Aims

Infective complications following implant related orthopaedic surgery or fracture related infection are associated with high costs and increased length of stay (LOS). However, the economic burden of disease before, during and after definitive osteomyelitis surgery is not well quantified. The Hospital Episode Statistics (HES) database captures all admissions, outpatient appointments and emergency department attendances at NHS hospitals in England. We identified all patients with a diagnostic code of osteomyelitis and quantified the tariff costs associated with the surgical treatment of osteomyelitis. We also collected all recorded healthcare events related to osteomyelitis for two years preceding the initial osteomyelitis treatment procedure, as well as for two years after the procedure. We compared average osteomyelitis treatment costs in England against a dedicated specialist multidisciplinary bone infection centre.

BACKGROUND

Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00.

Introduction

The number of revision hip arthroplasty procedures is rising annually with 7852 such operations performed in the UK in 2010. These are expensive procedures due to pre-operative investigation, surgical implants and instrumentation, protracted hospital stay, and pharmacological costs. There is a paucity of robust literature on the costs associated with the common indications for this surgery.

Aim. The number of periprosthetic joint infections (PJI) is increasing due to ageing population and increasing numbers of arthroplasty procedures and treatment is costly. Aim of the study was to analyze the direct healthcare costs of PJI in Europe for total hip arthroplasties (THA) and total knee arthroplasties (TKA). Method. A systematic review in PubMed with search of direct costs of PJI in European countries was performed. Thereby the term cost* AND (infection OR PJI) AND (prosthesis OR knee OR hip OR “TKA” OR “THA” OR arthroplast*) was combined with each European country to detect relevant publications. Publications with definition of performed procedure and joint localization were included into further analysis. The mean value of direct healthcare cost was calculated for the respective joint and the respective operation performed. Results. Screening revealed 1,274 eligible publications. After review of abstracts and full-texts n=11 manuscripts were included into final analysis (Figure 1). The mean combined direct hospital costs for revision for PJI after TKA and THA was 26,311€. Mean costs for revision procedures for PJI after TKA were 24,617€. Direct costs for TKA-PJI treated with debridement, antibiotics and implant retention (DAIR) were on average 10,121€. For two-stage revisions in knee arthroplasties total average costs were 30,829€. Referring to revision surgery for PJI in THA, the mean hospital costs in Europe were 28,005€. For a DAIR procedure direct healthcare costs of 5,528€ were identified. Two-stage revision cost on average 31,217€. Conclusions. PJIs are associated with significant direct healthcare costs. The financial burden of up to 30,000 € per case underlines the impact of the disease for European health care system. However, the number of detailed reports on PJI costs is limited and the quality of the literature is limited. There is a strong need for more detailed financial data on the costs of PJI treatment. For any tables or figures, please contact the authors directly

Introduction. Non-union is an unfortunate outcome of the fracture healing process for some patients; with an estimated annual incidence of 17.4- 18.9 per 100,00. The management of these patients depicts a significant clinical challenge for surgeons and financial burden to health services. External ultrasound stimulation devices (Exogen. TM. ) have been highlighted as a novel non invasive therapy to achieve union in cases of delayed and non-union. The aim of the current study was to assess the rate of union in patients using Exogen. TM. therapy for delayed fracture union in a district general hospital. Materials & Methods. This is a single centre retrospective continuous cohort study. Patients were identified from a prospective database of all patients prescribed Exogen. TM. therapy between June 2013- September 2021 in a district general hospital. Patient data was collected retrospectively using electronic patient records. Fracture union was assessed both clinically and radiographically and recorded in patient records. Failure of treatment was defined as progression to operative treatment due to lack of progression with ultrasound therapy or established asymptomatic non-union. Patient were excluded from the study if Exogen. TM. therapy was prescribed within 6 weeks of injury. Results. 142 potential patient were identified from the database. 35 patients were excluded from the data set (17 patients due to insufficient data available, 9 lost to follow up, 4 died and 5 excluded due to early application of Exogen. TM. therapy). 58 Patients progressed to union with an average time to union of 41 weeks. 49 cases failed to progress to union, of which 7 cases had conversion to operative management prior to completion of single course of Exogen. TM. therapy and were excluded from all other data review. 12% of cases that failed to unite with ultrasound therapy required multiple operations to establish union. Conclusions. A union rate of 58% was reported by the current study, which is lower than previously published. This likely reflects the heterogenous nature of the patient population and fracture distribution included. However, this is potentially a more reflective union rate for the general population than previously published. There were no adverse events associated with the use of Exogen. TM. therapy in the current study. Therefore supporting its use as a first line management to promote union in delayed fracture union in the general population. Additionally, failure to achieve fracture union with utilisation of Exogen. TM. therapy was associated with risk for requirement of multiple surgeries to achieve union. This could serve as an indicator for surgeon to consider the requirement additional measures at the initial surgical procedure

Background:. Injuries inflicted by gunshot wounds (GSW) are an immense financial burden on the South African healthcare system. The cost of treating an abdominal GSW has previously been estimated at R30 000 per patient. No study has been conducted to estimate the financial burden from an orthopaedic perspective. Objective:. To estimate the average cost of treating GSW victims requiring orthopedic interventions in a South African tertiary level hospital. Methods:. The study surveyed over 1,500 orthopedic admissions to our institution during 2012 to indentify GSW patients. A folder review yielded data on theatre time, implant cost, duration of admission, diagnostic-imaging studies performed, blood products used, laboratory costs and medicines issued to analyze costs. Results:. A total of 111 patients with an average age of 28 years (range 13–74) were identified. Each patient was hit by an average of 1.69 bullets (range 1–7). One hundred and forty seven fractures were sustained. Ninety-five patients received surgical treatment for a total of 128 orthopedic procedures, 15 concurrent general/vascular surgery procedures, and a cumulative surgical time of 198 hours 42 minutes. Cumulative anaesthetic time was 277 hours 33 minutes. Theatre costs (excluding implants) were estimated to be in excess of ten million rands. Ninety three of the patients received an implant during surgery which raised theatre costs even more. Total costs were in excess of R130 000.00 forward admissions, R180 000.00 for imaging, R190 000.00 for blood products, R16 000.00 for laboratory investigations and R16 000.00 for discharge medication. Conclusion:. Using varying calculations it was estimated that on average an orthopaedic GSW patient costs about R100 000.00 to treat, utilises about 2 hours of theatre time per operation and occupies a bed for an average period of 9 days

Aims. The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers. Methods. A model of referral, waiting list, and eventual surgery was created and calibrated using historical data from NHS England (April 2017 to March 2020) and was used to investigate the possible consequences of unmet demand resulting from fewer patients entering the treatment pathway and recovery strategies. NJR data were used to estimate the deficit of hip and knee arthroplasty by August 2020 and NHS tariff costs were used to calculate the financial burden. Results. By November 2020, the elective waiting list in England is predicted to be between 885,286 and 1,028,733. If reduced hospital capacity is factored into the model, returning to full capacity by November, the waiting list could be as large as 1.4 million. With a 30% increase in productivity, it would take 20 months if there was no hidden burden of unreferred patients, and 48 months if there was a hidden burden, to return to pre-COVID-19 waiting list numbers. By August 2020, the estimated deficits of hip and knee arthroplasties from NJR data were 18,298 (44.8%) and 16,567 (38.6%), respectively, compared to the same time period in 2019. The cost to clear this black log would be £198,811,335. Conclusion. There will be up to 1.4 million patients on elective orthopaedic waiting lists in England by November 2020, approximate three-times the pre-COVID-19 average. There are various strategies for recovery to return to pre-COVID-19 waiting list numbers reliant on increasing capacity, but these have substantial cost implications. Cite this article: Bone Jt Open 2021;2(2):103–110

Acute pain is one of the most common symptoms shared among patients who have suffered from an orthopedic trauma such as an isolated upper limb fracture (IULF). Development of interventions with limited side effects aiming to prevent the installation of chronic pain is critical as persistent pain is associated with an increased risk of opioid dependence, medical complications, staggering financial burdens and diminished quality of life. Theta burst stimulation (TBS), a non-invasive magnetic brain stimulation technique with minimal side effects, has shown promising results in patients experiencing various types of chronic pain conditions as it precisely targets brain regions involved in pain processing. Surprisingly, its impact on acute pain has never been investigated. This study aims to assess longitudinal effects of a 10-day continuous TBS (cTBS) protocol applied in the acute phase of an IULF on key functional outcomes. Patients with an IULF aged between 18 to 60 years old were recruited within 7 days post-accident at a Level I Trauma Center. Exclusion criteria included a history of brain injury, neurological disorders, musculoskeletal complications, and open fractures. In order to assess longitudinal changes, questionnaires measuring intensity and characteristics of pain (Numerical Rating Scale, NRS; McGill Pain Questionnaire, MPQ) as well as functional disability (DASH) were completed by all patients at three time points, namely prior to the start of the TBS program as well as 72 hours and 3 months post-intervention. Patients were randomly attributed to the active TBS protocol (active group) or to the placebo protocol (sham group). The stimulation site for each participant corresponded to the contralateral motor cortex of the injured arm. Fifty patients were recruited (female: 24; age: 40.38 years old), of which 25 were in the active group and 25 were in the sham group. Both groups were equivalent based on age, sex, type of injury, and surgical procedures (p>0.05). The intervention protocol was introduced on average 6.18 days post-accident. In comparison to the sham group, the active group showed a significant decrease in pain intensity (NRS) at 72h (F=6.02; p=0.02) and 3-month (F=6.37; p=0.02) post-intervention. No group difference was found early-on (72h post) in regard to pain characteristics (MPQ; F=3.90; p=0.06) and functional disabilities (DASH; F=0.48; p= 0.49). At three-month post-intervention, the active group showed statistically significant improvement on the MPQ (F=5.02; p=0.04) and the DASH (F=5.88; p=0.02) compared to the placebo group. No complications related to the treatment were reported. Results from this study show that patients who underwent active cTBS reported less pain and better functional states shortly after the end of the TBS protocol compared to sham patients and treatment effects were maintained at three months post-intervention. Given that acute pain intensity is an excellent predictor of chronic pain development, this safe technique available in numerous centers in Canada may help prevent chronic pain development when administered during the acute post-injury phase. Future studies should continue to investigate mechanisms involved to optimize this technique among the orthopedic trauma population and to reduce opioid consumption

Surgical site infections (SSIs) are associated with significant consequences in orthopaedic surgery, where their presence can lead to ultimate revision of the implant. Furthermore, infections and impaired wound healing can prolong length of hospital stay following orthopaedic surgery, which can place additional financial burdens on healthcare systems. The current analysis was conducted to determine whether the use of the PICO single-use negative pressure wound therapy (sNPWT) system after orthopaedic surgery reduced the incidence of SSIs and length of hospital stay compared with using conventional dressings. A systematic literature review (SLR) was performed using the PubMed, Embase and Cochrane Library databases. English-language studies comparing PICO sNPWT to conventional dressings published from 2011 to August 2018 with ≥10 patients in each treatment arm were included. Reference lists of included studies were searched for further relevant studies. Meta-analyses were performed using a fixed effect (I. 2. < 50%) or random effects model (I. 2. ≥ 50%). The SLR identified 6,197 studies, of which 5 relevant studies (607 patients) were included. The odds of an SSI were reduced by 57% (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.21–0.86; p = 0.02) and there was consistency between studies (I. 2. = 0%). Three studies reported on length of hospital stay. The mean difference between patient groups indicated that PICO sNPWT was associated with a 1-day reduction in hospital stay (mean difference [MD]: −0.99; 95% CI: −1.32 to −0.65; p < 0.00001) and there was again consistency between studies (I. 2. = 0%). These results suggest that the use of PICO sNPWT system after closed surgical incisions can reduce the incidence of SSIs and shorten the duration of hospital stay when used in orthopaedic patient populations

Aim. Despite advances in surgical and antibiotic therapies the treatment of chronic osteomyelitis remains complex and is often associated with a significant financial burden to the National Health Service. The aim of this review was to identify the different types of single-stage procedures being performed for this condition as well as to evaluate their effectiveness. Method. Ovid Medline and Embase databases were searched for articles on the treatment of chronic osteomyelitis over the last 20 years. 3511 journal abstracts were screened by 3 independent reviewers. Following the exclusion of paediatric subjects, animal models, non-bacterial osteomyelitis and patients undergoing multiple surgical procedures we identified 13 studies reported in English with a minimum follow up of 12 months. Following a quality assessment of each study, data extraction was performed and the results analysed. Results. 505 patients with chronic osteomyelitis underwent attempted single-stage procedures. Following debridement a range of techniques are described to eliminate the remaining dead space. These include musculocutaneous flaps, insertion of S53P4 glass beads or packing with antibiotic loaded ceramic or calcium-sulphate pellets. The average follow-up ranged from 12 to 110 months. The most common organism isolated was Staphylococcus Aureus. Success was defined as resolution of pain with no recurrence of sinuses and no need for a second procedure to treat infection. Success rates ranged from 60%-100%. Conclusions. There are currently a wide range of single-stage procedures being performed for chronic osteomyelitis with varying success rates. Treating patients with these methods in specialist centres can result in resolution of infection and may lead to improved quality of life for the patient and a financial saving for the National Health Service. So far no one technique has been shown to be superior and further long term follow up data is required

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure. Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure. The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision. A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision

National guidelines suggest which investigations should be performed for patients admitted with an acute hip fracture. We have observed practice often deviates from these guidelines. Our study aims to identify the incidence of deviation with regards to blood investigations and review the effect of deviation on management, and the financial burden on the healthcare system. A total of 250 acute hip fracture admissions over 12-months period reviewed retrospectively. Admission blood tests, time of presentation, and time of operation were recorded. The cost of admission blood investigations was calculated. Seventy-nine percent of admissions had one or more non-routine blood investigation tested. Twenty-Nine percent of these tests had abnormal results and these were found to be clinically relevant in 6% of patients. The most commonly requested non-routine investigations were: LFT in 79%, Coagulation screen in 56%, and CRP in 48%. Fifteen percent of patients did not have surgery within the time frame of 36 hours. The total cost of non-routine investigations was £1995.04. Deviation from admission investigations guidelines for hip fractures without clinical indication adds little clinical value, has no effect on management, and can be a potential cause of unnecessary investigations. This in turn leads to further delays and extra costs

This prospective five-year study analyses the impact of methicillin-resistant Staphylococcus aureus (MRSA) on an Irish orthopaedic unit. We identified 318 cases of MRSA, representing 0.76% of all admissions (41 971). A total of 240 (76%) cases were colonised with MRSA, while 120 (37.7%) were infected. Patients were admitted from home (218; 68.6%), nursing homes (72; 22.6%) and other hospitals (28; 8.8%). A total of 115 cases (36.6%) were colonised or infected on admission. Many patients were both colonised and infected at some stage. The length of hospital stay was almost trebled because of the presence of MRSA infection. Encouragingly, overall infection rates have not risen significantly over the five years of the study despite increased prevalence of MRSA. However, the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively

Financial impact and patient satisfaction with four different anticoagulants for hip and knee arthroplasty in patients with a previous history of VTE- A prospective randomised trial. Introduction. New generation oral anticoagulants (dabigatran/rivaroxaban) have recently become available for the prevention of venous thromboembolism (VTE) following hip and knee arthroplasty. Traditional therapies (warfarin/low molecular weight heparins) are less costly, but have several limitations. The aim of this study was to evaluate the financial impact of substituting enoxaparin and warfarin with newer therapies dabigatran and rivaroxaban. A secondary objective was to investigate patient satisfaction with these treatments. Methods. A randomised prospective study was conducted over a 12 month period. Patients with a history of VTE undergoing hip or knee replacement were randomised to receive one of four anticoagulants for five weeks post surgery. Information was gathered during the hospital stay and then post discharge, by telephone, for five weeks(35 days)to determine costs. The costs included cost of drug, nursing time, blood monitoring and transport costs. The patients were also asked to complete the Duke Anticoagulation Satisfaction Scale (DASS). The DASS is a 26 item questionnaire which has 7 responses for each question. Results. Although dabigatran and rivaroxaban had higher drug acquisition costs, warfarin and enoxaparin were financially more costly overall. These additional costs were mainly due to increased blood monitoring and time for training and administration which is not required for newer therapies. DASS scores were significantly better with dabigatran (38.5±5.1) and rivaroxaban (38.6±8.3) compared to warfarin (71.8±16.2) and enoxaparin (68.5±14.2) (p< 0.001). This indicates more satisfaction for patients prescribed dabigatran or rivaroxaban compared to traditional therapies. Conclusion. The use of new generation oral anticoagulants has the potential to significantly reduce the financial burden of thromboprophylaxis on the NHS with an additional benefit of better patient satisfaction when compared to traditional therapies

Background. The aim of this study was to identify and quantify any benefits of early active treatment of paediatric femoral shaft fractures for patients, their families, and the hospital. Patients and methods. Our protocol (1999-2002) uses flexible intramedullary nails for children older than five, early hip spica (within one week of injury) for the under five year olds, and external fixation for polytrauma (Early Active Group[EAG], n = 25). Prior to this (1999-2002), treatment consisted of late application of a hip spica (3-4 weeks following injury) or inpatient traction (Traditional Group [TG], n = 41). Outcome measures were length of hospital stay, degree of malunion, knee and hip movements, and leg length discrepancy. The financial burden to the family including waged and non-waged time lost, transport, childminder, and other extra costs were estimated. Hospital costs including inpatient stay, theatre, and implant costs were analysed. Results. A 40% reduction in the incidence of femoral fractures over the six-year period was noted. Mean hospital stay was 29 and 10 nights (p<0.001); family costs were £1,243 and £968; and hospital costs were £10,831 and £4,291 per patient (p<0.005) in the TG and the EAG respectively. Parents in both groups preferred early discharge (86%-94%). In the EAG, 10 patients were short at 3 months (0.5 - 3 cm). None was short at 2 years. Eight children were long at 2 years. At 2 years, all had good clinical and functional results. There was no significant difference in the mal-union rate between the two groups. All the fractures united by three months. Five out of nine complications occurred in the EAG. Conclusion. The use of our early active treatment protocol has resulted in a significant reduction in hospital stay, costs to the families and the hospital

Background. Meticillin-resistant Staphylococcus aureus (MRSA) are endemic in hospitals throughout Ireland and present a major concern in hospital hygiene causing significant morbidity, mortality and imposing a significant financial burden. This is particularly true in the field of orthopaedic surgery where a nosocomial MRSA infection can prove catastrophic to a patient's recovery from surgery. Much has been made of the possibility of healthcare workers acting as vectors for the transmission of MRSA and other pathogenic bacteria in the hospital setting. This focus has led to the implementation of strict hand decontamination policies in hospitals in order to counter the possibility of staff - patient transmission of such bacteria. Investigations have also attempted to assess the bacterial contamination of work uniforms such as white coats, ties and scrubs. An area that has been generally overlooked however, is the assessment of the bacterial contamination some of the most commonly handled items of many healthcare workers, namely pagers and mobile phones. In this study we aimed to assess the potential for these items to act as reservoirs for MRSA contamination and thus propagate its transmission in the hospital setting. Methods. Our study was performed at Cappagh National Orthopaedic Hospital, Dublin. We swabbed and cultured a sample of the pagers and mobile phones of staff. Questionnaires to assess the demographics of the staff sampled as well as the routine cleaning habits for their phone/pagers were also administered. Results. Bacteria were isolated from all pagers and mobile phones. Included in these isolated bacteria were MRSA and other potentially pathogenic organisms. Regular cleaning/disinfection of mobile phones and pagers was virtually non existent, either on a personal or institutional level. Conclusions. Mobile phones/pagers have thus far been generally overlooked as a possible reservoir and vector for the transmission of potentially pathogenic bacteria such as MRSA. We suggest that education about these possibilities takes place along with regular disinfection of these items in order to reduce the transmission of MRSA and other potentially pathogenic bacteria in the hospital setting

Introduction. Total hip arthroplasty (THA) is a commonly performed surgical procedure for the treatment of hip arthritis. Approximately 50,000 THAs are performed annually in Canada. The costs incurred to the healthcare system are tremendous, amounting to anywhere between 4.3 and 7.3 billion dollars each year. Despite the substantial financial burden of THA to the Canadian healthcare system, few studies have provided accurate cost estimations of this procedure. Purpose. To determine the impact of surgical approach on costs of THA from a hospital perspective, and provide an updated cost estimation of THA within a publically funded healthcare system. Methods. We recruited patients undergoing a THA through an anterior, posterior, or lateral approach for study participation. A single surgeon was designated to perform every case using the surgical approach of their expertise. Each patient received standardized implants: a collared, hydroxyapatite-coated, cementless femoral stem (Corail TM stem, DePuy Orthopaedics Inc., Warsaw, IN), a cementless acetabular cup (Pinnacle Sector II TM acetabular cup, DePuy Orthopaedics Inc., Warsaw, IN), a highly cross-linked polyethylene liner (AltrX TM polyethylene liner, DePuy Orthopaedics Inc., Warsaw, IN), and a cobalt chrome femoral head (Articul/eze TMcobalt chrome, DePuy Orthopaedics Inc., Warsaw, IN). We prospectively recorded costs of operating room time, length of stay in hospital, and medical and surgical interventions using a micro-costing method. Group comparisons were performed using Pearson's Chi-square and one-way Analysis of Variance (ANOVA), with post-hoc testing when necessary. All costs were reported in 2013 Canadian dollars. Results. One-hundred and eighteen patients (40 anterior, 38 posterior, and 40 lateral) completed the study. All three groups were similar with regards to age (p=0.79), sex (p=0.97), and body mass index (p=0.54). Mean operating room time was significantly shorter for the lateral (49.0 minutes, 95%CI 46.5 – 51.5) versus anterior (69.3 minutes, 95%CI 66.0 – 72.6, p<0.001) and posterior approach (61.6 minutes, 95%CI 57.5 – 65.5, p<0.001). Mean length of stay was shorter for the anterior (33.9 hours, 95%CI 29.6 – 38.2) compared to the posterior (65.8 hours, 95%CI 56.8 – 74.8, p<0.001) and lateral approach (64.2 hours, 95%CI 56.7 – 71.7, p<0.001). The operating room costs were significantly higher for the anterior versus posterior (p=0.008) and lateral approach (p<0.001, figure 1). The total inpatient costs were significantly for the anterior versus posterior and lateral approach (p<0.001 for both pair-wise comparisons, figure 2). Total costs were significantly less for the anterior ($7300.22, 95%CI 7064.49 – 7535.95) versus posterior ($8287.46, 95%CI 7906.41 – 8668.51, p<0.001) and lateral approach ($7853.10, 95%CI 7577.29 – 8128.91, p=0.031). Discussion / Conclusion. Total costs for THA were significantly less when performed using an anterior approach. A reduction in hospital length of stay contributed significantly to an overall reduction in costs from a hospital perspective. Future analyses will determine the cost-effectiveness of the anterior approach from both a hospital and societal perspective

Introduction. Neck and cup impingement resulted in producing larger amount of wear and risk for dislocation after total hip arthroplasty. DDH had more complex to adjust combined cup and femoral neck anteversion during surgery. Dislocation is the second most prevalent complication in total hip replacement with a 2–4% incidence. These resulted in significant financial burden to health care system. Sixteen million US dollars or more cost had in Japanese health insurance system every year. Purpose of this study was to evaluate neck-cup impingement with neck changeable M/L taper Kinectiv stem for DDH patients. Materials & Methods. Single surgeon's series were analyzed neck cup impingement of 1152 primary total hip surgeries with DDH. 269 hips in men, surgical approach were 754 mini-one antero-lateral, 284 mini- Watson-Jones, and 114 Hardinge. Acetabular cups were seated 20 degrees anteversion. Kinectiv Stem (Zimmer, Warsaw, IN) was inserted manually with standard technique. Femoral head selection was performed 26mm CoCr basis. 32mm were used for 75 years old or more, and 36mm were 80 years or older. First trial was performed with straight type of neck and 26mm femoral head based on preoperative templating. At neck and head trial to evaluated antero-superior impingement with “flex+add.+IR” and postero-inferior impingement with “ext.+add.+ER”. If the neck and cup impingement occurred even if no dislocation, necks were replaced counter version or larger offset. Results. Neck trial was 2 to 3 times during surgery (ave. 1.9). Version was changed 395(33%) cases. Surgeon selected larger offset in 246, 235 longer length, 99 shorter length. Larger offset with longer length were used in 229 (20%), 117 (10%) had larger offsets and shorter length compared to 2D templating before surgery. We had 2 dislocations (0.48%) with10 degree extended lip PE (2/359: 0.56%) and 2 for flat PE liner (2/793: 0.25%) fixed with manual reduction. All were using very short neck (E; minus 4 in length and S; minus 4 in length, plus 4 in offset) with smaller arc of movement type because of tight to redact compared expected proper positions. All dislocated cases were revised with larger femoral head. Our first series of 1500 Versys system with 10 degree extended lips had 0.74% (14/1880) (2004–9) dislocation rate. Kinectiv neck changeable stem had 66% reduction of dislocation rate (p<0.05). Averaged hospital stay was 7 (3–12) days. Discussion. One Kinectiv stem had 60 variety of necks based on 4 mm head center difference. Large amount of variation especially anteverted or retroverted neck selection might reduce neck-cup impingement compared to other straight type of femoral stems. Combined anteversion is very important especially in DDH patients, because of larger femoral anteversion. Proper offset and leg length are also very important issues for any type of patients. This type of stem had more advantages than straight type monolithic stems to reduce wear and dislocation caused by impingement. Care must be taken for reducing impingement with selecting shorter length or offset during surgery. Lower dislocation rate are very effective to health insurance system

The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration. Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed. Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture]. rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases

The main purpose of preoperative blood tests is to provide information to reduce the possible harm or increase the benefit to patients by altering their clinical management if necessary. This information may help clinicians assess the risk to the patient, predict postoperative complications and establish a baseline measurement for later reference. National Institute of Clinical Excellence (NICE) has issued guidelines around the need for pre-operative blood tests related to the age of the patient, comorbidities and the complexity of the procedure they will undergo. We decided to retrospectively review the pre-operative blood requests for patients under the age of 65 who were admitted at our institution over a 2 month period for open reduction and internal fixation of the ankle or tibial plateau and manipulation under anaesthesia of the lower limb. Patients were divided into 2 groups, under the age of 40 and between 40-65 years old. Patients under the age of 18 were excluded. These surgical procedures were classified as ‘intermediate complexity’. Admission clerkings of our 63 patient cohort were reviewed to ascertain if any patients had a significant co-morbidity or past medical history. The pre operative blood tests requested for each patient were audited against the NICE recommendations. None of the patients under the age of 40 had any significant comorbidites, whilst 8 patients above the age of 40 suffered with hypertension. 95% of patients had at least one blood test carried out. All patients over the age of 40 had at least one blood test. Tests requested included full blood count (91%), urea and electrolytes (91%), coagulation (66%), liver function tests (67%), group and save (69%), CRP (70%), ESR (2%), thyroid function tests (5%) and CK (2%). Only 5 patients (5%) followed the guidelines correctly. The clinical value of testing healthy individuals before an operation is debatable. The possible benefits of routine preoperative investigations include identification of unsuspected conditions that may require treatment before surgery or a change in surgical or anaesthetic management. The American Society of Anaesthesiologists has stated that ‘routine preoperative tests (i.e. tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anaesthesiologist.’. The overzealous requesting of preoperative blood tests also has a financial burden upon individual institutions. Our study also showed that some blood tests, such as inflammatory markers and thyroid function tests, were inappropriately requested. Adherence to the NICE guidelines would have resulted in a significant financial saving. This review has shown that adopting the NICE guidelines may result in a decrease in the amount of unnecessary blood tests patients undergo when they attend hospital for routine, minor or intermediate surgical procedures. If these guidelines were implemented for all surgical procedures, this would undoubtedly result in a significant financial saving for the institution and the NHS as a whole. At our institution we have implemented surgical and anaesthetic team awareness and education around these guidelines in a bid to reduce the use of unnecessary testing