Hip precautions are currently practiced in three-quarters of trauma hospitals in the UK, despite national recommendations from the ‘Blue Book’ not stating it as a requirement. Valuable therapist time is utilised alongside the need for specialised equipment, which can potentially delay discharge whilst it is being arranged. Objective of this study was to explore the current practice of the use of hip precautions on discharge following hemiarthroplasty for hip fractures. To also explore whether they are necessary and to identify areas for improvement to benefit patient care overall. Online survey distributed to various Trauma and Orthopaedic Departments across the UK. Survey was available over a 4-month period, collecting 55 responses overall. Majority of responses were from trauma and orthopaedic consultants who were aware of the ‘Blue Book’ recommendations. The majority of trusts who responded did not practice hip precautions and did not feel this increased the risk of dislocations on discharge. Recommendations included integration of hip precautions in the post-op advice in coordination with the physiotherapist and information leaflets on discharge regarding hip precautions. Hip precautions were not commonly practiced, for reasons including patient compliance and the inherently stable procedure of a hemiarthroplasty compared to a THR, reducing the need for hip precautions. Hip precautions are not widely regarded as a useful practice for post-hip hemiarthroplasty, viewed as utilising more resources and increasing costs and risk due to increased hospital stay. Thus, this potentially delays discharge overall. A consistent approach should be implemented in treating patients post-hip hemiarthroplasty

Introduction. The concept of same-day discharge has garnered increasing significance within orthopedic surgery, particularly in hip and knee procedures. Despite initial concerns surrounding the absence of prolonged hospital care, a burgeoning body of evidence highlights numerous advantages associated with same-day discharge, ranging from mitigating in-hospital infections to offering substantial financial and psychosocial benefits for both patients and healthcare providers. In this study, we aim to scrutinize the trends in same-day discharge specifically within the realm of total hip arthroplasties. Method. This retrospective analysis delves into the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database spanning from 2017 to 2021. Leveraging patient data sourced from the ACS NSQIP database, we sought to elucidate patterns and shifts in same-day discharge practices pertaining to total hip arthroplasties. Result. The preoperative analysis illuminated several notable disparities between patients undergoing same-day hip arthroplasty and those necessitating hospitalization. Notably, same-day hip patients skewed younger, comprising 48.3%females compared to 55.6% in hospitalized hip patients. Furthermore, a lower prevalence of medical comorbidities such as diabetes mellitus (8.5% vs.12.9%), current smoking (9.3% vs. 12.2%), and severe COPD(1.9% vs. 4.1%) was observed among same-day hip group. Operatively, same-day hip surgeries boasted shorter durations, averaging 83.9 minutes, in contrast to the 92.3minutes for hospitalized hip procedures. Postoperatively, same-day hip patients exhibited significantly diminished rates of 30-day readmissions (1.7%vs. 3.5%), procedure-related readmissions (1.0%vs.2.1%), reoperations (1.1%vs.1.9%), and mortality (0.02% vs. 0.04%). Moreover, the prevalence of the same-day discharge concept experienced a remarkable ascent from 2016 to 2021, with rates escalating from 1.5% to 25.6% of all total hip arthroplasties over a span of just six years. Conclusion. In conclusion, same-day discharge is a feasible and safe option for selected THA patients

There has been significant interest in day-case and rapid discharge pathways for unicompartmental knee replacements (UKR). Pathways to date have shown this to be a safe and feasible option; however, no studies to date have published results of rapid-discharge pathways using the NAVIO robotic system. To date there is no published experience with rapid discharge UKR patients using the NAVIO robotic system. We report an initial experience of 11 patients who have safely been discharged within 24 hours. With the primary goal of investigating factors that led to rapid discharge and a secondary goal of evaluating the safety of doing so. All patients were discharged within 24 hours; there were no post-operative complications and no readmissions to hospital. The mean length of stay was 16.9 hours (SD=7.3), with most patients seen once on average by physiotherapy. Active range of motion at 6 weeks was 0.7o to 130.5 o, with all patients mobilising independently. The average 6-month post-operative Oxford Knee Score was 43.5 out of 48. There were no readmission or complications in any of our patients. This initial feasibility study identified that patients could be safely discharged within 24 hours after UKR using the NAVIO robotic system. With growing uptake of robotic procedures, with longer operative durations than traditional procedures, it is essential to ensure a rapid discharge to reduce healthcare cost whilst ensuring that patients are discharged home in a safe manner

Eliminating pain and restoring physical activity are the main goals of total hip arthroplasty (THA). Despite the high relevance of activity as a rehabilitation goal of and criterion for discharge, in-hospital activity between operation and discharge has hardly been investigated in orthopaedic patients. Therefore, the aim of this study was to a) measure for reference the level of in-hospital physical activity in patient undergoing a current rapid discharge protocol, b) compare these values to a conventional discharge protocol and c) test correlations with pre-operative activities and self-reported outcomes for possible predictors for rapid recovery and discharge. Patients (n=19, M:F: 5:14, age 65 ±5.7 years) with osteoarthritis treated with an elective primary THA underwent a rapid recovery protocol with discharge on day 3 after surgery (day 0). Physical activity was measured using a 3D accelerometer (64×25×13mm, 18g) worn on laterally on the unaffected upper leg. The signal was analysed using self-developed, validated algorithms (Matlab) calculating: Time on Feet (ToF), steps, sit-stand-transfers (SST), mean cadence (steps/min), walking bouts, longest walk (steps). For the in-hospital period (am: ca. 8–13h; pm: ca. 13–20h) activity was calculated for day 1 (D1) and 2 (D2). Pre-operative activity at home was reported as the daily averages of a 4-day period. Patient self-report included the HOOS, SQUASH (activity) and Forgotten Joint Score (FJS) questionnaires. In-hospital activity of this protocol was compared to previously collected data of an older (2011), standard conventional discharge protocol (day 4/5, n=40, age 71 ±7 years, M:F 16:24). All activity parameters increased continuously between in-hospital days and subsequent am and pm periods. E.g. Time-on-feet increased most steeply and tripled from 21.6 ±14.4min at D1am to 62.6 ±33.4min at D2pm. Mean Steps increased almost as steep from 252 to 655 respectively. SST doubled from 4.9 to 10.5. All these values were sign. higher (+63 to 649%) than the conventional protocol data. Cadence as a qualitative measure only increased slowly (+22%) (34.8 to 42.3steps/min) equalling conventional protocol values. The longest walking bout did not increase during the in-hospital period. Gender, age and BMI had no influence on in-hospital activity. High pre-op activity (ToF, steps) was a predictor for high in-hospital activity for steps and SST's at D2pm (R=0.508 to R=0.723). Pre-op self-report was no predictor for any activity parameter. In-hospital recovery of activity is steep following a cascade of easy (ToF) to demanding (SST) tasks to quality (cadence). High standard deviations show that recovering activity is highly individual possibly demanding personalised support or goals (feedback). Quantitative parameters were all higher in the rapid versus the conventional discharge protocol indicating that fast activation is possible and safe. Equal cadence for both protocols shows that functional capacity cannot be easily accelerated. Pre-op activity is only a weak predictor of in-hospital recovery, indicating that surgical trauma affects patients similarly, but subjects may be identified for personalized physiotherapy or faster discharge. Reference values and correlations from this study can be used to optimize or shorten in-hospital rehabilitation via personalization, pre-hab, fast-track surgery or biofeedback

Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and day two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PTE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Summary Statement. There were significant differences in the pain experience, behaviors, and perceptions on analgesics, between the Australia and Singapore cohorts, after hospital discharge following TKR. These findings may be influenced by the ethnicity and cultural differences between these two countries. Introduction. In recent years the hospital length of stay after total knee replacement (TKR) has shortened. Hence, patients have to self-manage their pain earlier after the surgery. The aim of this study was to examine if the pain experience, self-management behaviors and potential barriers to optimal analgesia after hospital discharge for TKR differed in different ethnicity groups. Patients & Methods. We administered a questionnaire to patients undergoing TKR in 10 Australian hospitals, and one large Singaporean hospital, two weeks following hospital discharge.1 We asked participants about their pain severity, use of analgesics, side-effects, perceptions of analgesics use, and satisfaction with pain relief at home. The two groups were compared using Chi-squared test with SPSS 20.0 with statistical significance set at p < 0.05. Results. 171 (98%) participants from the Australian centers and 105 (94%) from the Singaporean hospital completed the questionnaire. Compared with the Singaporean patients, significantly more participants in the Australian cohort reported that their worst pain period occurred during the first two weeks at home (52% vs. 20%, p < 0.0001), and that their average pain at home was ‘severe/extreme’ (23% vs. 6%, p < 0.0001). More participants in the Australian cohort consumed an opioid alone or in combination with non-opioid analgesics (69% vs. 33%, p < 0.0001). Although many in both cohorts experienced analgesic-related side-effects, the proportion was higher in the Australian cohort (84% vs. 41%, p < 0.0001). A very much larger proportion of participants in the Australian cohort sought further medical help for their pain (60% vs. 3%, p < 0.0001). A much small proportion of patients in the Australian cohort perceived that analgesics could not control pain (26% vs. 44%, p = 0.002); were concerned about addiction (26% vs. 42%, p = 0.005) or developing tolerance to analgesics (28% vs. 49%, p < 0.0001); or preferred enduring pain than analgesic-related side-effects (25% vs. 42%, p < 0.002). There was no significant difference in satisfaction with analgesia between the two cohorts (64% vs. 74%, p = 0.179). Discussion/Conclusion. Following hospital discharge for TKR, there were differences in the pain experience, opioid consumption, side-effects, and perceptions of analgesics, between the Australian and Singaporean cohorts. Ethnic or cultural differences might have influenced the differences found, as the Australian cohort mostly comprised of Caucasians while the Singaporean cohort comprised exclusively patients of Asian origin. Interestingly, despite more participants in the Australian cohort experiencing severe pain and higher incidence of analgesic-related side-effects, the proportion who were satisfied with analgesia during the first two weeks after hospital discharge were similar, suggesting that satisfaction is a complex concept influenced by the interplay of many factors. Future studies are required to examine the extent to which ethnicity and cultural factors determine the pain intensity, behaviours and perceptions reported by patients after TKR

Abstract. There are numerous advantages of discharging patients early after any surgery. Day case arthroplasty in hip and knee is already brought into practice at many centres. We present our journey towards discharging elective shoulder arthroplasty patient on same after their surgery. An initial retrospective study of patients who underwent elective shoulder replacement between 2017 and 2020 were studied. It was identified that a selected group of patients could be discharged on the same of their surgery. The criteria to select a patient for this service was laid down that include ASA 1 or 2, good family support on discharge, personal wishes of patients and early identification of potential patients in the clinic and planning for day case shoulder arthroplasty56 consecutive patients underwent elective arthroplasty of shoulder. Among them 22 patients were discharges on the next day of surgery. The potential patients those could discharged on same were identified to be 11 out of 22 were under ASA 2 and had good family support at home on discharge. Average length of stay after surgery was 2.17 days. We have prospectively discharged 2 patients following the new criteria. This study demonstrates how outpatient elective shoulder could be implemented at other centres. Patient participation and selection with proper planning is key for success here. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Introduction. As per national guidelines for Ankle fractures in the United Kingdom, fractures considered stable can be treated with analgesia, splinting and allowed to weight bear as tolerated. The guidelines also suggest further follow-up not mandatory. This study was aimed at evaluating the current clinical practice of managing stable ankle fractures at a university hospital against national guidelines. Method. The study was undertaken using retrospectively collected data, the inclusion criteria being all adults with stable ankle fracture pattern treated non-operatively between December 2022 and April 2023. Collected data included age of patient, date of injury, type of immobilization, number of clinical visits and any complications. Results. 41 cases were identified and analyzed. The mean age of the cohort was 49.8 years (Standard deviation 20.01). Twelve percent (n = 5) were reviewed in clinic, treated and discharged as stable Weber B type fracture pattern as per national guidelines after the first visit. About 52% (n = 21) were seen in clinic twice before discharge, first visit between 1-2 weeks and the last clinic visit between 5-7 weeks. About a third of patients (30%, n = 12) were seen in clinic on more than two occasions. At the first clinic visit 87% (n = 36) were given a boot and allowed to weight bear as tolerated. Two patients were diagnosed with deep vein thrombosis/pulmonary embolism during the treatment duration. Three patients had extended duration of follow up for ongoing symptoms. None discharged after first or second visit needed surgery for displaced or malunited fracture. Conclusion. Patients discharged from clinic after first or second visit did not need any further surgery. As per national guidelines, patients deemed stable weber B lateral malleolus fracture pattern after weight bearing radiograph can be treated safely with a weight bearing walking boot with no further follow up

Radial head fractures are among the most common fractures around the elbow. Radial head arthroplasty is one of the surgical treatment options after complex radial head fractures. This surgery is usually done under general anaesthesia. However, there is a recent anaesthetic technique - wide awake local anaesthesia no tourniquet (WALANT) - that has proven useful in different surgical settings, such as in distal radius or olecranon fractures. It allows a good haemostatic control without the use of a tourniquet and allows the patient to actively collaborate during the surgical procedure. Furthermore, there are no side effects or complications caused by the general anaesthesia and there's an earlier patient discharge. The authors present the case of a seventy-six-year-old woman who presented to the emergency department after a fall from standing height with direct trauma to the left elbow. The radiological examination revealed a complete intra-articular comminuted fracture of the radial head (Mason III). Clinical management: The patient was submitted to surgery with radial head arthroplasty, using WALANT. The surgery was successfully completed without pain. There were no intra or immediate post-operative complications and the patient was discharged on the same day. Six weeks after surgery, the patient had almost full range of motion and was very pleased with the functional outcome, with no limitations on her activities of daily living. The use of WALANT has been expanded beyond the hand and wrist surgery. It is a safe and simple option for patients at high risk of general anaesthesia, allowing similar surgical outcomes without the intraoperative and postoperative complications of general anaesthesia and permitting an earlier hospital discharge. Furthermore, it allows the patient to actively collaborate during the surgery, providing the surgeons the opportunity to evaluate active mobility and stability, permitting final corrections before closing the incision

Ankle fractures are among the most common types of fractures. If surgery is not performed within 12 to 24 hours, ankle swelling is likely to develop and delay the operative fixation. This leads to patients staying longer in the ward waiting and increased hospital occupancy. This prolonged stay has significant financial implication as well as it is frustrating for both patients and health care professionals. The aim was to formulate a pathway for the ankle fracture patients coming to the emergency department, outpatients and planned for operative intervention. To identify whether pre-operative hospital admissions of stable ankle fracture patients are reduced with the implementation of the pathway. We formulated an ankle fracture fixation pathway, which was approved for use in December 2020. A retrospective analysis of 6 months hospital admissions of ankle fracture patients in the period between January to June 2020. The duration from admission to the actual surgery was collected to review if some admissions could have been avoided and patients brought directly on the surgery day. A total of 23 patients were included. Mean age was 60.5 years and SD was 17years. 94% of patients were females. 10 patients were appropriately discharged.7 Patients were appropriately admitted. 6 Patients were unnecessarily admitted. These 6 patients were admitted on presentation to ED. Retrospective analysis of this audit showed that this cohort of patients met the safe discharge criteria and could have been discharged. Duration of unnecessary stay ranged from 1 to 11 days (21 days in total). Total saving could have been £6300. Standards were met in 74% of cases. Preoperative hospital admission could be reduced with the proposed pathway. It is a valuable tool to be used and should be implemented to reduce unnecessary hospital admissions

There has been extensive research into neck of femur fractures in the elderly. Fragility non-hip femoral fractures share many of the same challenges [1]. Surgical management is complex, patients are frail and mortality rates have been reported as high as 38% [2]. Despite this, relatively little data is available evaluating the level of MDT care provided to non-hip femoral fractures. This audit aimed to evaluate the standard of MDT care provided for patients with non-hip femoral fractures according to the NHFD key performance indicators. The following fractures were included in the dataset: distal femoral, femoral shaft and peri-prosthetic femoral. Patients under 65 were excluded. Data was retrospectively collected using post-operative and medical documentation. Performance was assessed according to five key performance indicators:. Did orthogeriatrics review the patient within 72-hours?. Was surgery performed within 36-hours?. Was the patient weight bearing post-operatively?. Was a confusion assessment completed?. Was the patient discharged home?. 38 patients met the inclusion criteria. 84% of patients were seen by orthogeriatrics within 72 hours of admission. 32% of patients were operated on within 36-hours of admission, with time to theatre exceeding 36-hours in 92% of peri-prosthetic fractures. 37% of patients were not advised to full weight bear post operatively. 84% of patients received a confusion assessment whilst 61% of patients were discharged to their prior place of living. Our results suggest that non-hip femoral fractures do not receive the same standard of MDT care as neck of femur fractures. Greater prioritisation of resources should be given to this patient subset so that care is equivalent to hip-fracture patients. Time to surgery is a particular area for improvement, particularly in peri-prosthetic fractures, a trend that is mirrored nationally. Greater emphasis should be placed on encouraging full-weight bearing post-operatively to prevent post-surgical complications

Reduction of length of stay (LOS) without compromising quality of care is a trend observed in orthopaedic departments. To achieve this goal the pathway needs to be optimised. This requires team work than can be supported by e-health solutions. The objective of this study was to assess the impact of reduction in LOS on complications and readmissions in one hospital where accelerated discharge was introduced due to the pandemic. 317 patients with primary total hip and total knee replacements treated in the same hospital between October 2018 and February 2021 were included. The patients were divided in two groups: the pre-pandemic group and the pandemic group. The discharge criteria were: patient feels comfortable with going back home, patient has enough support at home, no wound leakage, and independence in activities of daily living. No face-to-face surgeon or nurse follow-up was planned. Patients’ progress was monitored via the mobile application. The patients received information, education materials, postoperative exercises and a coaching via secure chat. The length of stay (LOS) and complications were assessed through questions in the app and patients filled in standard PROMs preoperatively, at 6 weeks and 3 months. Before the pandemic, 64.8% of the patients spent 3 nights at hospital, whereas during the pandemic, 52.0% spent only 1 night. The median value changed from 3 days to 1 day. The complication rate before the pandemic of 15% dropped to 9 % during the pandemic. The readmission rate remained stable with 4% before the pandemic and 5 % during the pandemic. No difference were observed for PROMS between groups. The results of this study showed that after a hip and knee surgery, the shortening of the LOS from three to one night resulted in less complications and a stable rate of readmissions. These results are in line with literature data on enhanced recovery after hip and knee arthroplasty. The reduction of LOS for elective knee and hip arthroplasty during the pandemic period proved safe. The concept used in this study is transferable to other hospitals, and may have economic implications through reduced hospital costs

In current practice in the UK there are three main approaches to investigating suspected scaphoid fractures not seen on initial plain film x-rays. Early MRI of all cases. Review all cases in clinic at two weeks with repeat x-rays. Hybrid model. Virtual Fracture Clinic (VFC) triage to reduce those who are seen in clinic at two weeks by:. ∘. Organising early MRI for those with high-risk presentation. ∘. Discharging those with an alternative more likely diagnosis. Our unit uses the VFC model. We aimed to evaluate its efficiency, safety, clinical outcomes and economic viability. All patients attending the emergency department with either a confirmed or suspected scaphoid fracture between March and December 2020 were included (n=305). Of these 297 were referred to the VFC: 33 had a confirmed fracture on x-ray and 264 had a suspected fracture. Of the suspected fractures reviewed in VFC 14% had an MRI organised directly owing to a high-risk presentation, 79% were brought for fracture clinic review and 17% discharged with an alternative diagnosis such as osteoarthritis. Of those subsequently reviewed in fracture clinic at two weeks: 9% were treated as scaphoid fractures (based on clinical suspicion and repeat x-rays), 17% had MRI or CT imaging organised, 5% did not attend and 69% were discharged. Overall, 17% of cases initially triaged, had further imaging – 41 MRIs and 5 CTs. MRI detected: 5% scaphoid fracture, 17% other fracture, 24% bone contusion, complete ligament tear 10%, partial ligament tear 39% and normal study 10%. The results of MRI minimally affected management. 3 patients were taken out of plaster early, 1 patient was immobilized who was not previously and no patients underwent operative management. In the following 12-month period one patient re-presented with a hand or wrist issue. This approach avoided 218 MRIs, equating to £24000 and 109 hours of scanner time. VFC triage and selective use of MRI scanning is a safe, efficient and cost-effective method for the management suspected scaphoid fractures. This can be implemented in units without the resource to MRI all suspected scaphoid fractures from the emergency department

The primary purpose of this longitudinal study was to examine the impact of physical and mental well-being on a successful return to work after cartilage or ligament knee injury. A secondary purpose was to examine the effectiveness of our program regarding ordering imaging (plain X-rays, US, MRI, CT scan), and the impact that costly investigations made in clinical management. Workers who had sustained a work-related knee injury and were assessed at the lower extremity specialty clinic of our hospital program were followed up until they were discharged. All patients completed the numeric pain rating scale (NPRS), the Lower Extremity Functional Scale (LEFS), and the Hospital Anxiety and Depression Scale (HADS) on the initial assessment and at final follow-up. We included 30 patients, mean age, 50(9), 11(37%) females, 19(63%) males. The most common mechanisms of injury were twisting (13, 45%) and falls (12, 41%). The knee injuries included 10 anterior collateral ligament (ACL), 3 posterior collateral ligament (PCL), 19 medical and lateral ligament injuries, and 22 meniscus injuries with some injuries overlapping. Ten patients (30%) underwent surgery (8 meniscectomy, two ligamentous repairs). Patients showed improvement in pain scores (p<0.0001) and the LEFS scores (p=0.004). Seventeen patients (57%) returned to full-time work and 11 (37%) were not working at the time of discharge with one patient performing part-time work, and one on re-training. Higher levels of pre (p=0.02) and post-treatment (p=0.03) depression and post-treatment anxiety (p=0.02) had a negative impact on a successful return to work. Most clients had proper investigations ordered by their family physicians in the community (24 plain x-rays, 11 US, and 21 MRI). Our team ordered only 6 plain x-rays and 6 new MRI. We found significant improvement in pain and disability in injured workers who received an expedited multidisciplinary care. Anxiety and depression were the most important predictors of poorer recovery and a less successful work status. The judicious use of costly imaging is expected to reduce the overall health care cost of an injury, while providing new important information such as adding a new diagnosis or changing the management

Periprosthetic joint infections (PJI) are one of the most common reasons for orthopedic revision surgeries. In previous studies, it has been shown that silver modification of titanium (Ti-6Al-4V) surfaces by PMEDM (powder mixed electrical discharge machining) has an antibacterial effect on Staphylococcus aureus adhesion. Whether this method also influences the proliferation of bacteria has not been investigated so far. Furthermore, the effect is only limitedly investigated on the ossification processes. Therefore, the aim of this work is to investigate the antibacterial effect as well as the in vitro ossification process of PMEDM machined surfaces modified by integration of silver. In this study, we analyzed adhesion and proliferation of S. aureus in comparison to of surface roughness, silver content and layer thickness of the silver-integrated-PMEDM surfaces (N = 5). To test the in vitro ossification, human osteoblasts (SaOs-2) and osteoclasts (differentiated from murine-bone-marrow-macrophages) were cultured on the silver surfaces (N = 3). We showed that the attachment of S. aureus on the surfaces was significantly lower than on the comparative control surfaces of pure Ti-6Al-4V without incorporated silver, independently of the measured surface properties. Bacterial proliferation, however, was not affected by the silver content. No influence on the in vitro ossification was observed, whereas osteoclast formation was drastically reduced on the silver-modified surfaces. We showed that 1 to 3% of silver in the surface layer significantly reduced the adhesion of S. aureus, but not the proliferation of already attached bacteria. At the same time, no influence on the in vitro ossification was observed, while no osteoclasts were formed on the surface. Therefore, we state that PMEDM with simultaneous silver modification of the machined surfaces represents a promising technology for endoprostheses manufacturing to reduce infections while at the same time optimizing bone ingrowth

Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid related events, chronic opioid use, and increase the availability of opioids for unlawful diversion. Thus, decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits or worsened patient reported outcomes (PROs). The purpose of this quality improvement study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. Methods: Data originated from a statewide arthroplasty database (MARCQI). The database collects over 96% of all TJA performed in the state of Michigan, USA. Data was prospectively abstracted and included OMEs prescribed at discharge, readmissions, ED visits within 30 days and PROs. Data was collected one year before and after the creation of an opioid prescribing protocol that had decreased prescriptions by approximately 50% in opioid naive and tolerant patients. Trends were monitored using Shewhart control charts. 84,998 TJA over two-years were included. All groups showed a reduction in opioids prescribed. Importantly, no increased complications occurred concomitant to this reduction. No increases in ED visits or readmissions, and no decreases in KOOSJR/HOOSJR/PROMIS10 scores were noted in any of the groups. Using large data sets and registries can drive performance and improve quality. The MARCQI Postoperative opioid prescription recommendations and performance measures decreased total oral morphine equivalents prescribed over a large and diverse population by approximately 50% without decreasing PROs or increasing ED visits or hospital readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without an increase in complications across a large population

Background. Patients who undergo elective hip and knee arthroplasty often have multiple risk factors increasing their likelihood of suffering from hyponatraemia post operatively. Consequently suffering from hyponatraemia post elective hip and knee arthroplasty is common. Consequently we wanted to assess the occurrence of hyponatraemia in our elective arthroplasty unit, assess our effectiveness in managing this and importantly assess how its occurrence impacted on length of patient stay. Method. Retrospective analysis of elective hip and knee arthroplasty patients over a five month period. Pre-operative and post-operative sodium levels analysed and their grade measured using NICE reference ranges. In post-operative hyponatraemic patients blood results were analysed up until discharge. Discharge summaries were reviewed to assess communication between primary and secondary care. Length of admission calculated. Formal action plan developed in partnership with the anaesthetic department to improve future management. Results. 103 patients assessed. 24 (23%) suffered from post-operative hyponatraemia. 11 (48%) were discharged with a normalised sodium. 7 (29%) had documentation regarding their hyponatraemia in the discharge summary. 101 (98%) had a sodium drop post-operatively and 2 patients were hyponatraemic pre-operatively. Average length of stay for hyponatraemic hip patients was 5.00 days compared to 4.20 days for patients with normal sodium levels. Hyponatraemic post op knee patients had an average in hospital stay of 5.09 days compared to 4.13 days in knee patients with a normal post-operative sodium level. Conclusion. Hyponatraemia is common in the post-operative arthroplasty patient. In our unit it led to an increase in length of hospital stay. We believe the introduction of a structured post-operative oral rehydration regime with isotonic fluid would be a simple method to reduce occurrence post operatively. We feel standardising intra-operative fluid prescribing will reduce the likelihood of pushing patients into a post-operative hyponatraemic state. Finally we have introduced a hyponatraemia management flowchart to the department so ward based doctors can recognise and effectively manage hyponatraemic patients. If these measures are implemented length of stay in hospital can potentially be reduced

Abstract. Objectives. High tibial osteotomy for knee realignment is effective at relieving symptoms of knee osteoarthritis but the operation is surgically challenging. A new personalised treatment with simpler surgery using pre-operatively planned measurements from computed tomography (CT) imaging and 3D-printed implants and instrumentation has been designed and is undergoing clinical trial. The aim of this study was to evaluate the early clinical results of a preliminary pilot study evaluating the safety of this new personalised treatment. Methods. The single-centre prospective clinical trial is ongoing (IRCCS Istituto Ortopedico Rizzoli; IRB-0013355; ClinicalTrials.gov NCT04574570), with recruitment completed and all patients having received the novel custom surgical treatment. To preserve the completeness of the trial reporting, only surgical aspects were evaluated in the present study. Specifically, the length of the implanted osteosynthesis screws was considered, being determined pre-operatively eliminating intraoperative measurements, and examined post-operatively (n=7) using CT image processing (ScanIP, Synopsys) and surface distance mapping. The surgical time, patient discharge date and ease of wound closure were recorded for all patients (n=25). Results. Over the study period the average surgical time (skin incision to suture) reduced from 54 to 31 minutes (range: 17–62, n=25). It was noted that wound closure was easier than the conventional surgery due to the lower profile of the implant. Over seventy percent of patients were discharged day 2 post-op. The position, orientation and length of all screws matched the pre-operative configuration to within approximately 1mm. Conclusions. The early trial results are promising from a clinical perspective. It was evident that surgical time was saved because no intraoperative screw length measurements were required, and the use of custom instrumentation significantly reduced the surgical inventory. The reduced invasiveness and ease of surgery may contribute to faster patient recovery compared to conventional techniques. The full trial results will be reported later this year. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Abstract. Objective. To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Methods. This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59–82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2–4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results. The mean (range) duration of anaesthesia was 38.66 (20–60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130–210 and 75–145 mmHg, respectively (mean [range] drop, 74.13 [33–125] mmHg). Mean (range) propofol dose was 1.74 (1–3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20–50) min. The mean (range) postoperative recovery score (local scale, range 5–28 where lower values are superior) was 5.2 (5–8). The mean (range) length of stay was 8 (1–20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions. Our data demonstrate that rTSA under ISB-RA is safe, cost-effective and a potentially viable alternative for patients with multiple comorbidities. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours

An isolated avulsion fracture of the peroneus longus tendon is seldom seen and potentially can go undiagnosed using basic imaging methods during an initial emergency visit. If not managed appropriately it can lead to chronic pain, a reduced range of motions and eventually affect mobility. This article brings to light the effectiveness of managing such injuries conservatively. A 55 year old postman presented to clinic with pain over the instep of his right foot for 2 months with no history of trauma. Clinically the pain was confined to the right first metatarsophalangeal joint with occasional radiation to the calf. X-ray films did not detect any obvious bony injury. MR imaging revealed an ununited avulsion fracture of the base of the 1st metatarsal. The patient was subsequently injected with a mix of steroid and local anesthetic injections at the painful nonunion site under fluoroscopic guidance. Post procedure there was no neurovascular deficit. The patient was reviewed at three months and his pain score and functional outcome improved significantly. Moreover following our intervention, the Manchester Oxford Foot Questionnaire reduced from 33 to 0. At the one year follow up he remained asymptomatic and was discharged. The peroneus longus tendon plays a role in eversion and planter flexion of foot along with providing stabilization to arches of foot. The pattern of injury to this tendon is based on two factors one is the mechanism of insult, if injured, and second is the variation in the insertion pattern of peroneus longus tendon itself. There is no gold standard treatments by which these injuries can be managed. If conservative management fails we must also consider surgery which involves percutaneous fixation, or excision of the non-healed fracture fragment and arthrodesis. To conclude isolated avulsion fractures of peroneus longus tendon are rare injuries and it is important to raise awareness of this injury and the diagnostic and management challenges faced. In this case conservative management was a success in treating this injury however it is important to take factors such as patient selection, patient autonomy and clinical judgement into account before making the final decision