Abstract. Background. The European population is consistently getting older and this trend is expected to continue with fastest rise seen in those over 85 years old. As a consequence there will be more nonagenarians (over 90 years old) having lower limb arthroplasty. Objectives. To compare the length of stay, readmission and one year mortality between nonagenarians and people aged between 70 to 80 years after having lower limb arthroplasty. Methods. Retrospective review of patients electronic records over 90 years following total knee replacement (TKR) or total hip replacement (THR). The length of stay after surgery, 30 day readmission rate and one year mortality were compared with control group aged between 70 to 80 years who had lower limb arthroplasty during the same period. Results. There were 31 nonagenarians with mean age of 91.6 years and the control group consisted of 31 patients with the mean age of 74.6 years. The average length of stay was 5 days in the nonagenarians compared to 4 days in the younger group. There was no difference in the 1 year mortality. 30 day readmission's was 16% in the older cohort and 5% in the younger. There was an increase in trend of nonagenarians having lower limb arthroplasty over the years. Conclusions. There is increasing number of nonagenarians undergoing lower limb arthroplasty. Nonagenarians and those aged between 70 to 80 years have comparable length of stay and 1 year mortality but higher rate of readmissions after lower limb arthroplasty

Abstract. Aim. This study was aimed to look into factors responsible for delayed mobilization after lower limb arthroplasty and effect on length of stay. Methods. It is an observational study conducted at Kings Mill Hospital from August to October 2021. All patients undergoing primary knee or hip arthroplasty were included in the study, while patients with revision surgeries were excluded. A proforma was designed to record demographics and different variables including medications, type of anaesthesia, orthostatic hypotension, dizziness, preop and post op pain score, fall in haemoglobin, analgesia and length of stay. Patients were assessed on day one and data was recorded in the proforma. Data was analysed using SPSS. Results. There were 60 patients (32 females and 28 males) which were included in the study. Mean age was 69.62 years. Thirty patients underwent TKA while in the rest of 30 patients THA was done. Fifty patients were mobilized on day one while 10 patients failed to mobilise. Out of different variables assessed orthostatic hypotension, dizziness, pre mobilization pain score and pain score during mobilization were found to be significant. Mean length of stay was longer in patients with delayed mobilization (P=0.018). Conclusion. Pain, dizziness and orthostatic hypotension were independent factors affecting mobilization after lower limb arthroplasty and indirectly increasing the length of stay

Acute Kidney Injury (AKI) formerly known as “acute renal failure” results in rapid reduction in kidney function associated with a failure to maintain fluid, electrolyte and acid-base homeostasis. The UK NCEPOD published a report in 2010 on AKI that revealed many deficiencies in the care of patients with AKI. The UK Renal Association has published the final draft of Clinical Practice Guidelines for Acute Kidney Injury on the 08/01/2011. In our study we determined retrospectively the occurrence of this problem in a District General Hospital and its impact on recovery after lower limb arthroplasty. Data was collected retrospective study over 3 months between Oct to Dec 2010 from theatre registers and the hospital database system. 359 patients were identified. Preoperative (baseline) and postoperative blood investigations included Creatinine, Urea, K+, Na+, GFR, Haemoglobin were analysed. Data collection also included type of anaesthesia, timing of operation, duration of procedure and estimated blood loss. From the hospital database system and clinic letters we collected length of stay and time required for blood results to come back to baseline. A diagnosis of Acute Kidney Injury was based on the International Kidney Disease Improving Global Outcomes (KDIGO) staging classification as recently recommended by UK Renal Association. Stage I Creatinine increase by ≥ 26 μmol/L from baseline, Stage II Creatinine increase by 200-300% and Stage III Creatinine increase ≥ 300%. In our study 11.97% (43/359) of patients developed acute kidney injury following lower limb Arthroplasty. 18 patients (42%) developed Stage I (Cre increase ≥ 26 μmol/L), 17(39%) developed Stage II (Cre increase 200-300%) and 8 patients (19%) developed Stage III (Cre increase ≥ 300%) AKI. Most of these patients were operated during the afternoon session. Patients with acute kidney injury stayed longer in hospital (11.7days) compared to similar age group of patients (6.35days) admitted during the same period. 25% of patients took more than a month for renal parameters to come down to normal. AKI is a new definition and the incidence in our hospital is higher than the 1% expected nationally. Patients with AKI are often complex to treat and specialist timely referral and transfer to renal services if appropriate should be considered. The etiology of Acute Renal Injury is very complex and includes gentamicin antibiotic prophylactic, rapid blood loss in elderly frail patients, non-steroidal pain killers and preexisting cardiac and renal pathology. The need for careful postoperative observation cannot be overemphasised together with judicious blood replacement as required. Acute Kidney Injury following lower limb arthroplasty is a sensitive marker of postoperative care. A successful surgical outcome may not mean a successful renal outcome. Patients with AKI are often complex to treat the new AKI definition and staging system allows an earlier detection and management of this condition. Further prospective audit with large number of patients are required

Introduction. Enhanced recovery programmes (ERP) have recently been adopted in the UK, enabling patients to recover quickly and return home sooner. Choice of anaesthetic is an important factor effecting post-operative outcome; studies show regional anaesthesia is more cost-effective, decreasing the incidence of venous thromboembolic events and reducing intra-operative blood loss, the need for transfusion and the length of hospital stay. Objectives. The objective of this study was to compare the short-term outcome of patients enrolled in our ERP who underwent either general or spinal +/− epidural anaesthesia. Methods. We prospectively studied 1222 patients (age- and sex-matched) who underwent lower limb arthroplasty enrolled in our ERP between March 2010-December 2011. Patients were given the opportunity to discuss their preferred mode of anaesthesia with their anaesthetist. Group 1 underwent general anaesthesia (GA), Group 2 underwent spinal +/− epidural anaesthesia (SA+/−EA). Results. 1222 patients underwent lower limb arthroplasty during our study period; 690 patients underwent GA, and 532 patients received SA+/−EA. There were similar ratios of THRs and TKRs in each group 343:347 and 257:275, respectively. Group 1 had an average age of 67.8 years (range 23–92; 65% female, 35% male), group 2 average age was 70 years (range 29–96; 58% female, 42% male). Average length of stay was 4.65 days in group 1 and 4.75 days in group 2 (Median 4, range 1–23). Similar rates of post-operative wound complications were noted in each group. Both groups had just two incidences of venous thromboembolic events. Conclusion. Enhanced Recovery Programmes have been initiated to reduce hospital stay following lower limb arthroplasty. We have shown no statistically significant difference between the patient being asleep or awake during surgery in the short-term outcome following surgery. The biggest contributing factors to the mode of anaesthesia used were individual anaesthetists' preference and patient choice

The risk of venous thromboembolism in patients following arthroplasty may be reduced by continuing chemical thromboprophylaxis for up to 35 days post-operatively. This prospective cohort study investigated the compliance of 40 consecutive consenting patients undergoing lower limb arthroplasty with self-administration of a recommended subcutaneous chemotherapeutic agent for six weeks after surgery. Compliance was assessed by examination of the patient for signs of injection, number of syringes used, and a self-report diary at the end of the six-week period. A total of 40 patients, 15 men and 25 women, were recruited. One woman was excluded because immediate post-operative complications prevented her participation. Self-administration was considered feasible in 87% of patients (95% confidence interval (CI) 76 to 98) at the time of discharge. Among this group of 34 patients, 29 (85%) were compliant (95% CI 73 to 97). Patients can learn to self-administer subcutaneous injections of thromboprophylaxis, and compliance with extended prophylaxis to six weeks is good

Background. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58–0.90). There were no significant differences between the two groups for PE (OR=1.52; 0.77–2.97), major bleed (OR=0.73; 0.48–1.12), all-cause mortality (OR=0.93; 0.46–1.87) and re-admission rate (OR=1.21; 0.88–1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30–4.82). Discussion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, there were fewer DVTs in the Rivaroxaban group. However, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PE or all-cause mortality

Assessing risk is a key skill for all surgeons, playing a vital role in such diverse settings informed consent, audit and surgical planning. We undertook this study to define what is an acceptable level of risk for orthopaedic surgeons undertaking lower limb arthroplasty in today's medicolegal climate. We surveyed all consultants and trainees registered with the NZOA and asked them what change in their complication rate would cause them to consider changing their practice. We also asked them how certain they would have to be that this change was real and not simply due to chance (the so-called “cluster effect”). The specific complications we considered were DVT/PE, dislocation of total hip replacement or deep infection in lower limb arthroplasty patients. This allowed us to calculate with 95% accuracy the levels of complication surgeons would deem unacceptable. Using Cochrane's criteria for statistically valid survey results we obtained a greater than 95% representative sample. From these responses we calculated levels of complication which would worry the “average” surgeon (median value), the “vast majority” (95%) of surgeons and a change in complication rate which would be required to satisfy “statistical significance” (i.e. the level set literature proof with p<0.05 and power of 0.8). When considering deep infection following hip or knee arthroplasty: using a baseline of 0.9% as an average published rate, the average surgeon would consider changing their practice if their rate reached 2.5% and 95% of surgeons would consider changing if their rate reached 5%. For hip dislocation the baseline was set at 2.5% with the average surgeon intervening if their rate rose to 4% and the vast majority of surgeons intervening at 10%. For fatal PE the baseline was given as 0.2% with the average surgeon auditing their practice at 0.8% and the vast majority of surgeons concerned with a rate of 2.2% or higher. No difference was found in consultant/trainee responses except in the reason given for use of thromboprophylaxis where consultants used it for prevention of fatal PE and registrars for non-fatal PE. These results could be used both as a potential guide for trainees and consultants in audit and also in guiding the use of, for instance, thromboprophylaxis where the “number needed to treat” for low molecular weight heparin to prevent one fatal pulmonary embolus in a year would necessitate national use/guidelines

Introduction. Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban. Methods. Both groups received mechanical prophylaxis. In the first group 89 patients were given 40 mg subcutaneous clexane once daily from the day prior to surgery until they were independently mobile. The second group comprised 99 patients who were given 10 mg of oral rivaroxaban. Results. The mean length of stay was 5 days in the clexane group and 5.5 days in the rivaroxaban group. 24 patients stayed in hospital for 5 days or more because of wound leakage in the rivaroxaban group compared to 10 in the clexane group. 5 patients were readmitted in the clexane group: 3 for pulmonary embolism (PE), 1 for dislocation and 1 for periprosthetic fracture. 5 patients were also readmitted from the rivaroxaban group: 4 for infection and 1 for PE. No patients in the clexane group required re-operations. 2 patients in the rivaroxaban group went back to theatre: 1 for haematoma evacuation and 1 for haematoma evacuation and subsequent revision knee arthroplasty. Conclusion. This study raises concern regarding the rates of postoperative complications with rivaroxaban prophylaxis

The need for hip and knee replacement surgery is increasing. Enhanced recovery programmes, where patients mobilise quickly and safely after surgery, have been adopted now in many hospitals. There are anecdotal reports of Primary Care Trusts raising thresholds for referral for surgery based on patients' Body Mass Index (BMI). The aim of this study was to evaluate the early outcome of hip and knee arthroplasty in obese patients (BMI>30) enrolled in the enhanced recovery programme. Between March 2010 and January 2011, 672 patients were enrolled in our enhanced recovery programme. 316 patients (47%) were classified as obese (BMI>30, range 30-39). There was no significant difference in the length of stay: 4.58 days in the obese patients and 4.44 days in the non-obese. There was also no difference in the rates of superficial infections or oozy wounds. Knee replacements was performed more commonly than hip replacements in the obese group. There was no significant difference in the early outcome of hip and knee replacement surgery in patients with a higher Body Mass Index when undergoing lower limb arthroplasty through the enhanced recovery programme. These patients should continue to be offered surgery when clinically indicated

Introduction. Deep vein thrombosis(DVT) and pulmonary embolism(PE) are well-recognised complications following lower limb arthroplasty (Cohen et al, 2001). The National Institute for Clinical Excellence and British Orthopaedic Association recommend the use of both mechanical and chemical prophylaxis. At our institute regimens have changed reflecting new developments in the use of thombo-prophylaxis. Our aim was to assess the efficacy of these methods in preventing complications. Methods. Since moving from Aspirin and compression stockings (TEDS) only, three different treatment methods were prospectively audited. Regimen 1 consisted of Aspirin (150 mg OD) and TEDS for 6 weeks (n=660). Regimen 2 used Clexane 40mg OD (n=448). Regimen 3 used Rivaroxaban (n=100) as licensed and Regimen 4 Dabigatran (n=185) as licensed. We looked at rates of venous thromboembolism (VTE), rates of post op bleeding/haematoma and wound complications. Patients were reviewed prior to discharge, and at a six-week follow-up. Any casualty attendances were also recorded up to 12 weeks post-operatively. Results. Symptomatic VTE rates were as follows 3.78% for Regimen 1, 1.9% for Regimen 2, 0% for Regimen 3 and 1.6% for regimen 4. Haematoma/bleeding rates were as follows 1.06% Regimen 2, 5% Regimen 3, and 2.7% Regimen 4. Rates of serosanguineous exudate were as follows 0.2% Regimen 2, 8% Regimen 3 and 5.4% Regimen 4. Conclusion. Our move from Aspirin was based on local audit, which highlighted a higher than national average PE rate. A change towards oral based prophylaxis was based on ease of administration and potential reduction in costs. Although DVT/PE rates were lower with the oral thrombo-prophylaxis, bleeding and wound complications appear higher. This study highlights the need to monitor both VTE and bleeding rates when adopting any changes in protocol, with a view on individualised treatment on balance of risks

Introduction. Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty but do not recommend one particular pharmacotherapy over another. Objectives. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban, with respect to average length of stay, postoperative wound leakage, readmission within 30 days of surgery and re-do surgery. Methods. Both groups were comparable in terms of age, sex and proportion of hip and knee patients. Both groups received mechanical prophylaxis. In the first group 89 patients were given 40 mg subcutaneous clexane once daily from the day prior to surgery until they were independently mobile. The second group comprised 99 patients who were given 10 mg of oral rivaroxaban. The first dose was administered 8–10 hours postoperatively and continued once daily for 14 days for total knee replacement and 35 days for total hip replacement. Results. The mean length of stay was 5 days in the clexane group and 5.5 days in the rivaroxaban group. 24 patients stayed in hospital for 5 days or more because of wound leakage in the rivaroxaban group compared to 10 in the clexane group. 5 patients were readmitted in the clexane group: 3 for pulmonary embolism (PE), 1 for dislocation and 1 for periprosthetic fracture. 5 patients were also readmitted from the rivaroxaban group: 4 for infection and 1 for PE. No patients in the clexane group required re-do surgery. 2 patients in the rivaroxaban group went back to theatre: 1 for haematoma evacuation and 1 for haematoma evacuation and subsequent revision knee arthroplasty. Conclusion. This study raises concern regarding the rates of postoperative complications with rivaroxaban prophylaxis

We reviewed the current screening protocol for MRSA detection in patients admitted for elective lower limb arthroplasty as we thought it may not be cost effective and there is no evidence base for validity of MRSA screening swabs. The current institutional screening protocol includes MRSA swabs from nose and groin taken on 2 different occasions; the 1st swab taken at time patient was placed on the waiting list and the 2nd swab taken at the Orthopaedic pre-clerking clinic around 6–8 weeks later. We found that during the study period, of 1791 patients who underwent MRSA screening swabs, only 16 patients had positive results. Of these, 9 patients had known MRSA (2 in care home) and no data was available in 2 patients. However in 5 patients, there was an initial negative swab which later was found to be positive. The time interval in these ranged from 0.6 to 85 weeks (Conversion rate = 0.3%). The laboratory cost for these screening swabs was £9,027. Given the low prevalence rate of MRSA and low conversion rate at 6 weeks, there is a role for accepting a single-swab screening protocol. This would also result in significant cost savings of around £ 4,500. We can therefore conclude that in the indigenous population, it is unlikely a patient will de-novo acquire MRSA in the community unless exposed to independent risk factors. We have adopted the new screening protocol where patients are screened routinely for detection and eradication only once prior to admission unless independent risk factors such as previous MRSA colonisation, hospital admission or if being admitted from residential/care home. There is however no evidence in literature about the time period of validity of MRSA screening swabs

Urinary catheterization in the postoperative period is known to increase the risk of deep joint infection following arthroplasty. A number of studies have attempted to elucidate the individual patient factors and surgical procedural factors which predispose patients to postoperative urinary retention. We conducted a retrospective observational study of three hundred patients to specifically determine the effect of the anaesthetic technique on the incidence of urinary retention following elective lower limb arthroplasty. One hundred consecutive patients were surveyed in each of three groups differing by the type of the anaesthetic technique and the drug administered; 1) general anaesthesia with femoral nerve block, 2) spinal anaesthesia with intrathecal fentanyl, and 3) spinal anaesthesia with intrathecal morphine. The incidence of urinary retention requiring catheterisation in male patients receiving intrathecal morphine was 58% compared with 10% and 6% for those who had general anaesthesia with femoral nerve block and intrathecal fentanyl, respectively. This difference was statistically significant (p<0.01). The incidence of urinary retention in females across all groups was =2%. The average residual volume of urine following catheterisation was 750ml (460-1500ml). Our findings show that the use of intrathecal morphine greatly increases the risk of postoperative urinary retention in male patients, whereas no significant increase was found amongst female patients. This risk should be carefully considered when choosing the type of intraoperative anaesthetic/analgesic combination employed in male patients and be rationalised against the intended benefits to the patient

Introduction. Rivaroxiban is a direct inhibitor of factor Xa, a licensed oral thromboprophylactic agent that is increasingly being adopted for lower limb arthroplasty. Rivaroxiban has been NICE-approved for use in primary hip and knee arthroplasty following the RECORD 4 trials; proving it more effective in preventing venous thrombo-embolic (VTE) events compared to enoxaparin. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days. Methods. We prospectively studied 1223 patients (age- and sex-matched) who underwent lower-limb arthroplasty enrolled in our ERP between March 2010 and December 2011; 454 patients (Group 1) received enoxaparin, 769 patients (Group 2) received rivaroxiban. Patients wore thrombo-embolic stockings for six weeks post surgery. Patients were monitored for thrombo-embolic events and wound-related complications for 42 days post-operatively. Results. 1223 patients underwent lower-limb arthroplasty during our study period. There were similar numbers of THRs and TKRs in each group 230:224 and 370:399. Average length of stay was 4.9 days (range 1–19) in group 1 and 4.5 days (range 2–23) in group 2. The rate of VTE events was the same in both groups (< 1%). In group 1 (enoxaparin), 21(4.6%) of the 454 patients experienced oozing/infected wounds that required further surgical attention. In group 2 (rivaroxiban), 46 (6%) of the 769 patients had wound-related complications, of which 70% were in primary THR patients. Conclusion. Rivaroxabans use in clinical practice has been questioned concerning its wound-related complications. The RECORD 4 trial focused on major bleeding as the primary safety outcome, however we postulate slow post-operative oozing can lead to haematoma formation, increasing the risk of superficial wound and deep infections potentially requiring revision surgery. This study shows an increased wound complication rate in the Rivaroxiban group, highlighting the need for further clinical trials to assess its safety and efficacy

Background of study

Following the Montgomery ruling, consent is now a matter of law. The medical professionals have to show proof that risks and implications and material risks are explained to the patient and that they have accepted to go ahead with surgery.

Introduction

MRSA colonisation increases the risk of acquiring a surgical site infection (SSI). Screening identifies such patients and provides them with suitable eradication treatment prior to surgery to decrease their risk of infection. Our aim was to determine whether receiving effective eradication therapy decreases the risk of infection in a patient previously screening positive for MRSA to that of someone screening negative.

Background

Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to English NHS hospitals. This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale.

Background

There is a lack of information on the independent preoperative predictors of perioperative mortality, including the influence of previous stroke and acute coronary syndromes (myocardial infarction + unstable angina, ACS). Previous studies have grouped variables under the umbrella term “ischaemic heart disease”. In this study, we investigated the influence of vascular risk factors separately.

Introduction

Enhanced Recovery Protocol (ERP) for elective total hip or total knee replacement has become the gold standard. The main principles are to reduce bleeding, both with a tranexamic acid infusion and local injection of adrenaline, and to reduce the risk of postoperative thrombo-embolic complications by early mobilisation, enabled by local anaesthetic infiltration at time of surgery. The aim of this study is to evaluate the impact of the ERP.

Following the outcomes of the RECORD trials the protocol of extended thromboprophylaxis in patients undergoing elective primary total hip or knee arthroplasty has been changed in our institution.

Between June 2008 and May 2009 patients were offered extended thromboprophylaxis with 150mg of aspirin daily, commencing preoperatively on admission and continuing for a total of six weeks. From June 2009 onwards patients were treated with 10mg of rivaroxaban once daily for two weeks following total knee and five weeks following total hip arthroplasty commencing 4 to 6 hours postoperatively. Our cohorts were 700 patients before and after the introduction of the new regimen. The two groups were matched for age, sex and type of operation. All patients with no contraindication to treatment with aspirin or rivaroxaban respectively undergoing elective primary total hip or knee arthroplasty were included in the study. Patients receiving warfarin on admission were treated with warfarin postoperatively and were excluded.

We have compared the two treatment protocols in terms of safety and efficacy. Results focus on 4 safety outcome measures including mortality, haemorrhagic complications, transfusion requirements and infection rates and 2 efficacy outcome measures including thromboembolic complications and length of inpatient stay.

Rates of DVT were equal in the two cohorts (P< 0.005) as were the mortality rates. Transfusion requirements post-operatively were not affected by the introduction of the new regimen however there was a significant increase in both return to theatre rates and prolonged wound ooze (P< 0.005). Infection rates were slightly higher in the cohort treated with rivaroxaban but this was not statistically significant.

We conclude that further trials need to be done to confirm the suitability of routine use of rivaroxiban.