Aims. Joint arthroplasties may be associated with a blood loss, which necessitates transfusion. Especially, hip arthroplasties are highly associate with transfusion to compensate perioperative bleeding. Orthopaedic surgeons and patients have increasing concerns regarding complications of blood transfusions. Although various methods to reduce transfusions have been attempted in TJA, a high percentage of patients require a transfusion during and after the procedures. The purposes of this study were to evaluate the trends of the transfusion(transfusion rates, transfusion amounts, economic burden) in hip arthroplasties, using nationwide data from the National Health Insurance Service (NHIS). Patients and methods. We used data from nationwide claims database of Health Insurance Review Assessment Service (HIRA). The data managed by the NHIS were used to identify the 161,934 hip arthroplasties by 3 categories including bipolar hemiarthroplasty(BH), total hip arthroplasty(THA), and revision arthroplasty(RA) from 2007 to 2015. These 3 categories were classified using the operation code recorded in the requisition data of NHIS. The transfusion rates, transfusion amounts, proportion of transfusion, cost of each type of operation was investigated and stratified by age, gender, hospital type, and area in hip arthroplasties. The proportion of transfusion about whole blood, red blood cell, fresh frozen plasma, platelet, was also evaluated in hip arthroplasties. Results. The patients of hip arthroplasties who receive transfusion was observed 11,224/13,584 in 2007, 12,823/15,325 in 2008, 13,447/16.144 in 2009, 14,915/17,702 in 2010, 15,623/18,648 in 2011, 16,374/19,878 in 2012, 16,961/20,423 in 2013, 16,367/20,060 in 2014 and 16,116/20,170 in 2015. Total transfusion rate was 81.1% in 9 years data.(82.6% in 2007, 83.7% in 2008, 83.3% in 2009, 84.3% in 2010, 83.8% in 2011, 82.4% in 2012, 83% in 2013, 81.6% in 2014, 79.9% in 2015. The overall proportion of transfusion was 7% fresh frozen plasma, 12% platelet, and 77% RBC. The total amount of transfusion was 47,351 in 2007, 56.387 in 2008, 58,320 in 2009, 66,604 in 2010, 68,472 in 2011, 74,735 in 2012, 73,370 in 2013, 67,736 in 2014, and 62,749 in 2015. The average dose of transfusion is 4.1 times in bipolar hemiarthroplasty(343,815/ 83,729), 8.7 times in revision arthroplasty(35,044/4,024), 4.3 times in total hip arthroplasty from 2007 to 2015. Conclusion. In this nationally representative study of patterns of transfusion use in hip arthroplasty, we observed relatively high rates in the use of blood transfusion among patients undergoing hip arthroplasties regardless of many factors including patient, hospital, characteristics, compared with researches in other countries. The total amount of transfusion shows decreasing trends recently, however, it does not seem a big difference in transfusion rate

Purpose:. To investigate treatment patterns and efficacy of postoperative strong opioids in patients who underwent total knee arthroplasty (TKA) in Korea. Methods:. A prospective, non-interventional study of 301 patients who underwent TKA and received strong opioids following patient controlled analgesia (PCA) was conducted by reviewing patient charts and diaries from 19 teaching hospitals. Clinical characteristics, strong opioid treatment patterns, efficacy of strong opioid on a scale of 0–10, and opioid-related adverse events (AEs) were investigated during hospitalization and at first outpatient visit. Safety analysis was conducted on 301 patients, and efficacy analysis was conducted on full analysis set (FAS) which consisted of all the patients who had at least 1 efficacy result among 301 patients. Results:. Among the FAS population of 298 patients, 86.9% were female, and mean age was 68.7 ± 7.5 years. Average duration of PCA was 4.3 ± 1.7 days, and average length of hospital stay including surgery was 16.3 ± 7.6 days. The mean duration of strong opioid prescription on a regular basis between PCA discontinuation and discharge was 10.3 ± 6.7 days. At the initial treatment with strong opioid following PCA, mean pain intensity score was 6.1 ± 2.1 upon movement and 4.2 ± 2.4 at rest. At discharge, mean pain intensity score was 4.1 ± 1.9 upon movement and 2.3 ± 1.8 at rest. Meanwhile, pain intensity score at the first outpatient visit was assessed only in 146 patients (49.0%) treated with opioid, and mean pain intensity scores upon movement and at rest were 3.5 ± 2.1 and 1.7 ± 1.8, respectively. Most frequently prescribed opioid was oral oxycodone (47.4%), followed by pethidine injection (17.2%), oral oxycodone/naloxone (12.6%), and transdermal fentanyl (12.0%). Additionally, the most frequently prescribed opioid on a regular basis was oral oxycodone (53.3%), and that on a PRN (pro re nata) basis was pethidine injection (48.4%). Among treatments, mean duration and mean daily dose of oral oxycodone during hospitalization were 6.1 ± 5.6 days and 13.9 ± 8.2 mg, 1.6 ± 1.2 days and 45.5 ± 24.5 mg for pethidine injection, 7.3 ± 5.3 days and 16.2 ± 7.3 mcg/hr for transdermal fentanyl, and 9.4 ± 8.0 days and 23.2 ± 16.8 mg/11.6 ± 8.34 mg for oral oxycodone/naloxone. At discharge, 150 patients (50.3%) were prescribed opioids. The most frequently prescribed strong opioid as discharge medications and their mean daily dose were 17.9 ± 10.5 mg of oxycodone (56.6%), 26.8 ± 17.0 mg/13.4 ± 8.5 mg of oxycodone/naloxone (17.1%), and 15.9 ± 6.1 mcg/hr of fentanyl (11.4%). Of 301 patients, 36 opioid-related AEs were reported in 26 patients (8.6%); the most frequently reported opioid-related AEs were nausea/vomiting in 13 patients (4.3%) experiencing 17 events, constipation in 10 patients (3.3%) experiencing 10 events, and sedation in 3 patients (1.0%) experiencing 3 events. Conclusion:. The first nationwide non-interventional study was conducted to investigate treatment patterns and efficacy of strong opioids in patients who underwent TKA. Among these patients, strong opioids provided favorable pain relief and were well tolerated at relatively low dose following PCA till the first outpatient visit

Purpose

The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures

BACKGROUND

Periprosthetic infection is the most challenging complication following total knee arthroplasty (TKA). Poor oral hygiene has been assumed as an important risk factor for TKA infection. We aimed to investigate whether the improvement of oral hygiene through dental scaling could reduce the risk of TKA infection.

Background

Level 1 studies for fracture management of upper extremity fractures remains rare. The influence of these studies on management trends has yet to be evaluated. The purpose of this study was to examine alterations in national trends managing mid-shaft clavicle and intra-articular distal humerus fractures (DHF) surrounding recent Level 1 publications.

Aim. Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life, and high healthcare costs. In 2009 a nationwide, multidisciplinary infection control program was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%. The primary aim was to investigate whether the PRISS project reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis. Method. We obtained data on patients undergoing primary THA in Sweden (n = 45,723 patients, 49,946 THAs), 2012–2014. Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks antibiotic consumption were reviewed to verify PJI diagnosis (n = 2240, 2569 THAs). Results. The cumulative incidence of PJI following the PRISS project was 1.2% [95% CI 1.1–1.3] as compared to 0.9% [95% CI 0.8–1.0] before. Cox regression models for the PJI incidence post PRISS indicates there were no statistical significance difference versus pre PRISS (HR 1.1 [95% CI 0.9–1.3]. There were similar time to PJI diagnosis after the PRISS project 24 vs 23 days (p=0.5). Conclusions. Despite the comprehensive nationwide PRISS project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher ASA class, and more fractures as indications, explain the PJI increase among primary THA patients

Introduction. There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery. Methods. The BOSS Study is a series of nationwide observational cohort studies of pre-specified orthopaedic disease. All relevant hospitals treating the disease are invited to contribute anonymised case details. Data will be collected digitally through REDCap, with an additional bespoke software solution used to regularly confirm case ascertainment, prompt follow-up reminders and identify potential missing cases from external sources of information (i.e. national administrative data). With their consent, patients will be invited to enrich the data collected by supplementing anonymised case data with patient reported outcomes. The study will primarily seek to calculate the incidence of the rare diseases under investigation, with 95% confidence intervals. Descriptive statistics will be used to describe the case mix, treatment variations and outcomes. Inferential statistical analysis may be used to analyze associations between presentation factors and outcomes. Types of analyses will be contingent on the disease under investigation. Discussion. This study builds upon other national rare disease supporting structures, particularly those in obstetrics and paediatric surgery. It is particularly focused on addressing the evidence base for quality and safety of surgery, and the design is influenced by the specifications of the IDEAL collaboration for the development of surgical research

Use of anticoagulants for thromboembolic prophylaxis is strongly supported by evidence. However, the use of these medications beyond the prophylactic period is poorly understood. We identified anticoagulant naïve patients that underwent hip or knee replacement between 2012 and 2019 from an arthroplasty registry and probabilistically linked 3,018 surgeries with nationwide pharmaceutical claims data. Rates of anticoagulation use were examined during the early (<= 60 days post-discharge), mid-term (61–180 days post-discharge) and long-term (181–360 days post-discharge) periods. Multivariable logistic regression analysis was performed to identify patient- and surgery-related factors associated with long-term anticoagulant use. Anticoagulants were supplied to 20% of arthroplasties within 60 days of discharge, 7% between 61–180 days, and 10% between 181–360 days. Older age, obesity, increased comorbidity burden, a longer length of stay, occurrence of a complication necessitating anticoagulation and dispensation of an anticoagulant within 60 days of discharge were all risk factors for long-term anticoagulant use. Given the risks associated with unnecessary use of these medications, certain patients who are prescribed anticoagulants beyond prophylactic period may benefit from specialist medication review in the months following surgery

Introduction. Individuals with significant hip and knee trauma receive total knee (TKA) and total hip arthroplasty (THA) as definitive end-stage procedures. In Aotearoa, injury-related costs, including workers compensation, may be funded by ACC. With a steady increase of arthroplasty procedures in Aotearoa, we aim to understand the magnitude and characteristics of such procedures to inform future healthcare strategies. Method. This is a longitudinal collaborative study from 1st January 2000 to 31st December 2020, using ACC and New Zealand Joint Registry databases. Total cost was subcategorised into social and medical cost for analysis. Results. ACC funded 10179 TKA and 5611 THA, amounting to 918 million New Zealand Dollars. Most clients were between 55 and 65 years of age at time of surgery, with greater representation by Male sex and European prioritised ethnicity. Māori and Pacific peoples represent less than 10% of the study population. ACC identified requiring more than 182 days of workers’ compensation as a significant marker for needing additional supports. Risk of this was 21% for TKA and 11% for THA, with risk factors being younger age (RR 0.96), Male sex (TKA RR 1.12, THA RR 1.23), and heavy work-types (TKA RR 1.50, THA RR 1.57). Discussion. Supporting individuals with post-traumatic lower limb arthroplasty is costly. Workers’ compensation contributes to a significant proportion of social expenditure. Risk factors for increased cost utilisation can be used to highlight vulnerable clients and target interventions. Conclusions. This is one of few nationwide studies investigating the healthcare cost of post-traumatic lower limb arthroplasty. We need to focus on injury prevention, targeted treatment, and rehabilitation protocols to improve recovery and reduce time off work. These findings would be of interest to multiple stakeholders

Traumatic rotator cuff injuries can be a leading cause of prolonged shoulder pain and disability, and contribute to significant morbidity and healthcare costs. Previous studies have shown evidence of socio-demographic disparities with these injuries. The purpose of this nationwide study was to better understand these disparities based on ethnicity, sex, and socio-economic status, in order to inform future healthcare strategies. Accident Compensation Corporation (ACC) is a no-fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand (population in 2018, 4.7 million). Using the ACC database, traumatic rotator cuff injuries were identified between January 2010 and December 2018. Injuries were categorized by sex, ethnicity, age and socioeconomic deprivation index of the claimant. During the 9-year study period, there were 351,554 claims accepted for traumatic rotator cuff injury, which totalled over $960 million New Zealand Dollars. The greatest proportion of costs was spent on vocational support (49.8%), then surgery (26.3%), rehabilitation (13.1%), radiology (8.1%), general practitioner (1.6%) and “Other” (1.1%). Asian, Māori (Indigenous New Zealanders), and Pacific peoples were under-represented in the age-standardized proportion of total claims and had lower rates of surgery than Europeans. Māori had higher proportion of costs spent on vocational support and lower proportions spent on radiology, rehabilitation and surgery than Europeans. Males had higher number and costs of claims and were more likely to have surgery than females. There were considerably fewer claims from areas of high socio-economic deprivation. This large nation-wide study demonstrates the important and growing economic burden of rotator cuff injuries. Indirect costs, such as vocational supports, are a major contributor to the cost suggesting improving treatment and rehabilitation protocols would have the greatest economic impact. This study has also identified socio-demographic disparities which need to be addressed in order to achieve equity in health outcomes

Aim. To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery. Method. This was a population-based, nationwide, cohort study. We included 74,771 from the Danish Multidisciplinary Hip Fractures Register (1) consisting of patients 65 years of age or older, who underwent surgery between January 1. st. 2005 and December 31. st. 2016 for all types of hip fracture. Cross-linkage with the Danish National Patient Register and The Danish Civil Registration system was made. Demographic data extracted included vital status, civil status, gender, age, Body Mass Index (BMI), fracture classification (AO/OTA 31A-C) and surgical procedures binary registered as joint replacement or internal fixation, Charlson comorbidity index (CCI) and secondary diseases not included in CCI. Outcome was reoperations due to deep SSI in accordance with the definition from Centre for Disease Control (2). We computed cumulative incidence rates and risk ratios (RR) by calendar year periods and by different risk factors, considering death as competing risk and adjusting for age, gender, CCI, fracture type and surgery type. Results. Within 365 days of primary surgery 2.1% of all hip fractures had undergone reoperation due to deep SSI. During the period 2005–2016, the incidence of reoperation due to SSI decreased from 2.7% to 1.7%, We could not identify differences in reoperation due to SSI within one year regarding gender, BMI or CCI. Patients aged above 85 had about 50% lower risk of being reoperated compared with the youngest age group; 65–74 years (RR: 0.5; 95% CI: 0.4:0.6). The RR for reoperation due to deep SSI was lower for patients with pertrochanteric or subtrochanteric fractures (AO/OTA: 31A1-3) versus femoral neck fractures (AO/OTA: 31B1-3), RR was 0.7 (95%CI: 0.7:0.8). However, RR for surgery type (joint replacement vs internal fixation) at 365 days was significantly lower for joint replacement, RR: 0.6 (95% CI: 0.6:0.7). Conclusions. This study shows reoperation risk due to SSI for all types of hip fractures of 2.1%. There was a 45% decrease in reoperation over time from 2005 to 2016. However, the risk of revision is still high, and further action in avoidance of SSI should be taken

Aims. We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires. Methods. During the first four weeks of the nationwide lockdown due to COVID-19, the objective impact of the pandemic on each trainee’s surgical caseload exposure was assessed using data from individual trainee logbook profiles in the deanery of the Republic of Ireland. Independent predictor variables included the trainee grade (ST 3 to 8), the individual trainee, the unit that the logbook was reported from, and the year in which the logbook was recorded. We used the analysis of variance (ANOVA) test to assess for any statistically significant predictor variables. The subjective experience of each trainee was captured using an electronic questionnaire. Results. The mean number of total procedures per trainee over four weeks was 36.8 (7 to 99; standard deviation (SD) 19.67) in 2018, 40.6 (6 to 81; SD 17.90) in 2019, and 18.3 (3 to 65; SD 11.70) during the pandemic of 2020 (p = 0.043). Significant reductions were noted for all elective indicative procedures, including arthroplasty (p = 0.019), osteotomy (p = 0.045), nerve decompression (p = 0.024) and arthroscopy (p = 0.024). In contrast, none of the nine indicative procedures for trauma were reduced. There was a significant inter-unit difference in the mean number of total cases (p = 0.029) and indicative cases (p = 0.0005) per trainee. We noted that 7.69% (n = 3) of trainees contracted COVID-19. Conclusion. During the COVID-19 pandemic, the mean number of operative cases per trainee has been significantly reduced for four of the 13 indicative procedures, as outlined by the JCST. Reassignment of trainees to high-volume institutions in the future may be a plausible approach to mitigate significant training deficits in those trainees worst impacted by the reduction in operative exposure

Aim. National Joint Replacement Registries, which are important sources for periprosthetic joint infection (PJI) data, report an average PJI incidence ranging from 0.5 to 2.0%. Unfortunately, national registries including the Dutch Arthroplasty Register (LROI), are not specifically designed to register PJI. In the Netherlands, the LROI is a nationwide population-based registry with an overall completeness of more than 95%. 3. To ensure usability and reliability of PJI data from the LROI, it is important to evaluate the quality and completeness of these data. From 2013 onwards, eight hospitals in the South-East of the Netherlands, collected their PJI data in a detailed regional infection cohort (RIC), specifically designed for this purpose. This study aimed to determine the accuracy and completeness of PJI registration (hip and knee arthroplasty) in the LROI, by comparing the LROI with the RIC. Method. All patients registered with an acute PJI in the RIC between 2014–2018 were selected for the study and were matched with the LROI. According to the Workgroup of American Musculoskeletal Infections Society (MSIS), an acute PJI was defined as at least two phenotypically identical pathogens, isolated in cultures from at least two separate tissues, obtained from the affected peri-prosthetic tissue during the DAIR treatment (debridement, antibiotics, irrigation, and retention). Only PJI occurring within 90 days after primary hip or knee arthroplasty were included. The LROI data and completeness was based on the entered procedures and documented reason for revision infection, which was not specially based on the MSIS criteria. After checks on missing and incorrectly data, the completeness of registration in the LROI was calculated by comparing the number of registrations in the LROI with data from the RIC (gold standard). Results. Of the 639 primary total hip and knee arthroplasty with a suspected PJI registered in the RIC between 2014–2018, 352 cases met the definition of acute PJI. The overall incidence was 1%. When compared with the LROI, 164 of these cases were also registered in the LROI as PJI revision, resulting in a 53% underestimation of PJI for the LROI. Conclusions. LROI data on acute PJI shows a significant underestimation, which is comparable to scarce other literature sources. To ensure reliability and usability of national PJI data, a specifically part of the LROI has to be designed for registering PJI similar to the regional cohort

Aim. Our aim was to evaluate cementless one-stage revision in chronic periprosthetic hip joint infection. Method and patients. The study was performed as a multicentre, proof-of-concept, observational study with prospective data collection. Inclusion of patients with a chronic periprosthetic hip joint infection (PJI) were followed by protocolled surgical treatment (cementless one-stage revision - the CORIHA protocol) at one of 8 participating departments of orthopaedic surgery between 2009 – 2014, and the patients enrolled in a 2-year follow-up program. A PJI were diagnosed based on adopted criteria from McPherson and Zimmerli. At the time of initiation of the study in 2009, the collaborating departments performed approximately one-fourth of all nationwide primary HJR and more than one-third of all revisions. In total 56 PJI patients with a median age of 72 years and a median pre-operative ASA score of 2 met the established eligibility criteria and accepted to participate; 31 (55%) were males. The cohort had a mean follow-up time of 4.0 years, with all patients followed for minimum 2 years. The primary outcome were relapse described as re-revision due to infection (regardless of considered as a relapse or new infection). This was evaluated by competing risk analysis (competing risks: aseptic revisions and death). Secondary, all-cause mortality was evaluated by survival analysis. The study was approved by the local Committees on Biomedical Research Ethics. Results. Five patients were revised due to relapse of infection. The cumulative incidence of re-revision due to infection was 8.9% (95% Confidence Interval 3.2–18.1). Seven patients had died in the follow-up period. None of these were believed to have been re-infected. The 1 and 5 year survival incidence was 96 (95% Confidence Interval 86–99) and 89 (95% Confidence Interval 75–95). Several complications were registered in the follow-up period: Three patients sustained periprosthetic fractures. Five patients had closed reduction due to dislocation - none have been open revised. Five patients sustained acute renal failure without long-term complications. One patient suffered an acute non-stemi myocardial infarction 8 days post-operatively, but with no major sequelae. One patient had soft-tissue revision of the wound following the CORIHA surgery, but is believed free of infection; One patient has severe irritation by the cables left from the extended osteotomy, but no further surgery is planned. Conclusions. We found that cementless one-stage revision in chronic hip PJI is a valuable treatment. This method has gained nationwide acceptance as first-line treatment strategy following this study

Alternative bearing surfaces has been introduced to reduce wear debris-induced osteolysis after total hip arthroplasty (THA) and offered favorable results. Large population-based data for total joint surgery permit timely recognition of adverse results and prediction of events in the future. The purpose of this study was to present the epidemiology and national trends of bearing surface usage in primary total hip arthroplasty (THA) in Korea using nationwide database. A total of 30,881 THAs were analyzed using the Korean Health Insurance Review and Assessment Service database for 2007 through 2011. Bearing surfaces were sub-grouped according to device code for national health insurance claims and consisted of ceramic-on-ceramic (CoC), metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and metal-on-metal (MoM). The prevalence of each type of bearing surface was calculated and stratified by age, gender, hospital type, primary payer, and procedure volume of each hospital. The number of primary THAs increased by 25.2% from 5,484 in 2007 to 6,866 in 2011. The average age of the entire study population was 58.1 years, and 53.5% were male [Table 1]. CoC was the most commonly used bearing surface (76.7%), followed by MoP (11.9%), CoP (7.3%), and MoM (4.1%). The distribution of bearing surfaces was identical to that in the general population regardless of age, gender, hospital type, and primary payer [Table 2]. The mean age of patients that received hard-on-hard bearing surfaces (CoC and MoM) was significantly younger than that of patients receiving hard-on-soft bearing surfaces (CoP and MoP) (56.9 years vs. 62.6 years). During the study period, 55.1% of THAs that used a hard-on-hard bearing surface were performed in males, while 53.0% of THAs that used a hard-on-soft bearing surface were performed in females. The order of prevalence of bearing surfaces was identical in low- and medium-volume hospitals (CoC was first, MoP was second, CoP was third, and MoM was fourth). The mean hospital charges did not differ according to the bearing surface used, with the exception of CoP, which was associated with a lower mean hospital charge. There were no changes in the distribution of bearing surfaces in each year between 2007 and 2011. Overall, the percentage of THAs that used CoC bearing surfaces increased substantially from 71.6% in 2007 to 81.4% in 2011, while the percentage that used CoP, MoP, and MoM decreased significantly [Fig. 1]. One of the reasons for the dominant usage of hard-on-hard bearing surfaces may be that the principal diagnosis of primary THAs and the patient age group distribution in Korea differ from those in other countries. The most common indication for primary THA is osteonecrosis of the femoral head in Korea. In contrast, the majority of primary THAs are performed for osteoarthritis in Western countries. The choice of bearing surface may be affected by many factors, including the nation's medical delivery system, payment type, disease pattern, and age distribution of patients that undergo THA. In future, the results of a large-scale nationwide study on primary THAs using CoC bearing surfaces in Korea will be reported. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

The Dawn Hip - An Effective Strategy to Improve the Management of Traumatic Hip Fractures. Introduction. Traumatic hip fractures are managed with nationwide standards, and are regularly audited and published. A previous audit last year at the William Harvey revealed 66% of hip fractures were operated within 48 hours, compared to the national average of 75%. We implemented a strategy to improve this target by introducing the ‘Dawn Hip’ - a hip fracture operation which is prepared for surgery at 8am on the Emergency (CEPOD) list. Methods. Over a two month period after the introduction of the ‘Dawn hip’, the number of hip operations and start time on the CEPOD list were audited. Performance data were extrapolated from the National Hip Fracture Database (NHFD) and compared nationally. Results. Three months prior to the ‘Dawn hip’ the mean start time of surgery on the CEPOD list was 9.50am. Two months since the introduction of the dawn hip, 67% of all trauma hip operations were done on the CEPOD list. The mean start time of the CEPOD list improved to 8.38am. Data from the NHFD revealed 81% of traumatic hip fractures were operated on within 48 hours, with the national average being 80%. Conclusion. This is an effective strategy which increases efficiency of existing resources and improves hospital services and patient care. It requires a multidisciplinary approach and participation from both managerial and clinical departments. This strategy not only optimises the care we provide for hip fractures, but also increases trauma list space for other pending trauma operations. By meeting nationwide targets, the trust is rewarded with cash incentives, which is used to further improve services. In the current economic climate, this represents a method of optimising healthcare, increasing cost savings and maximising productivity and efficiency

Aim. Early discharge of patients after joint arthroplasty leaves patients responsible for monitoring their postoperative wound by themselves. This might result in a delayed presentation of postoperative complications. The use of a mobile woundcare app by patients after arthroplasty might result in (1) earlier report of complications, (2) an increase in patient satisfaction and (3) insight in the incidence and duration of postoperative wound leakage. Therefore, the ease of use and perceived usefulness of using a postoperative mobile woundcare app in patients after joint arthroplasty was investigated. Method. A cohort study was conducted in 2017 in 2 Dutch Hospitals. Eligible cases were all consecutive patients that received an arthroplasty and who owned a smartphone. During the first 30 postoperative days, patients filled in daily reviews of their wound and took a photo of the wound. Based on the review, an underlying algorithm calculated daily a score that prompted a mobile alert if needed, which advised patients to contact the hospital. Patients filled in a form on day 30 and day 90 in order to document occurrence of any postoperative wound complication. On day 15 and 30, patients were requested to fill in a questionnaire evaluating the perceived usefulness and the ease of use of the App. Results. Of 127 eligible patients, 30 (24%) did not have a smartphone. Of the remaining 97 patients, 69 patients (71%) were included. Median age was 68 years (range 33–90 years). Forty-one patients (59.4%) used the app until day 30. On average, the app was used for 19.1 days (95% CI 16.6–21.5). Nine patients (13.0%) stopped using the app directly after the first or second day. The overall mean grade on a scale of 1 (strongly disagree) to 5 (strongly agree) was 4.2 for ease of use and 4.1 for perceived usefulness. The scores on day 30 were comparable to day 15. One patient (1.4%) developed a prosthetic joint infection. Conclusions. The introduction of a mobile woundcare app resulted in a high overall satisfaction rate with respect to ease of use and perceived usefulness. Daily use of the app did not lead to more stress. Currently, a nationwide cohort study is set up to implement the mobile woundcare app in Dutch hospitals to improve patient care. The app will then also be used to investigate the correlation between duration of postoperative wound leakage after joint arthroplasty and the development of prosthetic joint infection

Background. Inpatient dislocation after total hip arthroplasty (THA) is considered a non-reimbursable “never event” by the Centers for Medicare and Medicaid Services. There is extensive evidence that technical procedural factors affect dislocation risk, but less is known about the influence of non-technical factors. We evaluated inpatient dislocation trends following elective primary THA, and identified patient and hospital characteristics associated with the occurrence of dislocation. Methods. We used discharge records from the Nationwide Inpatient Sample (2002–2011). Temporal trends were assessed and multivariable logistic regression modeling was used to identify factors associated with dislocation. Results. The in-hospital dislocation rate increased from 0.025% in 2002 to 0.15% in 2011, despite a downward trend in length of stay (P<0.001). Patient characteristics associated with the occurrence of dislocation were black or Hispanic race/ethnicity, lower household income, and Medicaid insurance. Comorbidities associated with dislocation included hemiparesis/hemiplegia, drug use disorder, chronic renal failure, psychosis, and obesity. Dislocations were less likely to occur at teaching hospitals and in the South. Conclusion. The in-hospital dislocation rate following elective primary THA is increasing, in spite of shorter stays and surgical advances over time. Given the sociodemographic disparities in dislocation risk documented herein, interventions to address social determinants of health might do as much or more to reduce the occurrence of dislocation than technical improvements

Down syndrome (DS), is a genetic disorder caused by a third copy of the 21st chromosome (Trisomy 21), featuring typical facial characteristics, growth delays and varying degrees of intellectual disability. Some degree of immune deficiency is variably present. Multiple orthopaedic conditions are associated, including stunted growth (90%), ligamentous laxity (90%), low muscle tone (80%), hand and foot deformities (60%), hip instability (30%), and spinal abnormalities including atlanto-axial instability (20%) and scoliosis. Hip disease severity varies and follows a variable time course. Rarely a child presents with DDH, but during the first 2 years the hips are characteristically stable but hypermobile with well-formed acetabulae. Spontaneous subluxation or dislocation after 2 presents with painless clicking, limping or giving way. Acute dislocation is associated with moderate pain, increased limp and reduced activity following minor trauma. Hips are reducible under anesthesia, but recurrence is common. Eventually concentric reduction becomes rarer and radiographic dysplasia develops. Pathology includes: a thin, weak fibrous capsule, moderate to severe femoral neck anteversion and a posterior superior acetabular rim deficiency. A number of femoral and acetabular osteotomies have been reported to treat the dysplasia, with acetabular redirection appearing to be most successful. However, surgery can be associated with a relatively high infection rate (20%). Additionally, symptomatic femoral head avascular necrosis can occur as a result of slipped capital femoral epiphysis. Untreated dysplasia patients can walk with a limp and little pain into the early twenties even with fixed dislocation. Pain and decreasing hip function is commonly seen as the patient enters adult life. Occasionally the hip instability begins after skeletal maturity. Total hip arthroplasty (THA) is the standard treatment when sufficient symptoms have developed. The clinical outcomes of 42 THAs in patients with Down syndrome were all successfully treated with standard components. The use of constrained liners to treat intra-operative instability occurred in eight hips and survival rates were noted between 81% and 100% at a mean follow-up of 105 months (6 – 292 months). A more recent study of 241 patients with Down syndrome and a matched 723-patient cohort from the Nationwide Inpatient Sample compared the incidence of peri-operative medical and surgical complications in those who underwent THA. Compared to matched controls, Down syndrome patients had an increased risk of complications: peri-operative (OR, 4.33; P<.001), medical (UTI & Pneumonia OR, 4.59; P<.001) and surgical (bleeding OR, 3.51; P<.001), Mean LOS was 26% longer (P<.001). While these patients can be challenging to treat, excellent surgical technique and selective use of acetabular constraint can reliably provide patients with excellent pain-relief and improved function. Pre-operative education of all clinical decision makers should also reinforce the increased risk of medical and surgical complications (wound hemorrhage), and lengths of stay compared to the general population

Background. There is growing clinical and policy emphasis on minimizing transfusion use in elective joint arthroplasty, but little is known about the degree to which transfusion rates vary across US hospitals. This study aimed to assess hospital-level variation in use of allogeneic blood transfusion in patients undergoing elective joint arthroplasty, and to characterize the extent to which variability is attributable to differences in patient and hospital characteristics. Methods. The study population included 228,316 patients undergoing total knee arthroplasty (TKA) at 922 hospitals and 88,081 patients undergoing total hip arthroplasty (THA) at 606 hospitals from January 1, 2009, to December 31, 2011, in the Nationwide Inpatient Sample database, a 20% stratified sample of US community hospitals. Results. The median hospital transfusion rates were 11.0% (interquartile range, 3.5% to 18.5%) in TKA and 15.9% (interquartile range, 5.4% to 26.2%) in THA. After fully adjusting for patient- and hospital-related factors using mixed-effects logistic regression models, the average predicted probability of blood transfusion use in TKA was 6.3%, with 95% of the hospitals having a predicted probability between 0.37% and 55%. For THA, the average predicted probability of blood transfusion use was 9.5%, with 95% of the hospitals having a predicted probability between 0.57% and 66%. Hospital transfusion rates were inversely associated with hospital procedure volume and directly associated with length of stay. Conclusions. The use of blood transfusion in elective joint arthroplasty varied widely across US hospitals, largely independent of patient case-mix and hospital characteristics