Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty, particularly for low volume surgeons. The recent introduction of robotic-arm assisted systems has allowed for increased accuracy, however new systems typically have learning curves. The objective of this study was to determine the learning curve of a robotic-arm assisted system for UKA.

Methods A total of 152 consecutive robotic-arm assisted primary medial UKA were performed by five surgeons between 2017 and 2021. Operative times, implant positioning, reoperations and patient-reported outcome measures (PROMS; Oxford Knee Score, EuroQol-5D, and Forgotten Joint Score) were recorded.

There was a learning curve of 11 cases with the system that was associated with increased operative time (13 minutes, p<0.01) and improved insert sizing over time (p=0.03). There was no difference in implant survival (98.2%) between learning and proficiency phases (p = 0.15), and no difference in survivorship between ‘high’ and ‘low’ usage surgeons (p = 0.23) at 36 months. There were no differences in PROMS related to the learning curve. This suggested that the learning curve did not lead to early adverse effects in this patient cohort.

The introduction of a robotic-arm assisted UKA system led to learning curves for operative time and implant sizing, but there was no effect on patient outcomes at early follow- up. The short learning curve was independent of UKA usage and indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons.

Background. Intraoperative blood loss is a known potential complication of total knee arthroplasty (TKA). Tranexamic acid (TXA) has been shown to reduce intraoperative blood loss and postoperative transfusion in patients undergoing TKA. While there are numerous studies demonstrating the efficacy of intravenous and topical TXA in patients undergoing TKA, there are comparatively few demonstrating the effectiveness and appropriate dosing recommendations of oral formulations. Methods. A retrospective cohort study of 2230 TKA procedures at a single institution identified 3 treatment cohorts: patients undergoing TKA without the use of TXA (no-OTA, n=968), patients undergoing TKA with administration of a single-dose of oral TXA (single-dose OTA, n=164), and patients undergoing TKR with administration of preoperative and postoperative oral TXA (two-dose OTA, n=1098). The primary outcome was transfusion rate. Secondary outcomes included maximum postoperative decline in hemoglobin, number of blood units transfused, length of hospital stay, total drain output, cell salvage volume, and operating room time. Results. Transfusion rates decreased from 24.1% in the no-OTA group to 13.6% in the single-dose OTA group (p<0.001) and 11.1% in the two-dose OTA group (p<0.001), with no significant difference in transfusion rates between single- and two-dose OTA groups (p=0.357). Operating room time was reduced from 154 minutes in the no-OTA group to 144 minutes in the one-dose OTA group and 144 minutes in the two-dose OTA group (p<0.01). Additionally, maximum postoperative decline in hemoglobin was reduced from 4.3 g/dL in the no-OTA group to 3.5 g/dL in the single-dose OTA group (p<0.01) and 3.4 g/dL in the two-dose OTA group (p<0.01), without a significant difference between the single- and two-dose regimens (p=0.233). Conclusions. OTA reduces transfusions and operating room time, with the potential advantages of greater ease of administration and improved cost effectiveness relative to other routes of administration. Further study such as a randomized clinical trial is needed to verify the effectiveness of OTA and further optimize dosing regimens in the TKA setting. Level of Evidence. Therapeutic Level III

Aims

No predictive model has been published to forecast operating time for total knee arthroplasty (TKA). The aims of this study were to design and validate a predictive model to estimate operating time for robotic-assisted TKA based on demographic data, and evaluate the added predictive power of CT scan-based predictors and their impact on the accuracy of the predictive model.

Aims. Traditionally, acetabular component insertion during total hip arthroplasty (THA) is visually assisted in the posterior approach and fluoroscopically assisted in the anterior approach. The present study examined the accuracy of a new surgeon during anterior (NSA) and posterior (NSP) THA using robotic arm-assisted technology compared to two experienced surgeons using traditional methods. Methods. Prospectively collected data was reviewed for 120 patients at two institutions. Data were collected on the first 30 anterior approach and the first 30 posterior approach surgeries performed by a newly graduated arthroplasty surgeon (all using robotic arm-assisted technology) and was compared to standard THA by an experienced anterior (SSA) and posterior surgeon (SSP). Acetabular component inclination, version, and leg length were calculated postoperatively and differences calculated based on postoperative film measurement. Results. Demographic data were similar between groups with the exception of BMI being lower in the NSA group (27.98 vs 25.2; p = 0.005). Operating time and total time in operating room (TTOR) was lower in the SSA (p < 0.001) and TTOR was higher in the NSP group (p = 0.014). Planned versus postoperative leg length discrepancy were similar among both anterior and posterior surgeries (p > 0.104). Planned versus postoperative abduction and anteversion were similar among the NSA and SSA (p > 0.425), whereas planned versus postoperative abduction and anteversion were lower in the NSP (p < 0.001). Outliers > 10 mm from planned leg length were present in one case of the SSP and NSP, with none in the anterior groups. There were no outliers > 10° in anterior or posterior for abduction in all surgeons. The SSP had six outliers > 10° in anteversion while the NSP had none (p = 0.004); the SSA had no outliers for anteversion while the NSA had one (p = 0.500). Conclusion. Robotic arm-assisted technology allowed a newly trained surgeon to produce similarly accurate results and outcomes as experienced surgeons in anterior and posterior hip arthroplasty. Cite this article: Bone Jt Open 2021;2(6):365–370

Aims. High body mass index (BMI) is associated with increased rates of complications in primary total hip arthroplasty (THA), but less is known about its impact on cost. The effects of low BMI on outcomes and cost are less understood. This study evaluated the relationship between BMI, inpatient costs, complications, readmissions, and utilization of post-acute services. Methods. A retrospective database analysis of 40,913 primary THAs performed between January 2013 and December 2017 in 29 hospitals was conducted. Operating time, length of stay (LOS), complication rate, 30-day readmission rate, inpatient cost, and utilization of post-acute services were measured and compared in relation to patient BMI. Results. Mean operating time increased with BMI and for BMI > 50 kg/m. 2. was approximately twice that of BMI 10 kg/m. 2. to 15 kg/m. 2. Mean inpatient cost did not vary significantly with BMI. Mean total reimbursement was lowest for the lowest BMI cohort and increased with BMI. Mean LOS was greatest at the extremes of BMI (4.0 days for BMI 10 kg/m. 2. to 15 kg/m. 2. ; 3.75 days for BMI > 50 kg/m. 2. ) and twice that of normal BMI. Mean complication rates were greatest in the lowest BMI cohort (16% for BMI 10 kg/m. 2. to 15 kg/m. 2. ) and five times the mean rate of complications in the normal BMI cohorts. Furthermore, 30-day readmissions were greatest in the highest BMI cohort (10% for BMI > 50 kg/m. 2. ) and five times the rate for normal BMI patients. Conclusion. LOS, complications, and 30-day readmissions all increase at the extremes of BMI and appear to be greater than those of patients with normal BMI. The lowest BMI patients had the lowest payment for inpatient stay yet were at considerable risk for complications and readmission. Patients with extreme BMI should be counselled about their increased risk of complications for THA and nutritional status/obesity optimized preoperatively if possible. Cite this article: Bone Joint J 2020;102-B(7 Supple B):62–70

Aims. Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically. Methods. This is a prospective series of 156 proximal hamstring surgical repairs, with a mean age of 48.9 years (21.5 to 78). Functional outcomes were assessed preinjury, preoperatively, and postoperatively (six months and minimum three years) using the Sydney Hamstring Origin Rupture Evaluation (SHORE) score. Operating time was recorded for every patient. Results. Overall, significant improvements in SHORE scores were seen at both six months and mid-term follow-up. Preoperatively, acute patients (median score 27.1 (interquartile range (IQR) 22.9)) reported significantly poorer SHORE scores than chronic patients (median score 42.9 (IQR 22.1); p < 0.001). However, this difference was not maintained postoperatively. For partial tears, acutely repaired patients reported significantly lower preoperative SHORE scores compared to chronically reapired partial tears (median score 24.3 (IQR 15.7) vs median score 40.0 (IQR 25.0); p < 0.001) but also significantly higher SHORE scores at six-month follow-up compared to chronically repaired partial tears (median score 92.9 (IQR 10.7) vs. median score 82.9 (IQR 14.3); p < 0.001). For complete tears, there was only a difference in preoperative SHORE scores between acute and chronic groups. Overall, acute repairs had a significantly shorter operating time (mean 64.67 minutes (standard deviation (SD) 12.99)) compared to chronic repairs (mean 74.71 minutes (SD = 12.0); t = 5.12, p < 0.001). Conclusion. Surgical repair of proximal hamstring avulsions successfully improves patient reported functional outcomes in the majority of patients, irrespective of the timing of their surgery or injury classification. However, reducing the time from injury to surgery is associated with greater improvement in patient outcomes and an increased likelihood of returning to preinjury functional status. Acute repair appears to be a technically less complex procedure, as indicated by reduced operating times, postoperative neurological symptoms and number of patients requiring bracing. Acute repair is therefore a preference among many surgeons. Cite this article: Bone Joint J 2020;102-B(10):1419–1427

Aims. Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery. Methods. A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed. Results. The greatest gains in productivity were in avoiding repeat intraoperative scans (a mean of 248 minutes for patients who had two scans, and a mean 180 minutes for those who had a single scan). Optimizing accuracy was the biggest factor influencing this, which was reliant on incremental changes to the operating setup and technique. Conclusion. The application of lean principles to the introduction of ION for AIS surgery helps assimilate this method into the environment of the operating theatre. Data and stakeholder analysis identified a reproducible technique for using ION for AIS surgery, reducing operating time, and radiation exposure. Cite this article: Bone Joint J. 2020;102-B(1):5–10

Aims. The aim of this retrospective study was to compare the correction achieved using a convex pedicle screw technique and a low implant density achieved using periapical concave-sided screws and a high implant density. We hypothesized that there would be no difference in outcome between the two techniques. Methods. We retrospectively analyzed a series of 51 patients with a thoracic adolescent idiopathic scoliosis. There were 26 patients in the convex pedicle screw group who had screws implanted periapically (Group 2) and a control group of 25 patients with bilateral pedicle screws (Group 1). The patients’ charts were reviewed and pre- and postoperative radiographs evaluated. Postoperative patient-reported outcome measures (PROMs) were recorded. Results. The number of implants (14.5 vs 17.1) and the implant density (1.5 vs 1.9) were significantly lower in Group 2 (p < 0.001). Operating time was 27 minutes shorter in Group 2 than in Group 1, with a mean of 217 minutes (SD 50.5; 120 to 346). The duration of surgery per instrumented vertebra was reduced by 19% in Group 2 (p = 0.011). No statistical difference was found in the postoperative Cobb angle, vertebral rotation, the relative correction achieved, or postoperative PROMs. Conclusion. Despite a lower implant density and achieving correction through a convex rod, surgical correction of the Cobb angle and vertebral body rotation was similar in both groups. Periapical pedicle screws and primary correction on the concave side do not seem to be mandatory in order to achieve good surgical results in idiopathic thoracic scoliosis. The operating time was shorter in the group with lower implant density. In conclusion, the technique provided good results and has the potential to reduce complications and costs. Cite this article: Bone Joint J 2021;103-B(3):536–541

INTRODUCTION. The efficacy and safety of the tourniquet are discussed, in particular with regard to the blood saving and tissue damage induced by ischemia. The quality of exsanguination and tissue necrosis in the compression zone are significant prognostic factors. The objective of this study was to evaluate the efficacy and safety of a new tourniquet system combining efficient and controlled exsanguination (figure 1) and ischemia maintained by pressure on a minimal surface (figure 2). The hypothesis tested was that the new system allowed tourniquet to reduce blood loss compared to conventional withers without increasing the risk of complications. MATERIAL. Two groups of 30 patients undergoing total knee arthroplasty (TKA) were compared. There were 39 women and 21 men with a mean age of 67 years and a mean BMI of 34. The study group was operated with the innovative tourniquet and followed prospectively. The control group was operated with the traditional tourniquet and analyzed retrospectively. METHODS. Operating time was measured between skin incision and dressing application. Blood loss was calculated with the Gross formula. Blood transfusion requirements were collected. Rehabilitation course was appreciated by the time to discharge. Complications, whether related or not to the tourniquet used, were recorded. Data were compared in both groups with the appropriate statistical tests at a 0.05 level of significance. The sample size was calculated to allow detecting a 300 ml decrease in mean blood loss with a power of 0.80. RESULTS. Both groups were comparable for all pre-operative data (age, gender, BMI, severity of the pre-operative deformation, pre-operative hematocrit level). Calculated blood loss was not significant different in the two groups (968 ml in the study group versus 1,022 ml in the control group, p<0.05). Operating time was not significantly decreased in the study group. Blood transfusion requirements were not significant different in the two groups (4 units versus 6 units). The complication rate was significantly decreased in the study group (no case versus 4 cases), especially for skin complications (3 cases of persistent bleeding or skin ischemia in the study group). The mean discharge time was significantly shorter in the study group (3rd post-operative day versus 5th post-operative day, p<0.05). DISCUSSION. The tested hypothesis was not confirmed. This preliminary study did not show any advantage of the new technology of tourniquet when analyzing blood loss. However, the decreased rate of local skin complications may be in relationship with a decreased intra-operative skin ischemia. This might lead to an earlier discharge. CONCLUSION. A prospective, randomized study is necessary to confirm these preliminary results

The common practice for insertion of distal locking screws of intramedullary (IM) nails is a freehand technique under fluoroscopic control. The process is technically demanding, time-consuming and afflicted to considerable radiation exposure to patient and surgical personnel. A new technique is introduced which guides the surgeon by landmarks on the X-ray projection. 18 fresh frozen human below-knee specimens (incl. soft tissue) were used. Each specimen was instrumented with an Expert Tibial Nail (Synthes GmbH, Switzerland) and was mounted on an OR-table. Two distal interlocking techniques were performed in random order using a Siemens ARCADIS C-arm system (Siemens AG, Munich, Germany). The newly developed guided technique, guides the surgeon by visible landmarks projected onto the fluoroscopy image. A computer program plans the drilling trajectory by 2D-3D conversion and provides said guiding landmarks for drilling in real-time. No additional tracking or navigation equipment is needed. All four distal screws (2 mediolateral, 2 anteroposterior) were placed in each procedure. Operating time, number of taken X-rays and radiation time were recorded per procedure and for each single screw. 8 procedures were performed with the freehand technique and 10 with the guided technique. A 58% reduction in number of fluoroscopy shots per screw was found for the guided technique (7.4±3.4 vs. 17.6±10.3; p < 0.001). Total radiation time was 55% lower for the guided technique (17.1 ± 3.7s vs. 37.9 ± 9.1s) (p = 0.001). Operating time was shorter by 22% in the guided technique (3.2±1.2 min vs. 4.1±2.1 min p = 0.018). In an experimental setting, the newly developed guided freehand technique has proven to markedly reduce radiation exposure when compared to the conventional freehand technique. The method enhances established clinical workflows and does not require cost intensive add-on devices or extensive training. A newly developed simple navigated technique has proven to markedly reduce radiation exposure and time for distal locking of intramedullary nails

In this study we randomised 140 patients who were due to undergo primary total knee arthroplasty (TKA) to have the procedure performed using either patient-specific cutting guides (PSCG) or conventional instrumentation (CI). . The primary outcome measure was the mechanical axis, as measured at three months on a standing long-leg radiograph by the hip–knee–ankle (HKA) angle. This was undertaken by an independent observer who was blinded to the instrumentation. Secondary outcome measures were component positioning, operating time, Knee Society and Oxford knee scores, blood loss and length of hospital stay. A total of 126 patients (67 in the CI group and 59 in the PSCG group) had complete clinical and radiological data. There were 88 females and 52 males with a mean age of 69.3 years (47 to 84) and a mean BMI of 28.6 kg/m. 2. (20.2 to 40.8). The mean HKA angle was 178.9° (172.5 to 183.4) in the CI group and 178.2° (172.4 to 183.4) in the PSCG group (p = 0.34). Outliers were identified in 22 of 67 knees (32.8%) in the CI group and 19 of 59 knees (32.2%) in the PSCG group (p = 0.99). There was no significant difference in the clinical results (p = 0.95 and 0.59, respectively). Operating time, blood loss and length of hospital stay were not significantly reduced (p = 0.09, 0.58 and 0.50, respectively) when using PSCG. . The use of PSCG in primary TKA did not reduce the proportion of outliers as measured by post-operative coronal alignment. . Cite this article: Bone Joint J 2015;97-B:56–63

Aims. We conducted a randomised controlled trial to assess the accuracy of positioning and alignment of the components in total knee arthroplasty (TKA), comparing those undertaken using standard intramedullary cutting jigs and those with patient-specific instruments (PSI). Patients and Methods. There were 64 TKAs in the standard group and 69 in the PSI group. The post-operative hip-knee-ankle (HKA) angle and positioning was investigated using CT scans. Deviation of > 3° from the planned position was regarded as an outlier. The operating time, Oxford Knee Scores (OKS) and Short Form-12 (SF-12) scores were recorded. Results. There were 14 HKA-angle outliers (22%) in the standard group and nine (13%) in the PSI group (p = 0.251). The mean HKA-angle was 0.5° varus in the standard group and 0.2° varus in the PSI group (p = 0.492). The accuracy of alignment in the coronal and axial planes and the proportion of outliers was not different in the two groups. The femoral component was more flexed (p = 0.035) and there were significantly more tibial slope outliers (29% versus 13%) in the PSI group (p = 0.032). Operating time and the median three-month OKS were similar (p = 0.218 and p = 0.472, respectively). Physical and mental SF-12 scores were not significantly different at three months (p = 0.418 and p = 0.267, respectively) or at one year post-operatively (p = 0.114 and p = 0.569). The median one-year Oxford knee score was two points higher in the PSI group (p = 0.049). Conclusion. Compared with standard intramedullary jigs, the use of PSI did not significantly reduce the number of outliers or the mean operating time, nor did it clinically improve the accuracy of alignment or the median Oxford Knee Scores. Our data do not support the routine use of PSI when undertaking TKA. Cite this article: Bone Joint J 2016;98-B:1043–9

This is a prospective randomised study comparing the clinical and radiological outcomes of uni- and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. A total of 44 patients were randomised to undergo either uni- or bipedicular balloon kyphoplasty. Self-reported clinical assessment using the Oswestry Disability Index, the Roland-Morris Disability questionnaire and a visual analogue score for pain was undertaken pre-operatively, and at three and twelve months post-operatively. The vertebral height and kyphotic angle were measured from pre- and post-operative radiographs. Total operating time and the incidence of cement leakage was recorded for each group. Both uni- and bipedicular kyphoplasty groups showed significant within-group improvements in all clinical outcomes at three months and twelve months after surgery. However, there were no significant differences between the groups in all clinical and radiological outcomes. Operating time was longer in the bipedicular group (p < 0.001). The incidence of cement leakage was not significantly different in the two groups (p = 0.09). A unipedicular technique yielded similar clinical and radiological outcomes as bipedicular balloon kyphoplasty, while reducing the length of the operation. We therefore encourage the use of a unipedicular approach as the preferred surgical technique for the treatment of osteoporotic vertebral compression fractures. Cite this article: Bone Joint J 2013;95-B:401–6

Aims

In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component.

Aims

Robotic-assisted unicompartmental knee arthroplasty (R-UKA) has been proposed as an approach to improve the results of the conventional manual UKA (C-UKA). The aim of this meta-analysis was to analyze the studies comparing R-UKA and C-UKA in terms of clinical outcomes, radiological results, operating time, complications, and revisions.

Aims

Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment.

Total knee arthroplasty (TKA) is a common procedure with good success rates. The literature shows resection accuracy plays a crucial role in device longevity. 1. Computer guidance is used by some surgeons to enhance accuracy. This study reports on a continuous series of Optetrak knee prostheses (Exactech Inc., FL, USA) implanted by three senior surgeons between October 2010 and December 2013. 324 TKA were implanted at the Joseph Ducuing Hospital, Toulouse, France (Site 1), the Cleveland Clinic, Cleveland, OH, USA (Site 2) and the Riverview Hospital, Noblesville, IN, USA (Site 3) using Exactech GPS (Blue-Ortho, Grenoble, FR), a new computer-assisted guidance system. Each centre in this study used different surgical profiles defined specifically for their surgeical preferences. Planned tibial and femoral cuts were compared to actual cuts digitised using GPS. Operating time was analyzed and post-operative leg alignment was compared to pre-operative. The mean error between planned and digitised proximal tibial cuts was 0.06°±0.89 of valgus and 0.53°±0.90 of anterior slope for Site 1, 0.18°±0.85 of varus and 0.25°±1.18 of posterior slope for Site 2, and 0.02°±0.51 of valgus and 0.60°±1.15 of anterior slope for Site 3. The mean error between planned and digitised femoral distal cuts was 0.14°±0.85 of valgus and 0.49°±0.93 of flexion for Site 1, 0.15°±0.96 of varus and 0.04°±1.54 of extension for Site 2, and 0.09°±0.54 of varus and 0.48°±1.21 of extension for Site 3. Average operating time was 29 minutes for Site 1, 39 minutes for Site 2, and 33 minutes for Site 3. Post-operative Hip-Knee-Ankle angle (HKA) varied between 172° and 184° with an average of 179° for Site 1, 177° to 183° with an average of 179° for Site 2, and 177° to 185° with an average of 180° for Site 3. Pre-operative HKA ranged from 162 to 189°. Site 1 was already reporting in the series presented at ISTA 2013. 2. Sites 2 and 3 were added later and could therefore benefit from the early feedback the analysis of site 1 cases provided. The use of the computer guidance at the new sites was associated with promising results and it did not take long to the surgeons to reach a reproducibility equivalent to the one of site 1. Average surgical time was similar in all three sites. GPS guidance added an average of 10 minutes to standard surgical times. All surgeons agreed the increased accuracy justified the additional time. Average post-operative HKA was 179°. HKA scores were within 3° of perfect alignment in 96% of the cases of Site 1, 99% of Site 2 and 97% of Site 3. According to the literature. 1. , HKA between 177° and 183° is linked with high implant survival. Participating surgeons still associated Exactech GPS with satisfactory immediate post-operative results

The Fixion expandable nailing system provides an intramedullary fracture fixation solution without the need for locking screws. Proponents of this system have demonstrated shorter surgery times with rapid fracture healing, but several centres have reported suboptimal results with loss of fixation. This is the largest comparative series to be reported to date. We compared outcomes between 50 consecutive diaphyseal tibial fractures treated with a Fixion device at our institution to an age, sex and fracture configuration matched series of 57 fractures at a neighbouring hospital treated with a conventional interlocked intramedullary nail. Minimum follow up time was 2 years. Operating time was significantly reduced in the Fixion group (mean 61 minutes, range 20–99) compared to the interlocked group (88 minutes, 52–93), p< 0.00001. The union rate was no different between the Fixion group (93.9%) and the interlocked group (96.5%), p=0.527. Time to clinical and radiological union was significantly faster in the Fixion group (median 85 days, range 42–243) compared to the interlocked group (119, 70–362), p< 0.0001. The overall reoperation rate was lower in the Fixion series (24.5% vs 38.6%, p=0.121), although the majority of reoperations in the interlocked group were more minor, for screw removal. 3 Fixion nails were revised for fixation failure and 2 manipulations were required for rotational deformities after falls; all of these patients were non-compliant with post-operative instructions. There were no fixation failures in the interlocked group. 3 fractures were noted to propagate during inflation of Fixion nails. The Fixion nail is faster to implant and allows more physiological loading of the fracture, with a faster union time. However, these advantages are offset by a reduction in construct stability. Our results have demonstrated a learning curve with a reduction in complications as our indications were narrowed, avoiding osteoporotic, multifragmentary, unstable fractures and non-compliant patients

We reported the first single surgeon series comparing outcome of microscopic and open primary single level unilateral lumbar decompression or discectomy. We aimed to determine any difference in outcomes between the two techniques. Forty-six decompressions were performed with use of an operating microscope (microscopic), and forty without (open) at two different hospitals. All procedures were performed by the senior author. Information was obtained by analysis of the patients' notes. The average age of the patients in both groups was comparable. Operating time was shorter in the microscopic group (68min, range 30-130) compared to the open group (83 mins, range 30-180). Dural tear rate was 4.3% with use of a microscope (0% symptomatic dural tear rate) and 7.5% without (2.5% symptomatic dural tear rate). Nerve damage incidence was 0% with use of a microscope and 5% (two patients) without. One of these was a neurapraxia and the patient made a full recovery. Wound infection rates, diagnosed on grounds of clinical suspicion, were 4.3% and 2.5% for microscopic and open respectively. There were no incidences of deep infection or post-operative discitis. Average inpatient stay was under 48 hours in both groups. Using the modified Macnab criteria, results using the microscope were 0% poor, 14% fair, 32% good, and 55% excellent. The results for the open group were 0% poor, 10% fair, 37% good and 53% excellent. Average follow-up was six months (1-19) for the microscope group, and seven months (2-16) for the open group. We conclude that primary single level unilateral lumbar decompressive surgery, performed without the use of a microscope, has a higher dural tear rate than the same surgery performed with the benefit of an operating microscope. Surgical time and incidence of nerve damage are also reduced by use of the microscope

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail. We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy. Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation. This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group