Abstract. Objectives. The purpose of this study was to determine the cost of inpatient admissions for developmental dysplasia of the hip (DDH) at a UK tertiary referral centre, and identify any association between newborn screening (NIPE) status and the cost of treatment. Methods. This was a retrospective study, using hospital episodes data from a single NHS trust. All inpatient episodes between 01/01/2014 to 30/06/2019 with an ICD-10 code stem of Q65 ‘congenital deformities of hip’ were screened to identify admissions for management of DDH. Data was subsequently obtained from electronic and paper records. Newborn screening status was recorded, and patients were divided into ‘NIPE-positive’ (diagnosed through selective screening) and ‘NIPE-negative’ (not diagnosed through screening). Children with neuromuscular conditions or concomitant musculoskeletal disease were excluded. The tariff paid for each inpatient episode was identified, and the number of individual clinic attendances, surgical procedures and radiological examinations performed (USS, XR, CT, MRI) were recorded. Results. 41 patients with DDH were admitted for inpatient management. 44% (n = 18) were NIPE-positive, diagnosed mean age 6.7 weeks. 56% (n = 23) were NIPE-negative, diagnosed mean age 26 months. The total cost of inpatient care in the NIPE-positive group was £171,471 (£9,526.18 per-patient) compared to £306,615 (£13,331.10 per-patient) for NIPE-negative. In the NIPE-positive group, there were 99 clinic attendances, 47 inpatient admissions and 160 radiological examinations performed (36 USS, 107 XR, 17 CT). This compared to 148 clinic attendances, 59 inpatient admissions and 215 radiological examinations (187 XR, 26 CT, 2 MRI) in the NIPE-negative group. Conclusion. A greater proportion of inpatient admissions for DDH are among NIPE-negative children. They incur a higher cost of treatment per patient and necessitate more inpatient resources. This study adds to the ongoing conversation around the cost-effectiveness of selective screening for DDH in the UK. 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

Objectives. Aged trauma patients are at high risk for various comorbidities and loss of function following hip fracture. Consequently a multidisciplinary approach for the treatment of these patients has become more famous in order to maintain the patients” activity level and health status prior to trauma. This study evaluates the effect of a multidisciplinary inpatient rehabilitation on the short- and long-term functional status of geriatric patients following hip fracture surgery. Methods. A collective of 158 hip fracture patients (> 80 years) who underwent surgery were included in this study. An initial Barthel Index lower than 30 points was a criteria to exclude patients from this study. Two subgroups, depending on the availability of treatment spots at the rehabilitation center were made. No other item was used to discriminated between the groups. Group A (n=95) stayed an average of 21 days at an inpatient rehabilitation center specialized in geriatric patients. Group B (n=63) underwent the standard postoperative treatment. As main outcome parameter we used the Barthel Index, which was evaluated for every patient on the day of discharge and checkups after three, six and twelve months. Results. After three months, the average Barthel Index was 82,27 points for group A and 74,68 points for group B (p=0,015). In the six-months-checkup group A”s average Barthel Index was 84,05 points and group B”s was 74,76 points (p=0,004). After twelve months, patients from group A had an average Barthel Index of 81,05 while patients from group B had an average Barthel Index of 71,51 (p=0,010). Conclusion. This study reveals a significant better outcome in both, the short-term and the long-term functional status for geriatric hip-fracture patients, who underwent an inpatient treatment in a rehabilitation center following the initial surgical therapy. This is shown at the timepoints three, six and twelve month after discharge. To maintain quality of life and mobility as well as the patient”s independence in daily life, a treatment in a rehabilitation center specialized in geriatric patients is highly recommendable

Background

The current average tariff of a total knee replacement (TKR) is £5500. The approximate cost of each knee prosthesis is £2500. Therefore, length of patient stay (LOS) and the cost of patient rehabilitation influence the total costs significantly. Previous studies have shown a mean LOS of between 5 and 9.4 days for patients undergoing primary unilateral TKR but none looked at the factors influencing length of stay following bilateral primary total knee replacements (BTKR) at the same sitting.

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

Introduction and Objective. In anticipation of reduced workload and need for minimisation of staff contact with infectious patients during the COVID-19 lockdown in 2020, Cairns Hospital reduced the junior orthopaedic staffing and absolved team structure. Materials and Methods. We performed a retrospective audit of our department's workload during a predetermined three week period during the 2020 lockdown and in 2019. Results. 699 patient referrals from Emergency Department were captured; 358 in 2019 and 341 in 2020, a decrease of 4.7%. The same proportion were admitted (64.5%); similar numbers required operative intervention; 51.7% (2019) vs 50.1% (2020). There was a small reduction in spine and neck of femur fracture presentations (2% and 0.9% respectively). Common presentations such as supracondylar fractures and distal radius fractures remained nearly unchanged (increased 0.7% and 0.2% respectively). Overall, the referred patients’ demographics were essentially unchanged. Department workforce was reduced by 45% (20 vs 11 doctors). Elective operating, excluding category 1, was suspended, resulting in an overall reduction of total admissions and operations by 29.7%. The average length of stay of inpatients increased by 25.3% (2.5 vs 3.16 days). Conclusions. During lockdown, the acute orthopaedic burden remained almost unchanged. Despite a reduction in inpatient patient load, the average length of stay increased. This was multifactorial, including staffing reduction disproportional to workload, loss of team structure and continuity of care, and government enforced restrictions to the Cape York region. This can be used in future for planning the staffing allocation if further lockdowns are enforced during this, or future, pandemic

The covid-19 pandemic had a great impact in the daily clinical and surgical practice. Concerning patients with a femoral neck fracture, there is the need of a negative Sars-CoV-2 test or an established isolation period for the positive cases, pre-operatively. The goal of this study was to evaluate the impact of the pandemic in the management of patients with femoral neck fractures, who were submitted to surgical treatment with hemiarthroplasty, in our hospital. A retrospective, observational study was performed, analysing the patients with femoral neck fractures submitted to hip hemiarthroplasty, during the years 2019 (before the pandemic) and 2020 (first year of the pandemic). We analysed the first 5 patients operated in each month of the mentioned years. We analysed 56 and 60 patients submitted to surgery in the years 2019 and 2020, respectively. The inpatient days were, in average, 14.1 and 13.1. Patients were operated, in average, 3.0 and 3.8 days after admission (corrected to 2.5 and 3.6 days if the time of discontinuation of anticoagulants or antiplatelets needed before surgery is deducted). There were peri-operative complications in 53.6% and 46.7% of the patients, in 2019 and 2020 respectively. The most common complication in both groups was a low postoperative haemoglobin level needing red blood cell transfusion. One-year postoperative mortality rate was 17.9% and 13.3%, respectively. Despite the changes triggered by the new pandemic, there was an overall maintenance of the quality of the management of these patients, with only a slight increase in the interval between admission and surgery. Some of the remaining variables even showed an improvement when comparing the two groups of patients. Nevertheless, it is important to mention that there were patients infected with Covid-19 who died before being submitted to surgery, therefore not being present in these statistics

The e-scooter trial was part of a wider initiative from the Department for Transport in response to COVID pandemic. New emergency legislation was introduced in 2020 to make e-scooters legal in the UK for the first time. This scheme was launched in our county from September 2020. The aim of this case series was to identify the types of Orthopedic injuries resultant from electric scooter transport that presented to our District General Hospital over a 16-month period between September 2020 and December 2021. This study involved retrospective collection of data from electronic hospital records. Data on demographics, laterality, date of injury, type of injury, treatment, HDU/ITU admissions, mortality, and operating time were collected to characterize the types of e-scooter-related injuries and to investigate the frequency of such injuries over the duration of our search. A total of 79 orthopedic patients identified with electric scooter injuries between September 2020 and December 2021. 78.5% were males and the mean age was 30.1 years. Summer months accounted for most of the injuries. 17 patients required inpatient care. 23 patients required surgical intervention and a total of 29 surgeries were performed in our hospital. This accounted for a total surgical time of 2088 minutes. One patient admitted with shaft of femur fracture developed pulmonary embolism after the definitive operation and died in HDU. Electric scooters provide a space efficient, affordable, environmentally friendly mode of transportation which reduce the urban congestion and parking issues. This study demonstrates an increasing frequency of significant orthopedic injury associated with e-scooter use treated at our centre over the course of 16 months. This small series underlines an important problem given that this increase has occurred after the start of the electric scooter trial. Legalization might result in further increase in the incidence of injury

To describe clinical situations for use of modified VAC in POC based on: diagnosis, comorbidities, BMI, wound size in cm, days following trauma when VAC was first applied, total duration of uninterrupted use, frequency of change, settings, bacterial growth, outcomes. To report the outcomes of mVAC use in POC within 6 months to help improve and standardize its application in the institution. This study involves data gathering from inpatients handled by orthopedic surgeons in training and subspecialty rotations in POC. The data collected are highly dependent on the doctors-in-charge's complete charting, thorough reporting and accurate documentation. Modified Vacuum Assisted Closure (mVAC) is used frequently in this study and is defined as a form of revised, adapted and reformed use of VAC based on available materials in the involved institution. The materials that are included are, but not limited to the following: sterile Uratex™ blue foam, nasogastric or suction tubing, phlegm suction machine, Bactigras™ and Opsite™ or Ioban™. A total of 58 patients were included in the study. The average age of the population was 35 and are predominantly male. The most common mechanism of injury was motorcycle accident and 37 of the patients were diagnosed with an open fracture of the lower extremity with open tibia fractures (22) being the most common. Average wound area measured was 24.12 cm. 3. All patients yield a bacteria growth with e. coli being the most frequent. Average during of uninterrupted use was 39 days. Of the 58 included in the study, 8 patients underwent STSG, 2 had a flap coverage surgery, 4 patients eventually underwent amputation and 33 with complete resolution of soft tissue defect after conversion to biologic dressing post-mVAC. The rest of the population were still ongoing mVAC at the end of the study. mVAC is an alternative temporary medium for soft tissue coverage for cases with or without concomitant fractures. mVAC promotes removal of exudate from the wound, supports wound apposition and granulation bed proliferation. Usage mVAC helps prepare for skin coverage procedure and on some cases leads to full resolution of defect

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

Background. Post-operative acute kidney injury is significant complication following surgery. Patients who develop AKI have an increased risk for progression into chronic kidney disease, end-stage renal failure and increased mortality risk. The patient outcomes following total knee replacement (TKR), who develop AKI has been a topic of interest in recent years as it may have patient and medicolegal implications. Nevertheless, there are no studies looking at the incidence, risk factors and outcomes of AKI following bilateral TKRs at the same sitting. Objectives. To determine the incidence, risk factors and outcomes of post-operative AKI following bilateral TKRs surgery at the same sitting. Methods. This was a retrospective single-centre study performed at the Princess Royal Hospital, which performed a total of 25 BTKR. The incidence, Surgical and patient risk factors were recorded and analysed. Results. The incidence of AKI as defined by NICE guidelines following bilateral TKRs was 20%. 16% (4 patients) had stage 1 and 4% (1 patient) had stage 2 AKI. The mean change in Creatinine between pre- and post-operative blood tests was +19μmol/L. There was a strong significant correlation between CKD and AKI (r=0.75, P<0.05). Furthermore, a moderate correlation was found between higher BMI and pre-operative Charlson index and AKI. AKI did not have an effect on the length of inpatient stay with the mean inpatient length of stay for patients who had an AKI of 10 days compared to 11days for those who did not. All AKIs were resolved within 72 hours. There were no associated mortalities with AKI. Conclusion. The incidence of AKI following bilateral TKR was 20%. Pre-operative chronic kidney disease as well as having a higher BMI were identified as risk factors for developing AKI. Pre-operative CKD optimisation and careful adequate hydration intra-operatively should be considered in these patients. AKI was not associated with an increased length of stay or mortality in our study

Abstract. Objectives. Stiffness is reported in 4%–16% of patients after having undergone total knee replacement (TKR). Limitation to range of motion (ROM) can limit a patient's ability to undertake activities of daily living with a knee flexion of 83. o. , 93. o. , and 106. o. required to walk up stairs, sit on a chair, and tie one's shoelaces respectively. The treatment of stiffness after TKR remains a challenge. Many treatment options are described for treating the stiff TKR. In addition to physiotherapy the most employed of these is manipulation under anaesthesia (MUA). MUA accounts for up to 36% of readmissions following TKR. Though frequently undertaken the outcomes of MUA remain variable and unpredictable. CPM as an adjuvant therapy to MUA remains the subject of debate. Combining the use of CPM after MUA in theory adds the potential benefits of CPM to those of MUA potentially offering greater improvements in ROM. This paper reports a retrospective study comparing patients who underwent MUA with and without post-operative CPM. Methods. Standard practice in our institution is for patients undergoing MUA for stiff TKR to receive CPM for between 12–24hours post-operatively. Owing to the COVID-19 pandemic hospital admissions were limited. During this period several MUA procedures were undertaken without subsequent inpatient CPM. We retrospectively identified two cohorts of patients treated for stiff TKR: group 1) MUA + post-operative CPM 2) Daycase MUA. All patients had undergone initial physiotherapy to try and improve their ROM prior to proceeding to MUA. In addition to patients’ demographics pre-manipulation ROM, post-MUA ROM, and ROM at final follow-up were recorded for each patient. Results. In total 168 patients who had undergone MUA between 2017–2022 were identified with a median Age of 66.5 years and 64% female. 57% had extension deficit (>5. o. ), 70% had flexion deficit (< 90. o. ), and 37% had both. 42 had daycase MUA without CPM and the remaining 126 were admitted for post-operative CPM. The mean Pre-operative ROM was 72.3. o. (SD:18.3. o. ) and 68.5. o. (19.0. o. ) for the daycase and CPM groups respectively. The mean ROM recorded at MUA was 95.5. o. (SD:20.7. o. ) and 108.3. o. (SD:14.1. o. ) [p<0.01] and at final follow-up was 87.4o (SD:21.9o) and 92.1o (SD:18.2o) for daycase and CPM groups respectively. At final follow-up for the daycase and CPM groups respectively 10% vs. 7% improved, 29% vs. 13% maintained, and 57% vs. 79% regressed from the ROM achieved at MUA. The mean percentage of ROM gained at MUA maintained at final follow-up was 92% (SD:17%) and 85% (SD:14%) [p=0.03] for daycase and CPM groups respectively. Conclusion. Overall, there was no significant difference in ROM achieved at final follow-up despite the significantly greater improvement in ROM achieved at MUA for the CPM group. Analysis of the percentage ROM gained at MUA maintained at follow up showed that most patients regressed from ROM achieved at MUA in both groups with those in the CPM only maintaining 85% as opposed to 92% in the daycase patients. It is our observation that post-operative CPM does not improve ROM achieved after MUA as compared to MUA alone. 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

Introduction and Objective. Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation. Materials and Methods. A retrospective study of adult patients in all UK hospitals, who underwent fibula nail fixation between 01/01/2018 and 31/10/2020 was performed. Primary outcome measures included time to union, infection rate, other post-operative complications associated with the fixation and length of hospital stay. The secondary outcome measure was to identify the indication for fibula nailing. Data tabulation was performed using Microsoft Excel and analysis was performed using SPSS Version 23 (SPSS Statistics). Results. 2 Major Trauma Centres (MTCs) and 9 Trauma Units (TUs) were eligible for inclusion. 102 patients were included and 91% were classified as ankle fractures of 68% (n=69) were Weber B, 24% (n=24) Weber C and 8% (n=9) were either distal tibial fractures with an associated fibula fracture or pilon fractures. The mean age was 64 years of which 45 were male patients and 57 were female. The average BMI was 30.03kg/m. 2. and 44% of patients were ASA 3. 74% of patients had poor pre-op skin condition including swelling and open wounds. The calculated infection rate for fibula nail was 4.9% and metal-work complication rate was 4.9%. The average time to union was 13 weeks and length of inpatient stay was 15 days (SD +/− 12 days). Conclusions. MEFNO has demonstrated that fibula nail is an ideal implant in patients who have a physiologically higher risk of surgery, poor skin condition and a complex fracture pattern. The time to union, complication and infection risks are lower than that reported in literature for ankle ORIFs

Acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Conservative management is reserved for those unfit for extensive reconstruction, or those who achieve ‘secondary congruence' of a complex fracture. We present demographic data and the results of conservative management in patients over 65 years of age. The Fracture Outcome Research Database (FORD) at our unit was interrogated for all patients over 65 years, who had sustained an acetabular fracture between June 2008 and June 2016. 410 patients were identified. Following exclusions, thirty-two patients were included for analysis. They had a mean age of 80 (66–91), and a mean ASA equivalent score of 3.1 (2–4). Mean follow up was five (1–9) years. Twenty-five patients lived in their own home and seven in a nursing home. Thirty had low energy injures, two high energy. Twenty-four (75%) had anterior column posterior hemitransverse fractures, seven (22%) had associated both column and one (3%) had a T-type fracture. The mean length of inpatient stay was 43 days (4–140). Maximum post-operative mobility was limited to a hoist in eight (25%), a frame with or without assistance in 15 (47%), a stick in five (16%) and independence in four (13%). Thirty-day mortality was 6%- and one-year mortality 22%. The data demonstrates that conservative treatment in this cohort leads to long inpatient stays, poor mobility and significant levels of mortality. Complex reconstruction remains demanding on both surgeon and patient. Innovative ways of managing these patients are needed to improve outcomes

Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The cost savings from reduced LOS amounts to £110 - £247 per patient when NPWT is used. We hypothesize that in primary TKA patients with high risk of wound related problems that may delay discharge from hospital, there may be an overall cost saving when using NWPT dressings. 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

Object. The aim of this study was to investigate the impact of the COVID-19 pandemic on the management and outcome of patients with neck of femur fractures. Methods. Data was collected for 96 patients with neck of femur fractures who presented to the emergency department between March 1, 2020 and May 15, 2020. This data set included information about their COVID-19 status. Parameters including inpatient complications, hospital quality measures, mortality rates, and training opportunities were compared between the COVID-19 positive and COVID-19 negative groups. Furthermore, our current cohort of patients were compared against a historical control group of 95 patients who presented with neck of femur fractures before the COVID-19 pandemic. Results. Seven (7.3%) patients were confirmed COVID positive by RT-PCR testing. The COVID positive cohort, when compared to the COVID negative cohort, had higher rates of postoperative complications (71.4% vs 25.9%), increased length of stay (30.3 days vs 12 days) and quicker time to surgery (0.7 days vs 1.3 days). The 2020 cohort compared to the 2019 cohort, had an increased 30-day mortality rate (13.5% vs 4.2%), increased number of delayed cases (25% vs 11.8%) as well as reduced training opportunities for Orthopaedic trainees to perform the surgery (51.6% vs 22.8%). Conclusions. COVID-19 has had a profound impact on the care and outcome of neck of femur fracture patients during the pandemic with an increase in 30-day mortality rate. There were profound adverse effects on patient management pathways and outcomes while also affecting training opportunities

Hip fractures are a common injury in elderly patients. The UK has a National Hip Fracture Database to collect data on all patients presenting to hospital with a hip fracture. Literature evidence suggests that early surgery for hip fracture patients improves morbidity and mortality. UK national guidelines (BOA, NICE) recommend that surgery is performed within 36 hours of presentation and/or diagnosis for inpatients. Best Practice Tariffs ensure that hospitals are paid a set value if they meet this target of surgery within 36 hours. This study aims to look at reasons for delay to surgery for patients presenting to our busy level 2 trauma unit. This is a retrospective review of prospectively collected data for patients referred to the orthopaedic team at our hospital with a diagnosis of a neck of femur fracture between 1st April and 31st December 2018. Patients under the age of 65 year of age were excluded from our study. Only patients who were operated on after 36 hours were included. The database for reasons of surgical delay was reviewed and electronic patient records were used to collect further data on length of stay and 30-day mortality. A total of 249 patients were diagnosed with a hip fracture during the study period. 2 patients were too unwell for an operation and died within 24 hours of diagnosis/admission. 46 patients were included in the study. The primary reasons for surgical delay were patients not being fit for surgery (14/46) and the use of anti-coagulation (14/46). Other reasons included a lack of surgical capacity (7/46) and delayed diagnosis due to further imaging (CT). Mean delay to surgery was 51.8 hours (range 34.5 – 157.2 hours; median 42.9 hours), mean length of stay 20.4 days (range 5.3 – 55.7 days, median 15.6 days). 30-day mortality was 4/46 (8.6%) for patients who were delayed. Many of the issues we found in this study are unusual however these problems are commonly faced in many level 2 trauma units that serve an ever growing ageing population. Changing practice to provide improved out-of-hours medical care to facilitate medical optimisation and using current literature evidence that shows that the use of DOACs/NOACs does not adversely affect outcomes when patients are operated on within 24 hours of the last dose may help improve times to surgery

INTRODUCTION. Preoperative optimization and protocols for joint replacement care pathways have led to decreased length of stay (LOS), decreased narcotic use and are increasingly important in delivering quality, cost savings and shifting appropriate cases to an outpatient setting. The intraoperative use of vasopressors is independently associated with increased length of stay, risk of adverse postoperative events including death and in total hip arthroplasty there is an increased risk for ICU admission. Our aim is to characterize the patient characteristics associated with vasopressor use specifically in total knee arthroplasty (TKA). METHODS. We retrospectively reviewed 748 patients undergoing inpatient primary total knee arthroplasty at a single academic institution by two surgeons from 1/1/17 to 12/21/18. Demographics, comorbidities, perioperative factors and intraoperative medication administration were compared with multivariate regression to identify patients who may require intraoperative vasopressors. RESULTS. Seven hundred-forty eight patients underwent total knee arthroplasty and 439 patients required intraoperative vasopressors while 307 did not require vasopressors. Significant predictors of vasopressor use were male sex (p=0.035), history of prior cerebrovascular event (p=0.041) and older age (p=0.048). NPO time, anesthesia provider level of training, operative time, and intraoperative mean arterial pressure and heart rate were not significant predictors of vasopressor use intra-operatively during total knee arthroplasty. CONCLUSION. In this study, nearly fifty-nine percent of patients undergoing TKA received intraoperative vasopressor support. Male gender, history of stroke and older age were significantly associated with increased intraoperative vasopressor use. Surgical time and case order do not appear to be optimizable factors to minimize the use of vasopressors in TKA. Our results highlight variation in anesthesia practices and an opportunity to standardize vasopressor triggers and identify patients who may require vasopressor support during preoperative optimization and selection of their surgical setting

Background. Intracapsular neck of femur fractures are one of the most common injuries seen in Orthopaedics. When the fracture is amenable to internal fixation there are 2 main treatment options, namely multiple cannulated hip screws (MCS) and 2-hole sliding hip screws (SHS). In this retrospective study we examine the outcomes associated with these two methods of internal fixation. At present there is little consensus regarding which treatment should be used. Methods. 161 patients were found to have suffered intracapsular neck of femur fracture treated with either SHS or MCS fixation over a 5 year period from April 2009 to April 2014, allowing at least 1 year follow up following injury. The patients imaging and clinical notes were then reviewed to ascertain the outcome of their treatment and any complications. Results. 93 patients were treated with a sliding hip screw compared to 68 that had been treated with cannulated screws. To ensure the fractures in each group were comparable in terms of fracture severity they were classified using gardens and pauwels score. The mean age of the group treated with SHS was 75.15 years, 7.69 years higher than those treated with MCS. The mean length of inpatient stay was 4.7 days longer for patients treated with sliding hip screws than those treated with cannulated screws, which is significantly more than would be predicted by age difference alone. Further patients were excluded for analysis of failure rate if they had not been sufficiently followed up, leaving 122 patients, 58 treated with MCS and 64 with SHS. A significantly higher (p=0.0136) proportion of patients treated with SHS (32%) suffered failure of their fixation compared to those treated with MCS (10%). The SHS group was further classified by whether or not a permanent derotation screw was employed. The use of a derotation screw provided protection against failure with a number needed to treat of 3.82, decreasing the failure rate to 14% which was not significantly more than the failure rate for MCS. Conclusions. We recommend that the first choice treatment for intracapsular neck of femur fractures amenable to internal fixation should be cannulated screws due to a lower rate of failure and shorter length of inpatient stay. If a surgeon has a strong preference for sliding hip screw we strongly recommend inserting a permanent derotation screw

NHS Greater Glasgow & Clyde has six hospitals that provide an inpatient trauma service, but only two have facilities to receive patients by helicopter. The Southern General Hospital contains regional Neurosurgical and Spinal Injuries services and attracts the majority of major trauma delivered by helicopter. This study explores the impact that Emergency Medical Retrieval (EMRS) and Air Ambulance services have on the Trauma & Orthopaedic department at our Hospital. We examined the period 1. st. January 2010 to 31. st. December 2010 identifying Trauma & Orthopaedic admissions brought to our hospital by the Emergency Medical Retrieval and Air Ambulance services. These patients were identified from records kept by our Trauma Nurse Practitioner and an additional search of the hospital admissions database. Details of the admissions were extracted from this database, clinical records and various electronic patient records. Patients admitted to other departments were excluded from the study. 48 admissions (30 male, 18 female) were identified. Age ranged from 16-87 years. 16 patients had multiple injuries. 8 required High-Dependency or Intensive Care admission and there was 1 death in our cohort. 21 patients required surgery. In total, these patients required approximately 52.5 hours of operative time. These patients accounted for 373 inpatient days with an average hospital stay of 7.7 days (1-36 days). In addition, 25 patients have required a total of 35 outpatient appointments to date. This study quantifies the significant impact on inpatient and outpatient Trauma & Orthopaedic services from helicopter derived admissions. Some patients admitted under Neurosurgery and Spinal Injuries also undergo surgery, but were not included in the study, representing an additional workload. We believe this study supports an argument for additional investment in this growing trauma service, especially given the recent expansion of EMRS to cover the whole of Scotland

Physiotherapy is generally accepted as an important component in the care pathway surrounding total knee replacement. Therapy interventions can be delivered prior to surgery, as part of the inpatient stay, and post-operation through outpatient appointments. Though ‘physiotherapy’ is generally promoted there is considerable national and international variation in actual therapy provision. Specific rehabilitation protocols are strongly entrenched at individual physiotherapy departments however the wider efficacy of varying physiotherapeutic interventions is poorly established. This uncertainty as to effectiveness of physiotherapy makes it difficult for commissioning organisations, healthcare providers, and patients to make decisions as to what therapy is ‘needed’ and therefore the correct level and mechanism of funding for such services. This talk will explore the variation in physiotherapy service provision and evidence for different interventions surrounding total knee replacement