Periprosthetic joint infections (PJIs) are uncommon but are devastating complications of total knee replacement (TKR). We analysed the risk factors of revision for PJI following primary TKR and their association with PJI at different post-operative periods. Primary TKRs and subsequent revision surgeries performed for PJI from 2003–2014 were identified from the National Joint Registry (NJR). Multilevel piece-wise exponential non-proportional hazards models were used to estimate the effect of the investigated factors at different post-operative periods. Patient, perioperative and healthcare system characteristics were investigated and data from the Hospital Episode Statistics for England were linked to obtain information on specific comorbidities. The index TKRs consisted of 679,010 primaries with 3,659 subsequently revised for PJI, 7% within 3 months, 6% between 3–6months, 17% between 6–12months, 27% between 1–2years and 43% ≥2 years from the index procedure. Risk factors for revision for PJI included male sex, high BMI, high ASA grade and young age. Patients with chronic pulmonary disease, diabetes and liver disease had higher risk of revision for PJI, as had patients who had a primary TKR for an indication of trauma or inflammatory arthropathy. Surgical procedure, fixation method, constraint and bearing type influenced the risk of revision for PJI. Their effects were period-specific. No or small associations were found with the operating surgeon grade, surgical volume and hospital surgical volume. These findings from the world's largest joint replacement registry show a more complex picture than the meta-analyses published to date with specific time-dependent effects for the identified risk factors

Introduction

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip replacement.

A recent systematic review of patient risk factors for PJI identified male gender, smoking status, increasing BMI, steroid use, previous joint surgery and comorbidities of diabetes, rheumatoid arthritis and depression as risk factors for developing PJI. Limitations of the current literature include the short term follow up of most published studies.

We investigated the role of patient, surgical and healthcare factors on the risk of revision of a primary hip replacement for PJI at different time-points in the post-operative follow-up. It is important that those risk factors are identified so that patients can be appropriately counselled according to their individual risk profile prior to surgery and modifiable factors can be addressed to reduce the risk of PJI at an individual and healthcare system level.

The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to free hand orthopaedic operation notes. A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to free hand operation notes. 97 cases were identified, of which 74 were free hand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes vs 0 (0%) in the free hand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the free hand op-note group (templated median 14, range 12-14, vs. free hand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by Registrars or Consultants identified Registrars as more likely to document the antibiotic prophylaxis given (p = 0.025). Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations

Introduction. Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM: EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI. Methods. A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from the previous INFORM research programme. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385). Result. The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development. Conclusions. This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems

Abstract. Background. 1. 63,284 patients presented with neck of femur fractures in England in 2020 (NHFD report 2021)2. To maximise theatre efficiency during the first wave of COVID-19, NHSE guidance recommended the use of HA for most patients requiring arthroplasty.3. The literature reports an incidence of Hemiarthroplasty dislocations of 1–15%. Aims. 1. To study the number and possible causes of dislocations in patients with Primary hemiarthroplasty for fracture neck of femur2. To compare our data with national and international data in terms of dislocation and revision rates for Hemiarthroplasty. Methods. Retrospective study Duration- 1st April 2021–31st March 20223. Inclusion criteria- Patients with neck of femur fracture treated with Hemiarthroplasty. Exclusion criteria- Patients treated with other surgical options for neck of femur fractures. Results. 1. No. of neck of femur patients- 4442. No. of patients treated with Hemiarthroplasty- 2143. No. of dislocations- 44. 75% were female, 75% had AMTS>7, 50% were operated within 36 hours of trauma, 75% dislocated within a month of surgery, 75% of the dislocations were revised. 5. One dislocation was due to >72 hour delay to surgery, second dislocation was due to smaller offset and shortening, third was due to acetabular dysplasia, fourth was due to larger head used. Discussion-1. Our 1.86% dislocation rate matches that in the literature of 1–6%2. 75% dislocated within a month of surgery matches that in the literature that maximum dislocations occur within one month. 3. Closed reduction as definitive method of management of dislocation 25% matches that in the literature of 22–25%4. 75% dislocations revised similar to literature of 75–80% revision rate. Conclusion. Pre-operative templating can reduce surgical error involving limb length discrepancy and shortening to prevent dislocations. 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

Abstract. Introduction. Several studies have shown that patients over 65 years have a higher mortality with covid. Combine with inherently increased morbidity and mortality in neck of femur (NoFF) fractures, it is logical to think that this subset would be most at risk. Aims. Investigate whether there is actual increase in direct mortality from Covid infection in NoFF patients, also investigate other contributing factors to mortality with covid positivity and compare the findings with current available literature. Methods. 1-year cross sectional, retrospective study from 1st March 2020 at two DGHs, one in Wales and one in England. Surgically treated NoFF patients with isolated intra/extracapsular fracture included. Mortality analysis done by creating a matched comparison group for each risk factor and combinations known to confer highest mortality. Chi square test for independence used to compare COVID status with 1 year mortality. Results. 610 patients, 62 patients had COVID-19RTPCR+ive test during hospital stay/in the community. 21(34%) deaths in COVID positive and 95 (17.33%) deaths in COVID negative patients. There was no mortality in ASA 1 or 2 patients. Analysis of asa matching with 10-year age ranges from 65years revealed a nearly double mortality rate in covid+ group as opposed to covid negative for both ASA 3 and 4 groups. Parameters such as preinjury mobility, residential status, AMTS score, time to surgery, did not seem to play a significant role in mortality. Conclusion. First of its kind study with a large subset of patients and unique parameters to identify causes leading to mortality in the vulnerable population of NoFF. Higher morality in Covid positive NoFF patients, but increase may not be as significant as identified by most current studies in the literature and still within the confines of NHFD stats(2019). 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

There is an inherent risk of iatrogenic new neurological deficit (NND) arising at the spinal cord, cauda equina and nerve root during spinal surgery. Intraoperative neurophysiological monitoring (IONM) can be employed to preserve spinal cord function during spinal surgery. IONM techniques include somatosensory and motor evoked potentials, amongst others. A Canadian survey of 95 spinal surgeons showed that 62.1% used IONM and a similar survey in France of 117 spinal surgeons showed that only 36% used IONM. Unavailability was a common reason for its disuse. Current literature by the British Society of Clinical Neurophysiology has outlined the importance of IONM in preventing NND and the need for the implementation of guidelines for IONM. The lack of an established guideline has resulted in a varied approach in the use of IONM in England. There has been no previous attempt to ascertain the current use of IONM in England. Our study is aimed at assessing the variability of the use of IONM in England as well as identifying the rationale amongst surgeons that dictate their use of IONM. We are in the process of investigating the indications of use of IONM for cervical and lumbar spine procedures in 252 spinal surgeons from 33 hospitals with spinal services. Our survey will illustrate the current use of IONM in spinal surgery in England. It will highlight some of the reasons for the variability of use of IONM and identify factors that can contribute to a more standardised use of IONM in spinal surgery

Spondylolisthesis is common recognized spine pathology. A lot of studies targeted spondylolisthesis in the recent years, few of which have made a major influential impact on the clinical practice. To the extent our knowledge this is the first study to highlight and analyze the top 100 cited articles on spondylolisthesis through a systematic search strategy used previously in published studies in different medical specialty. The aim of this study is to identify the most cited studies on spondylolisthesis and report their impact in spine field. Thomson Reuters Web of Science-Science Citation Index Expanded was searched using title-specific search “spondylolisthesis”. All studies published in English language between 1900 and 2019 were included with no restrictions. The top 100 cited articles were identified using “Times cited” arranging articles from high to low according to citation count. Further analysis was made to obtain the following items: Article title, author's name and specialty, country of origin, institution, journal of publication, year of publication, citations number, study design. The citation count of the top 100 articles ranged from 69 to 584. All published between 1950 – 2016. Among 20 journals, Spine had the highest number of articles 47, with citation number of 5964 out of 13644. Second ranked was Journal of Bone and Joint Surgery with 16 articles and a total citation of 3187. In respect to the primary author's specialty, Orthopedic surgeons contributed to the majority of top 100 list with 82 articles, Neurosurgery was the second specialty with 10 articles. United states had produced more than half of the list by 59 articles. England was the second country with 7 articles. Surgical management of lumbar spondylolisthesis was the most common discussed topic. This article identifies the top 100 influential papers on spondylolisthesis and recognizes an important aspect of knowledge evolution served by leading researchers as they guide today's clinical decision making in spondylolisthesis

Open lower limb fractures are resource-intensive fractures, accounting for a significant proportion of the workload and cost of orthopaedic trauma units. A recent study has evaluated that the median cost of direct inpatient treatment of open lower-limb fractures in the National Health Service (NHS) is steep, at £19189 per patient. Healthcare providers are expected to be aware of the costs of treatments, although there is very limited dissemination of this information, neither on a national or local level. Older adults (>65 years old) are at an increased risk of the types of high-energy injuries that can result in open lower limb fractures. Generally, there remains a significant lack of literature surrounding the cost of open fracture management, especially in specific patient groups that are disproportionately affected by these fractures. This study has calculated the direct inpatient care costs of older adults with open lower limb fractures. Open lower limb fractures in adult patients over 65 years old treated at Addenbrooke's Hospital of Cambridge University Hospitals NHS Trust were identified over the period of March 2014-March 2019. Isolated fractures of the femur, tibia and fibula over this time period were included. Direct inpatient care costs were calculated using information about the sustained fracture, operative time, implant(s) and theatre kit(s) used, the number of patient bed-days on the orthopaedic ward and critical care unit, and the number of hours of inpatient physiotherapy received. Direct inpatient care costs were compared with the income received by our centre for each of these cases, according to Healthcare Resource Group (HRG) cost codes. Our data was also compared with existing literature on Patient Level Costing (PLC) figures for open lower limb fractures. We extracted data from 58 patients over the age of 65 years treated for open isolated lower limb fractures at Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, between March 2014 and March 2019. The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. The absence of published primary literature and clinical audits on this topic continues to hinder the inclusion of cost-effectiveness as an important factor in clinical decision-making. This study provides valuable insight into the true cost of open lower limb fractures in a key patient population in a Major Trauma Centre in England and highlights the large losses incurred by hospitals in treating these cases. These results support the revision of the remuneration structures in the NHS for the treatment of elderly patients with these injuries

In the UK and USA in 2016 more than 263,000 primary knee replacements were performed. Around 20% of patients report chronic post-surgical pain (CPSP) at three or more months after total knee replacement (TKR). A large proportion of adults with all types of chronic musculoskeletal pain do not use services for a number of reasons, despite being in constant or daily pain. Given the high prevalence of CPSP, there is potentially a large hidden population with an unexpressed need for care, experiencing ongoing pain and disability; understanding why they do not use health services may herald further insight into why many remain dissatisfied with knee replacement surgery. The aim of this study is to understand why some people with CPSP after TKR do not access services or make little use of healthcare. We conducted face-to-face in-depth interviews with 34 patients from 2 high-volume orthopaedic hospitals in England, to investigate their experience of long-term pain after knee replacement; their knowledge and understanding of CPSP; and their decisions about consulting for CPSP. The sample size was based on achievement of saturation and participants provided written informed consent. Interviews were transcribed and analysed using an inductive thematic approach with double coding for rigor. Ethical approval for the study was granted by the West Midlands Solihull Research Ethics Committee (15/WM/0469). A core theme within the analysis suggests that participants do not seek healthcare because they believe that nothing further can be done, either by themselves or by healthcare professionals. Surgeons' satisfaction with the knee surgery and reassurances that pain would improve, left patients feeling uncertain about whether to re-consult, and some assumed that further consultation could lead to further surgery or medication, which they wish to avoid. Some participants' comorbidities took precedence over their knee pain when seeking healthcare. Others felt they had received their “share” of healthcare resources and that others were more deserving of treatment. People's descriptions of pain varied, from dull, or aching to shooting pains. Many described their pain as “discomfort” rather than pain. The majority described pain that was better than their pre-surgical pain, though others described pain that was worse, which they believed to be nerve damage. Many expressed disappointment in the outcome of their TKR. Expectations of pain varied, where most had expected some post-surgical pain, others underestimated it, and some had expected to be completely pain free following their TKR. Our analysis suggests that the reasons that some people with CPSP after TKR do not consult are varied and complex, spanning psychosocial, structural, moral, and organisational domains. There was an overriding sense that further consultation would be futile or may lead to unwanted treatment. Results suggest that improved information for patients about CPSP and appropriate post-surgical healthcare services may help patients and clinicians to manage this condition more effectively

Objectives. To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA). Methods. This was a retrospective study including all patients (17 116) referred to fracture clinics in a London District General Hospital from May 2013 to April 2016, using hospital-level data. We used interrupted time series analysis with segmented regression, and direct before-and-after comparison, to study the impact of VFCs introduced in December 2014 on six clinical parameters and on local Clinical Commissioning Group (CCG) spend. Student’s t-tests were used for direct comparison, whilst segmented regression was employed for projection analysis. Results. There were statistically significant reductions in numbers of new patients seen face-to-face (140.4, . sd. 39.6 versus 461.6, . sd. 61.63, p < 0.0001), days to first orthopaedic review (5.2, . sd. 0.66 versus 10.9, . sd. 1.5, p < 0.0001), discharges (33.5, . sd. 3.66 versus 129.2, . sd. 7.36, p < 0.0001) and non-attendees (14.82, . sd. 1.48 versus 60.47, . sd. 2.68, p < 0.0001), in addition to a statistically significant increase in number of patients seen within 72-hours (46.4% 3873 of 8345 versus 5.1% 447 of 8771, p < 0.0001). There was a non-significant increase in consultation time of 1 minute 9 seconds (14 minutes 53 seconds . sd. 106 seconds versus 13 minutes 44 seconds . sd. 128 seconds, p = 0.0878). VFC saved the local CCG £67 385.67 in the first year and is set to save £129 885.67 annually thereafter. Conclusions. We have shown VFCs are clinically and cost-effective, with improvement across several clinical performance parameters and substantial financial savings for CCGs. To our knowledge this is the largest study addressing clinical practice implications of VFCs in England, using robust methodology to adjust for pre-existing trends. Further studies are required to appreciate whether our results are reproducible with local variations in the VFC model and payment tariffs. Cite this article: A. McKirdy, A. M. Imbuldeniya. The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison. Bone Joint Res 2017;6:–269. DOI: 10.1302/2046-3758.65.BJR-2017-0330.R1

The development of an algorithm that provides accurate individualised estimates of revision risk could help patients make informed surgical treatment choices. This requires building a survival model based on fixed and modifiable risk factors that predict outcome at the individual level. Here we compare different survival models for predicting prosthesis survivorship after hip replacement for osteoarthritis using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. In this comparative study we implemented parametric and flexible parametric (FP) methods and random survival forests (RSF). The overall performance of the parametric models was compared using Akaike information criterion (AIC). The preferred parametric model and the RSF algorithm were further compared in terms of the Brier score, concordance index (C index) and calibration. The dataset contains 327 238 hip replacements for osteoarthritis carried out in England and Wales between 2003 and 2015. The AIC value for the FP model was the lowest. The averages of survival probability estimates were in good agreement with the observed values for the FP model and the RSF algorithm. The integrated Brier score of the FP model and the RSF approach over 10 years were similar: 0.011 (95% confidence interval: 0.011–0.011). The C index of the FP model at 10 years was 59.4% (95% confidence interval: 59.4%–59.4%). This was 56.2% (56.1%–56.3%) for the RSF method. The FP model outperformed other commonly used survival models across chosen validation criteria. However, it does not provide high discriminatory power at the individual level. Models with more comprehensive risk adjustment may provide additional insights for individual risk

Patients with knee prosthetic joint infection (PJI) frequently receive one- or two-stage revision. To explore the feasibility of a randomised controlled trial (RCT) comparing methods, we analysed a UK registry, interviewed patients and surgeons, systematically reviewed literature, held a consensus meeting, and assessed progress of an RCT in hip PJI. In 2014, in England and Wales, knee PJI was treated with one- or two-stage procedures in 19% and 71% of patients respectively. Between 2007 and 2014, use of one-stage procedures doubled and, in major centres, up to 42% of treatments were one-stage. We conducted in-depth interviews with 16 patients with knee PJI and 11 surgeons performing one- or two-stage revision. Patients considered randomisation acceptable with appropriate counselling and, depending on infecting organisms and health status, surgeons would randomise treatments. In meta-analysis, two-year re-infection rates in 10 one-stage series (423 patients) and 108 two-stage series (5,129 patients) were 7.6% (95%CI 3.4,13.1) and 8.8% (7.2,10.6) respectively. In a series of patients with knee PJI, surgeons from 2 major centres considered 6/15 patients eligible for either treatment, with 4 more potentially eligible after treatment of soft tissue infection. In an ongoing RCT of surgical treatment of hip PJI, 116 patients have been randomised at 14 centres in 3 years. Randomising patients with PJI is feasible but, as knee PJI is uncommon, a multicentre RCT would be required. Based on WOMAC score outcome and appropriate assumptions on eligibility and acceptability, 170 patients would need to be randomised over 4 years at 14 major centres

Introduction. Guidelines from the North American Spine Society (2009 and 2013) are the best evidence-based instructions on venous thromboembolism (VTE) and antibiotic prophylaxis in spinal surgery. NICE guidelines exist for VTE prophylaxis but do not specifically address spinal surgery. In addition, the ruling of the UK Supreme Court in 2015 resulted in new guidance on consent being published by the Royal College of Surgeons of England (RCSEng). This study assesses our compliance in antibiotic, VTE prophylaxis and consent in spinal surgery against both US and UK standards. Methods. Retrospective review of spinal operations performed between August and December 2016. Case notes, consent forms and operation notes were analysed for consent, peri-operative antibiotic prescribing and post-operative VTE instructions. Results. Four Spinal surgeons performed 45 operations during this period. 31 patients (69%) received a copy of the signed consent with this process being formally documented in 22 (71%) of those cases. All patients were consented by a competent surgeon. 82% of cases consented prior to the date of procedure were countersigned on the day of operation. There was a mean time of 25.3 days between initial consent and operation (Range: 0–170). 37 (82%) cases had clear instructions for VTE and antibiotic prophylaxis. All prescribed post-operative antibiotics were administered. Discussion. The North American Guidelines state that prophylactic antibiotic is appropriate in all spinal surgery with prolonged cases requiring intraoperative re-dosing and only complex cases needing a postoperative regimen. Eight patients underwent a complex procedure and 7 appropriately received postoperative antibiotics. Of the 29 patients that underwent a simple procedure, 12 did not receive post-operative regimen, in line with the guidelines. However, the remainder 17 were over treated. The US Guidelines recommend mechanical VTE prophylaxis only in elective spinal surgery except in high risk patients. All our patients received VTE mechanical prophylaxis. RCSEng guidelines require consent being taken prior to procedure by a competent surgeon and confirmed on day of procedure. All patients in our cohort were consented prior to the date of operation allowing time for considering options and independent research. 82% of patients had consent confirmed on day of operation. Conclusion. This study demonstrates that we met guideline advice for all patients with regards VTE prophylaxis. We have a tendency to over treat with post-operative antibiotics and not all patients had their consent confirmed on day of procedure but was consented well before day of operation. North America still lead the way with guidelines on spinal surgery to which we should adhere, with NICE guidelines providing limited instructions. New consenting guidelines from RCSEng may not be currently widely known and thus should be a source of education for all surgeons

Background. Hip fractures affect 1.6 million people globally per annum, associated with significant morbidity and mortality. A large proportion are extracapsular neck of femur fractures, treated with the dynamic hip screw (DHS). Mechanical failure due to cut-out is seen in up to 7% of DHS implants. The most important predictor of cut-out is the tip-apex distance (TAD), a numerical value of the lag screw”s position in the femoral head. This distance is determined by the psychomotor skills of the surgeon guided by fluoroscopic imaging in theatre. With the current state of surgical training, it is harder for junior trainees to gain exposure to these operations, resulting in reduced practice. Additionally, methods of simulation using workshop bones do not utilise the imaging component due to the associated radiation risks. We present a digital fluoroscopy software, FluoroSim, a realistic, affordable, and accessible fluoroscopic simulation tool that can be used with workshop bones to simulate the first step of the DHS procedure. Additionally, we present the first round of accuracy tests with this software. Methods. The software was developed at the Royal National Orthopaedic Hospital, London, England. Two orthogonally placed cameras were used to track two coloured markers attached to a DHS guide-wire. Affine transformation matrices were used in both the anterior-posterior (AP) and cross table lateral (CTL) planes to match three points from the camera image of the workshop bone to three points on a pre-loaded hip radiograph. The two centre points of each marker were identified with image processing algorithms and utilised to digitally produce a line representing the guide-wire on the two radiographs. To test the accuracy of the system, the software generated 3D guide-wire apex distance (GAD) (from the tip of the guide-wire to a marker at the centre of calibration) was compared to the same distance measured with a digital calliper (MGAD). In addition, the same accuracy value was determined in a simulation scenario, from 406 attempts by 67 medical students. Results. The median absolute inaccuracy of FluoroSim with 270 measurements was 3.35mm (IQR = [1.15mm, 6.53mm]). The absolute inaccuracy showed a graded increase the further away the tip of the guide-wire was from the centre of calibration; MGAD ≤10mm, median absolute inaccuracy = 1.53mm; MGAD 10mm<x≤20mm, median absolute inaccuracy = 4.97mm; MGAD >20mm, median absolute inaccuracy = 7.23mm. Comparison between all three groups reached significance (p < 0.001). In a simulation scenario with medical students, FluoroSim had a significantly greater median absolute inaccuracy of 4.79mm compared to the testing scenario (p < 0.001). Conclusion. FluoroSim is a safe and inexpensive digital imaging adjunct to workshop bones simulation. To our knowledge this technology has not been explored in the context of DHS simulation, and has the potential to be extended to other orthopaedic procedures

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