There has been a significant increase in the demand for arthroplasty as a result of the Covid 19 pandemic and lack of beds on the green pathway. The average length of in-hospital stay following knee replacements has been successfully reduced over the years following introduction and adoption of enhanced recovery protocols. Day case arthroplasty has the potential to be efficient as well as cost-effective. We present our day case pathway for elective knee arthroplasty and early results of its adoption at a district general hospital. Our pathway was developed through a multidisciplinary input from surgeons, anaesthetists, physiotherapists, nursing staff, administrative staff, surgical care practitioners and pharmacists. Inclusion criteria were defined to identify patients suitable for cay case arthroplasty. Results of 32 patients who underwent day case partial and total knee replacement at our institution between 2018 to 2022 are presented. 31 out of 32 (97%) were discharged safely on the day of surgery. Patients were discharged at a mean of 7 hours following surgery. There were no re-admissions following discharge. There were no surgical complications at a mean follow-up of 2 years. Patient feedback revealed high levels of satisfaction and that they would recommend the pathway to others. Cost analysis revealed savings towards bed costs. Our early results demonstrate day case knee arthroplasty to be safe and cost effective. With limited resources to tackle the enormous backlog of arthroplasty, it offers the potential to make theatre utilization efficient

Aims. Cauda equina syndrome (CES) is a rare condition which requires urgent treatment to reduce the risk of long term neurological morbidity. Most authors recommend surgical decompression within 24–48 hours of the onset of symptoms, which may not be possible if there are delays in referral to hospital, performance of diagnostic imaging or poor access to a spine surgeon. We present a snap shot of referrals of patients with suspected cauda equina syndrome to the Orthopaedic department in a district general hospital including the diagnoses, management and outcome. Methods. A retrospective review of 20 consecutive patients (mean age 49, 11 males, 9 females) referred via Primary Care to the orthopaedic on call team between April and December 2010 was carried out. Data were recorded including the clinical symptoms and signs on admission, time taken to undergo MRI, diagnosis and treatment. Results. 18/20 patients had red flag symptoms. Two patients with convincing neurological evidence of CES were transferred to the local neurosurgical unit for urgent assessment and surgical intervention. 12 patients required urgent inpatient MRI scans; mean time to MRI for these patients was 22 hours from the initial Orthopaedic assessment. Of these, none showed cauda equina and 3 were offered elective surgery for spinal nerve root compression. 14 out of 20 patients presented outside normal working hours when immediate access to MRI was unavailable. Conclusions. The majority of patients in this study had red flag symptoms, although few actually had CES. Usually patients present in the evening when access to MRI is unavailable, potentially delaying the diagnosis. Such information may be useful to radiology departments to help plan out of hours services or help district hospital Orthopaedic departments develop protocols with nearby neurosurgical units for rapid patient transfer when CES is suspected

The significance of ring-fencing orthopaedic beds and protected elective sites have recently been highlighted by the British Orthopaedic Association & Royal College of Surgeons. During the pandemic many such elective setups were established with various degrees of success. This study aimed to compare the functioning and efficiency of a Orthopaedic Protected Elective Surgical Unit (PESU) instituted during the pandemic with the pre-pandemic elective service at our hospital (Pre-Pandemic ward or PPW). We retrospectively collected data of all patients who underwent elective Orthopaedic procedures in a protected elective unit during the pandemic (March 2020 – July 2020) and a similar cohort of patients operated via the routine elective service immediately prior to the pandemic (October 2019 – February 2020). Various parameters were compared and analysed. To minimise the effect of confounding factors a secondary analysis was undertaken comparing total hip replacements (THR) by a single surgeon via PESU (PESU-THR) and PPW (PPW-THR) over 5 months each from March-July 2021 and March-July 2019 respectively. A total of 192 cases were listed on PESU during the studied period whereas this number was 339 for PPW. However more than half (52%) of those listed for a surgery on PPW were cancelled and only 162 cases (48%) were actually performed. PESU had a significantly better conversion rate with only 12.5% being cancelled and 168 (87.5%) cases performed. 49% (87 out of 177) of the cases cancelled on PPW were due to a ‘bed unavailability’. A further 17% (30/177) and 16% (28/177) were cancelled due to ‘emergency case prioritisation’ and ‘patient deemed unfit’ respectively. In contrast only 3 out of the 24 patients cancelled on PESU were due to bed unavailability and the main reason for cancellation here was ‘patient deemed unfit’ (9/24). Single surgeon THR, showed similar demographic features for the 25 patients on PESU and 37 patients on PPW. The average age for these patients was 63 on PESU and 69 on PPW whereas the BMI was 33 and 30 respectively. The patients on PESU also demonstrated a decrease in length of hospital stay with an average of 3 days in comparison to 4.8 days for those admitted to PPW. PROMS scores were comparable at 6 weeks with an average improvement of 16.4/48 in the PESU-THR cohort and of 18.8/48 in the PPW-THR cohort. There were no readmissions or revisions recorded in the PESU-THR cohort while the PPW-THR cohort had 1 readmission and revision. Our study shows how a small ring fenced Orthopaedic elective unit in a district general hospital, even during a global pandemic, can function more efficiently than a routine elective facility with many shared services

Total hip arthroplasty (THA) has high rates of patient satisfaction; however patient expectations for recreational and sporting activities are not always met. Our study aimed to identify preoperative factors that predict whether patient expectations for sporting or recreational activity are met 12 months following THA. Patient reported outcome measures (PROMs) were collected prospectively from 2015-2018 at one private hospital in Sydney. Age, gender, postcode, weight, and height were recorded preoperatively. Included participants underwent primary THA by one of the investigating surgeons. Univariable and multivariable analyses were performed with an expectation fulfilment score used as the primary outcome variable. Preoperative predictor variables included: age, gender, BMI, Socio-economic Indexes for Areas (SEIFA), Oxford Hip Score, Hip Osteoarthritis Outcome Score, EQ-5D-5L and EQ Visual Analogue Scale (EQ VAS). 1019 participants were eligible and included. 13% reported that preoperative expectations of sport or recreation were not met at 12 months. Younger age, lower preoperative EQ VAS, and higher BMI were associated with failed expectations on multivariable analysis. Odds of failed expectations increased by 2% for every one year younger in age (OR= 0.98, 95% CI = 0.96 to 1.00, p=.048), by 2% for every one point lower on EQ VAS (OR=0.98, 95% CI = 0.98 to 0.99, p=.002), and by 4% for every one-point increase in BMI (OR = 1.04, 95% CI = 1.00 to 1.09, p=.042). Failure to have expectations met for sporting or recreational activity was associated with younger age, poorer general health, and high BMI. With a rise in younger patients who likely have higher physical demands, a tailored preoperative education is preferable to generic models to better manage patient expectations. Younger age, higher BMI, and poorer health may predict unmet expectations for sport and recreation after THA. Tailored education in these groups should be considered

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis. The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts. Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care). General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates

DAIR procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our experience of DAIR following hip and knee replacements in a District General Hospital (DGH), where we delivered comparable results to leading tertiary centres in short to mid-term followup. We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Microbiological support was provided by a Microbiologist with interest in musculoskeletal infections. 14 patients [9 males, 5 females; age 62 to 78 years (Mean 70.7); BMI 22 to 44.2 (Mean 33.8)] with multiple comorbidities underwent DAIR procedure within 3 weeks of onset of symptoms. 12 out of 14 grew positive cultures with two growing Vancomycin resistant Enterococci. Intravenous antibiotics were started after multiple samples intraoperatively and continued in six patients after discharge, while 8 were discharged with oral antibiotics. One patient died of overwhelming intraoperative septic shock in postoperative period. Another patient died of myocardial infarction subsequently. 12 (85.7%) patients were doing well with regular followup (Mean 20 months). With good patient selection, DAIR is a far simpler solution and a safe and reproducible surgical option for early PJI following hip and knee replacements compared to one or two stage revisions. But published data in contemporary literature is predominantly from specialised centres. Our small series provides a perspective of comparable early to mid-term results of DAIR from DGH

Purpose. In a previously published multicenter randomized clinical trial it was shown that young patients (16–60 years-old) with displaced mid-shaft clavicle fractures had superior limb specific outcomes when they were treated with primary plate fixation versus non operative treatment at one year follow-up. This study examines the general health status of this cohort of patients at two-years post injury. Method. We evaluated the general health of a cohort of patients with displaced mid-shaft clavicle fractures comparing non-operative versus plate fixation at two-years after injury. At the conclusion of our study, eighty-nine patients (fifty-four from the operative group and thirty-five from the non-operative group) completed the two-year follow-up. Outcome analysis included the standard clinical follow-up and SF-36 scores. Results. SF-36 scores were significantly improved in the operative fixation group at all time-points: 6 weeks, 3, 6, 12, 24 months (P<0.01). At two-years after the injury, the patients in the operative group had better patient oriented outcome scores, especially in the physical performance component of the SF-36 scores (Physical component (PCS) 57.1 versus 51.0, P<0.05). Conclusion. Operative treatment more reliably restored pre-operative levels of general health status compared to non-operative treatment. Operative fixation of a displaced mid-shaft clavicle fracture in young active patients resulted in improved patient oriented general health status at two-year follow-up. The improvement is especially pronounced in the physical component of the SF-36 scores. These findings support primary plate fixation of displaced mid-shaft clavicle fractures in young active adults

Purpose. The purposes of this study are as follows; 1) to compare postoperative blood loss between general anesthesia(GA) and spinal anesthesia(SA) and 2) to analyze the affecting factors of postoperative blood loss through the subgroup analysis. METHODS. A retrospective analysis was made on the clinical data of 122 patients with osteoarthritis undergoing primary TKA between January 2012 and December 2013. According to different anesthetic method, the patients were divided into the General Anesthesia group (73 cases) and the Spinal Anesthesia group (49 cases). Each group was divided subgroup as age, BMI, Preoperative blood pressure, Surgery time, Torniquet time, INR. The total blood loss, Post Operation 1 day blood loss, hidden blood loss, and the percentage of hidden blood loss were compared between 2 groups. For the analysis of postoperative blood loss, each group was compared postoperative blood loss using hemovac drainage per day and total blood loss. In preoperative blood pressure, Higher than 140 mmHg in systolic blood pressure and higher than 90 mmHg in diastolic blood pressure were employed as a cut-off value to group the well-controlled hypertension group(n=42) and uncontrolled hypertension group(n=29). RESULTS. One day after the surgery blood loss(p=0.322) and total blood loss(p=0.560) showed no significant differences between two group. But in the uncontrolled hypertension group showed a large amount of bleeding one day after the surgery(p=0.003) and total blood loss(p=0.004) in the spinal anesthesia. CONCLUSION. It seems that, general anesthesia is effective method to reduce postoperative blood loss. Preoperative blood pressure control is one of the important affecting factor of postoperative blood loss

Unicompartmental knee replacement (UKR) is associated with higher revision rates than total knee replacement and it has been suggested that surgeons should receive specific training for this prosthesis. We investigated the outcome of all UKR in a district general hospital over ten years. All patients who had received UKR from 2003 to 2013 were identified from theatre records, as were all revision knee arthroplasties. We contacted all patients (or their GP) with no known revision to ascertain UKR status. A life table analysis was used for three categories: all surgeons and types of UKR, Oxford UKR only and Oxford UKR by surgeons with specific training. There were 319 UKR (one loss to follow up), four types of prosthesis, 21 failures and a 5-year cumulative survival rate of 91.54%. There were 310 Oxford UKR with 17 failures and 5-year survival 93.56%. Surgeons with training in use of Oxford UKR completed 242 replacements with 10 failures and 5-year survival of 95.68%. In comparison with results for Oxford UKR in 11th annual NJR report, our results are satisfactory and support continued use of this prosthesis in a non-specialist centre. Our established programme of surveillance will monitor the survival of UKR in our hospital

Aims. The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic. Methods. A prospective cohort study was undertaken between 17 March 2020 and 30 April 2020 and compared with retrospective data from same time period in 2019. We compared the number of patients requiring acute hospital admission or orthopaedic referrals and indications of referrals from our admission sheets and obtained operative data from our theatre software. Results. Between 17 March to 30 April 2020, there were 48 acute spine referrals as compared to 68 acute referrals during the same time period last year. In the 2019 period, 69% (47/68) of cases referred to the on-call team presented with back pain, radiculopathy or myelopathy compared to 43% (21/48) in the 2020 period. Almost 20% (14/68) of spine referrals consisted of spine trauma as compared to 35% (17/48) this year. There were no confirmed cases of cauda equine last year during this time. Overall, 150 spine cases were carried out during this time period last year, and 261 spine elective cases were cancelled since 17 March 2020. Recommendations. We recommend following steps can be helpful to deal with similar situations or new pandemics in future:. 24 hours on-call spine service during the pandemic. Clinical criteria in place to prioritize urgent spinal cases. Pre-screening spine patients before elective operating. Start of separate specialist trauma list for patients needing urgent surgeries. Conclusion. This paper highlights the impact of COVID-19 pandemic in a district general hospital of England. We demonstrate a decrease in hospital attendances of spine pathologies, despite an increase in emergency spine operations. Cite this article: Bone Joint Open 2020;1-6:281–286

Abstract

Malalignment is a common complication following tibial surgery, occurring in 10% of fractures. This is associated with prolonged healing time and non-union. It occurs due to inability to maintain a satisfactory reduction. A reduction device, such as the Staffordshire Orthopaedic Reduction Machine (STORM), permits the surgeon to manipulate the fracture and hold it reduced.

A retrospective parallel case series was undertaken of all patients undergoing tibial nails over a six-year period from 2014 to 2021. Patient demographics were obtained from medical records. Operative times obtained from the theatre IT system and included the time patient entered theatre and surgical start and finish times for each case.

Anteroposterior and lateral long leg post-operative radiographs were reviewed. Angulation was measured in both coronal and sagittal planes, by two separate orthopaedic surgeons. A reduction was classified to be ‘mal-aligned’ if the angle measured was greater than 5 degrees. One tailed unpaired t-test was used to compare alignment in each plane. Bony union was assessed on subsequent radiographs and was determined according to the Radiographic Union Score for Tibial Fractures

31 patients underwent tibial nail during the time period. 8 patients were lost to follow up and were excluded. Of the remaining 23 patients, the STORM device was utilised in 11.

The overall mean alignment was acceptable across all groups at 2.17° in the coronal plane and 2.56° in the saggital plane. Analysing each group individually demonstrated an improved alignment when STORM was utilised: 1.7° (1°–3°) vs 2.54° (0°–5°) for the coronal plane and 1.6° (0°–3°) vs 3.31° (0°–9°) in the saggital plane. This difference was significant in saggital alignment (p=0.03) and showed a positive trend in coronal alignment, although was not significant (p=0.08)

The time in theatre was shorter in the control group with a mean of 113 minutes (65 to 219) in comparison to STORM with a mean of 140 minutes (105 to 180), an increased theatre time of 27 minutes (p=0.04).

This study demonstrates that STORM can be used in the surgical treatment of tibial fractures resulting in improved fracture alignment with a modest increase in theatre time.

Purpose. The pros and cons of general anesthesia versus spinal anesthesia in total hip arthroplasty has been a long debated topic. The purpose of this study was to compare the surgical times, blood loss and transfusion requirements between anesthetic types in patients undergoing primary total hip arthroplasty. Method. A consecutive series of 1600 THA procedures with complete preoperative and postoperative data were evaluated. Twenty eight percent of procedures were performed with a general anesthetic (GA), 67% with a spinal anesthetic (SP) and 5% with a combination of the two. Outcomes were compared and tested for significance using the Independent Samples Kruskal Wallis or Pearson Chi-Square analysis. Results. Comparing GA and SP respectively, there was a statistically significant difference in patient age between the groups (age 63.73 14.5 vs 66.6 12.8, p<0.05), but not in ASA scores and distribution, or preoperative hemoglobin levels (131.74 32.5 vs 133.21 28.9). There was a statistically significant difference in length of time proceeding surgical procedure favoring Generals (SP: 35 mins (10 72) vs GA: 30 mins (8 65), p<0.05), however overall time in room was longer in Generals (GA: 132.83 29.0 vs SP: 127.15 22.5). There was a statistically significant difference in discharge hemoglobin favoring Spinals (SP: 97.9 14.2 vs GA: 94.9 16.4, p<0.05), lower transfusion rates (SP: 8.4% vs GA: 14.0%, p<0.05) and shorter length of stay (SP: 4.9 days vs GA: 5.3 days, p<0.05). The patients receiving a combination of anesthetic had a significantly greater length of time prior to proceeding the surgical procedure (43 mins (20 145)) and overall time in room (142.85 27.2) compared to both GA and SP, however were similar in all other outcomes. Conclusion. In this consecutive series of patients undergoing general anesthesia, spinal anesthesia and a combination for total hip arthroplasty, the general anesthesia cohort demonstrated advantages in statistically significantly shorter time proceeding the surgical procedure, however the overall procedure time was significantly longer. The spinal group had less blood loss and lower transfusion rates and the combination group had statistically longer procedure times compared to both GA and SP

Abstract

Fewer delays in starting a trauma list can reduce cancellations. A novel system has been previously described where a patient is identified the day before and optimised for theatre. The patient is listed first and designated “Golden Patient”. This project aimed to assess the impact of introducing a “Golden Patient” system on trauma list start times in a district general hospital. Two months of first case sending and anaesthetic start times were recorded retrospectively (43 cases). The “Golden Patient” system was introduced with a multi-disciplinary implementation group. Target send time of 0830 hours (hrs) and anaesthetic start time of 0900hrs was agreed. First patients on trauma lists were noted in two cycles, two months apart (Cycle 1: 46, Cycle 2: 38). Prior to implementation: Mean Send Time (MST) of 0855hrs, Mean Anaesthetic Start Time (AST) of 0921hrs. Cycle 1: MST fell by 9 minutes (p = 0.03) and AST by 11 minutes (p = 0.023). Lists labelled with a “Golden Patient” (47.8%) were sent 14 minutes earlier (p = 0.004) and started 12 minutes earlier (p = 0.02) than those not labelled “Golden”. Cycle 2: Implementation produced a 13-minute reduction in send times (p = o.oo3) and start times (p = 0.008) overall. “Golden Patient” cases (42.1%) showed an improved MST of 0836hrs and AST of 0902hrs, 10 minutes earlier than those not designated “Golden”. Implementation of the “Golden Patient” produced a significant improvement in trauma list starts overall. Specifically, “Golden Patients” help to improve efficiency in sending and anaesthetic start times, by up to 19 minutes on average

Debridement Antibiotics Implant Retention (DAIR) is a recognised procedure in the management of acute prosthetic joint infection (PJI). We present an experience of DAIR following hip and knee replacements in a District General Hospital. A retrospective review of 14 patients who underwent DAIR procedures between August 2012 and December 1015 were collated. The cohort included primary, complex primary and revision hip and knee replacements. All patients received multidisciplinary care with surgery performed by one of two arthroplasty surgeons. 9 males and 5 females with age 62 − 78 years (Mean 70.7) and BMI 22–44.2 (Mean 33.8) with various co-morbidities underwent DAIR. Surgical criteria required DAIR to be performed within 3 weeks of the onset of symptoms of infection. The time from index surgery however ranged from 15 days to 58 months. 12 of 14 grew positive cultures including two growing Vancomycin Resistant Enterococcus. Intravenous antibiotics were commenced after intraoperative samples and tailored OPAT. Antibiotic schedule varied from six weeks to eight months. 12 (85.7%) patients remain under follow up. Mean follow is 20 months (RANGE 6months-3years10months) with no recurrence of infection or reoperation. With appropriate patient selection, DAIR is safe and reproducible surgical option in PJI in hip and knee replacements, avoiding the implications of a one or two stage revision. Published Data in contemporary literature is predominantly from specialised centres. Our small series provides a perspective of early to mid term results of DAIR to DGH. Interestingly each procedure is categorised as a failed implant on the National Joint Register

We evaluated the long-term survival and patient reported outcome of the Copeland mark III humeral resurfacing hemi-arthroplasty (Biomet, Warsaw, Indiana). At a UK District General Hospital 95 shoulder replacements in 85 patients were performed from 1994 to 2003 (mean age 68.9). At the time of follow-up (mean of 12 years, range 8.7–18.0) 49 patients had survived. This study group were posted Oxford Shoulder Score (OSS) and SF-12 questionnaires and their case notes were reviewed. There was an 82% response rate. The responders comprised 46 shoulders in 40 patients. 40 shoulders had a pre-operative diagnosis of osteoarthritis and 6 had other pathologies. The median OSS was 36. The median functional score was 24 (IQR: 9.5), where 32 is the best. The median pain score was 13 (IQR: 7) with 16 being the best score. There was a median SF 12 score of 31 (IQR: 3), where the maximum score is 47. There were 3 revision operations and 95% survivorship at 18 years, according to Kaplan Meier survival analysis. The Copeland mark III hemi-arthroplasty prosthesis has a good long term survival, few post-operative complications and a good functional outcome in an elderly population. We would advocate its use in this patient group

Aims. This retrospective study aimed to determine the causes of in-hospital death after Neck of Femur (NOF) fracture in Southampton General Hospital (SGH) over a 6 year period, comparing the clinical cause of death with findings at post-mortem. A previous study showed discrepancies between pre-mortem clinical diagnosis and autopsy findings after in-hospital deaths in SGH. Methods. The study included all patients who died in SGH after NOF fracture from 2007–2013. Case notes were reviewed to determine the pre-mortem clinical diagnosis and compared with the autopsy findings to analyse major and minor discrepancies. Data were also analysed from the period 1997–2003 in order to compare the causes of death. Results. 43 cases were referred for autopsy after NOF fracture during the 6 year study period, of which 39 cases (90.1%) were available for analysis. There was complete agreement between pre-mortem clinical diagnosis and autopsy findings in 64.1% of cases. Major discrepancies were found in 35.9% of cases and minor discrepancies in 23.1% of cases. Causes of death due to bronchopneumonia and pulmonary embolism had decreased significantly during the recent 6 year period when compared with the previous study period. No pulmonary emboli were identified as the primary causes of death between 2007 and 2013. Conclusion. Deaths due to pulmonary emboli after NOF have declined significantly. The reasons for this are unclear and are the subject of an ongoing study which will be discussed. Discrepancies between pre- and post-mortem diagnoses highlight the importance of autopsy findings. The current study revealed a similar rate of major discrepancies compared to the previous study

Severe deformity and bone loss in patients with degenerative changes of the knee present a challenging surgical dilemma to the knee surgeon. We present the outcome following complex primary total knee replacements at our unit over 12 years undertaken by a single surgeon. Method:. 65 patients were followed up prospectively with regards to their pre- and post-operative Oxford knee scores, diagnoses, preoperative deformity, bone loss, surgical technique, type of implant used, bone substitutes, and perioperative, or long term complications. These patients were followed up annually. Result:. 70 complex primary total knee replacements were performed in 65 patients. The mean age was 70.5 years and the mean follow up was 62.4 months. Sleeve/wedge augmentation, and stemmed implant (Sigma®TC3- DePuy) were used in general. Bone grafting was utilized for contained bone defects. All except 4 patients were allowed to fully weight bear immediately postoperatively. The mean range of flexion was 112.5 degrees at their last follow up. The mean preoperative Oxford Knee Score was 12.8, and 41.5 postoperatively. 89.4% of patients had either an excellent or good, and the rest a fair outcome. Radiological appearance has been satisfactory in all patients at subsequent follow up, with no evidence of implant loosening. None required revision surgery. 6 patients required blood transfusion postoperatively. 2 patents developed symptomatic deep vein thrombosis and a further 2 had pulmonary embolus. Conclusion:. Our experience with complex primary total knee replacements has been promising with a good outcome

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499