over the risks of performing surgery on the very elderly. We aim to investigate the outcome of Total Knee Replacement (TKR) in a nonagenarian population. Methods. The Elective Orthopaedic Centre, Epsom has an established patient reported outcome measures (PROMs) programme into which all patients are routinely enrolled. We retrospectively reviewed our data set for a cohort of nonagenarians undergoing primary TKR, between April 2008 and October 2011. Post-operative complications, mortality rates and functional outcomes were compared to those of a time matched 70–79 year old cohort. Only patients with a primary diagnosis of osteoarthritis were included whereas an exclusion criterion consisted of patients undergoing revision surgery, simultaneous bilateral replacements or conversion from a Unicompartmental Knee replacement. Results. We identified 31 nonagenarian patients, with a mean age of 91.0 (90–96) and the control group consisted of 36 patients, with a mean age of 74.5 (70–79). Following a TKR, the nonagenarian cohort achieved a lower mean Oxford Knee Score (OKS) at 1 year (31.7+/−9.5) (p=0.15), but no difference existed by 2 years (p=0.157), and a mean outcome satisfaction of 85.2% (+/− 22.75) at 1 year, which was similar to the younger group. The nonagenarians had a greater risk of requiring a blood transfusion following a TKR (p=0.0373; CI 1.08 to 16.65), and a longer length of stay than their younger counterparts (p=0.001). Mortality rates were higher in the nonagenarian cohort, but these were in keeping with the life expectancy projections identified by the Office for National Statistics. Conclusion. In conclusion, we identified that over a 2 year period, nonagenarians achieved the same functional outcome and satisfaction rates following a TKR as 70–79 year olds. Level of Evidence IV

Introduction. In 2011 the Scottish Government published national MRSA screening requirements. A comparison of Orthopaedic and ENT elective surgery intended to juxtapose a specialty known to take MRSA screening seriously with one that has little clinical concern with regards MRSA infection. ENT surgery parallels Orthopaedics in using implants and there potentially being MRSA colonisation at or close to the site of surgery. In Orthopaedics MRSA infection is infrequent, but implant infection with antibiotic resistant bacteria has a particularly poor prognosis. In ENT MRSA infection is rare and colonisation does not influence patient care. Aims. An evaluation of MRSA screening practice for elective Orthopaedics and ENT surgery at Gartnavel General Hospital with regards strategy and implementation. Method. Review of 342 consecutive elective ENT patients and 325 Orthopaedic patients attending for inpatient or day case surgery. The reference standards were the regional and national guidelines on MRSA screening. Results. Overall screening rates were 145 (42%) of 342 ENT patients and 270 (83%) of 326 Orthopaedic patients. 100% of Orthopaedic patients admitted (154) were screened, in compliance with both regional and national policy. 91 (70%) of 130 ENT patients admitted were screened for MRSA, and no risk assessment was carried out, which was not in compliance with either regional or national policy. Discussion. Orthopaedic surgery has an established and reliable practice of screening elective inpatient cases, and when identified MRSA colonisation results in a change in patient management. ENT surgery should have established a similar practice according to existing local guidelines. The Government consider ENT a lower risk speciality for MRSA, but still require as a minimum a documented MRSA risk assessment process

Total hip replacement (THR) is a common elective surgical procedure and can be effective for reducing chronic pain. However, waiting times for THR can be considerable, and patients often experience significant pain during this time. A pain self-management intervention may provide patients with the skills to enable them to manage their pain and its impact more effectively before surgery. However, studies of arthritis self-management programmes have faced challenges because of low recruitment rates, poor intervention uptake, and high attrition rates. This study aimed to evaluate the feasibility of a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of a group-based pain self-management course for patients undergoing THR. Specific objectives were to assess trial design, ascertain recruitment and retention rates, identify barriers to participation, refine data collection methods, and evaluate uptake and patient satisfaction with the course. Patients listed for THR in an elective orthopaedic centre Bristol, UK were sent a postal invitation about the study. Participants were randomised to attend a pain self-management course plus standard care or standard care only using a computer-generated randomisation system. The pain self-management course was delivered by Arthritis Care and consisted of two half-day group sessions prior to surgery and one full-day group session 2–4 months after surgery. A structured course evaluation questionnaire was completed by participants. Outcomes assessment was by postal questionnaire prior to surgery and 1-month, 3-months and 6-months after surgery. Self-report resource use data were collected using a diary prior to surgery and inclusion of resource use questions in the 3-month and 6-month post-operative questionnaires. Brief telephone interviews were conducted with non-participants to explore barriers to participation. Postal invitations were sent to 385 eligible patients and 88 patients consented to participate (23% recruitment rate). Participants had a mean age of 66 years and 65% were female. Brief interviews with 57 non-participants revealed the most common reasons for non-participation were perceptions about the intervention and difficulties in getting to the hospital for the course. Of the 43 patients randomised to the intervention group, 28 attended the pre-operative pain self-management sessions and 11 attended the post-operative sessions. Participant satisfaction with the course was high, and patients enjoyed the group format. Retention of participants was acceptable, with 83% completing follow-up. Questionnaire return rates were high (76–93%), with the exception of the pre-operative resource use diary (35%). Completion rates for the resource use questions varied by category and allowed for an economic perspective from the health and social care payer to be taken. Undertaking feasibility work for a RCT is labour-intensive; however this study highlights the importance of conducting such work. Postal recruitment resulted in a low recruitment rate and brief interviews with non-participants provided valuable information on barriers to participation. Embedding collection of resource use data within questionnaires resulted in higher completion rates than using resource use diaries. While patients who attended the course gave positive feedback, attendance was low. Findings from this feasibility study enable us to design successful definitive group-based RCTs in the future

Objectives

Infection of implants is a major problem in elective and trauma surgery. Heating is an effective way to reduce the bacterial load in food preparation, and studies on hyperthermia treatment for cancer have shown that it is possible to heat metal objects with pulsed electromagnetic fields selectively (PEMF), also known as induction heating. We therefore set out to answer the following research question: is non-contact induction heating of metallic implants effective in reducing bacterial load in vitro?