Escalating health care expenditure worldwide is driving the need for effective resource decision-making, with medical practitioners increasingly making complex resource decisions within the context of patient care. Despite raising serious legal and ethical issues in practice, this has attracted little attention in Australia, or internationally. In particular, it is unknown how orthopaedic surgeons perceive their obligations to the individual patient, and the wider community, when rationing care, and how they reconcile competing obligations. This research explores legal and ethical considerations, and resource allocation by Australian orthopaedic surgeons, as a means of achieving public health cost containment driven by macro-level policy and funding decisions. This research found that Australian orthopaedic surgeon's perceptions, and resource allocation decision making, can be explained by understanding how principles of distributive justice challenge, and shift, the traditional medical paradigm. It found that distributive justice, and challenges of macro level health policy and funding decisions, have given rise to two new medical paradigms. Each which try to balance the best interests of individual patients with demands in respect of the sustainability of the health system, in a situation where resources may be constrained. This research shows that while bedside rationing has positioned the medical profession as the gate keepers of resources, it may have left them straddling an increasingly irreconcilable void between the interests of the individual patient and the wider community, with the sustainability of the health system hanging in the balance

Primary Care Trusts across the country are being encouraged to ration service provision due to austerity measures. Obesity has been suggested as a rationing tool with poor clinical outcomes sited as justification. There is, however, a lack of evidence in the literature pertaining to clinical outcomes post elective foot and ankle surgery in patients with an increased Body Mass Index (BMI). All patients undergoing elective foot and ankle surgery at Queen Alexandra Hospital, Portsmouth are entered into a prospective database, which includes their BMI at time of assessment in clinic. From this, we analysed the notes of all patients with a BMI ≥30, excluding any not operated on between July 2007 and August 2009 or with a BMI of <30 at time of surgery, to determine whether there was an increased incidence of peri- or post-operative complications. Included in the study were 109 patients with a mean age of 54 (range 21 - 79). Female patients accounted for 63% of those notes reviewed and the mean BMI was 34 (range 30 - 50). A mixture of hindfoot and forefoot procedures were carried out (20 different procedures). Median length of stay was 0 nights (range 0 – 15 days). The causes for excessive length of stays (>4 nights) included a pre operative Lower Respiratory Tract Infection missed prior to intubation and the initiation of CPAP post operatively in a patient with known Obstructive Sleep Apnoea. We found 3 cases of post operative Venous Thrombo-embolism within 3 months of surgery and 1 proven wound infection in a non-insulin dependent diabetic patient. Also noted were 3 non-unions, all requiring further surgery. Based on our historical evidence of infective and thrombo-embolic complications in patients with a BMI <30, we conclude that peri- and post-operative complications in obese patients occur no more frequently than in a patient population with a BMI <30

Introduction. Computer navigation is a highly sophisticated tool in orthopedic surgery for component placement in total hip arthroplasty (THA). A number of recommendations have been published. Although Lewinnek's safe-zone is the best-known among these its significance is questioned in recent years since it addresses the acetabular socket only ignoring the femoral stem. Modern target definitions consider both socket and stem and provide well-defined recommendations for complementary component positioning. We present a new small-sized hand-held imageless navigation system that implies these targets and supports the surgeon in realizing the concept of combined anteversion and combined Target-Zone (cTarget- Zone) in THA and to control leg length and offset without altering the standard surgical work-flow and we report initial results. Methods. The targets for positioning the components of a total hip as expressed by radiographic cup inclination (cRI) and anteversion (cRA), stem antetorsion (sAT) and neck-to-shaft angle (sNSA) are determined for a specific prosthesis system using a computerized 3D-model. The optimizing goal is maximizing the size of the cSafe-Zone providing the largest target zone for an impingement-free prosthetic range of motion (pROM) in order to minimize the risk for dislocation in physiologic and combined movements. Independent parameters like head size, head-to-neck ration and also component orientations like cRI, cRA, sAT and sNSA were varied systematically and the optimal cSafe-Zone was computed in semi-automated batch runs. These optimized prosthesis-specific results were introduced into the software of the hand-held navigation system. This system measures leg length, offset, acetabular and femoral head centers intraoperatively. Results. In contrast to Lewinnek the outline of our cSafe-Zone is not rectangular but polygonal. Its size shows prosthesis-specific maxima. The largest zones are found for optimal sNSA values at 126° +/−4°, optimal ranges for cRI depend on head size and range from 44° to 36°, best sAT range from 10° to 18°, cRA from 18° to 25°. There is a prosthesis- specific linear correlation between sAT and cRA that denotes the combined anteversion. The target value for combined anteversion is not dependent on pelvic tilt but on sNSA. The hand-held navigation system displays all these orienting parameters as well as leg-length and offsets. Furthermore, it supports a virtual reduction work-flow thus accelerating surgery. All these information provide important decision-making details for the surgeon intraoperatively in real-time for augmented quality. Conclusion. The combined Target-Zone provides the basis for patient- and implant-specific control of prosthesis implantation. It includes all important positioning parameters of both total hip components and such gives well-defined individual recommendations for the targets. The new hand-held navigation system (Naviswiss) provides a smart way to direct and control the total hip implantation according to the best combined orientation considering also the concept of combined Safe-Zone. Such it prevents outliers, provides better safety and documents the surgical workflow and the final result of the surgery

Introduction. Total knee arthroplasty (TKA) is an excellent treatment for end-stage osteoarthritis of the knee. In Asian countries, the number of TKA performed has rapidly increased, and is expected to continue so with its 4.4 billion population and increasing life expectancy. Asians' knees are known to be kinematically different to Caucasians after TKA. Controversy exists as to whether multi-radius (MR) or the newer single-radius (SR) TKA has superior outcome. Studies regarding this have been largely based on Caucasian data with few small sample Asian data. Methods. This is a retrospective analysis of prospectively collected institutional registry data between 2004 and 2015. Outcomes of 133 single-radius (SR) (Scorpio NRG, Stryker) and 363 multi-radius (MR) (Nexgen LPS, Zimmer) primary TKA for primary osteoarthritis were compared. All TKA was performed or directly supervised by the senior author. Range of motion (ROM), Oxford Knee Score (OKS), SF-36 physical component score (SF36-PCS), SF-36 mental component score (SF36-MCS), Knee Society Function Score (KS-FS) and Knee Score (KS-KS) were recorded preoperatively and at 2 years post-operation. Results. The mean age in both groups were similar at 66 ± 8 years (p=0.66). Both groups were in majority female (71% and 70% females in SR and MR respectively, p=0.10) and ethnic Chinese (79% and 84% in SR and MR respectively, p=0.53). The preoperative ROM and outcome scores in both groups were similar. MR-TKA achieved significantly greater improvement over 2 years in terms of ROM (7.5º ± 18.2º vs. 3.5º ± 19.3º, p=0.04), KS-KS (49.0 ± 20.9 vs. 42.7 ± 21.1, p=0.01), OKS (17.4 ± 18.4, p=0.03), and SF36-PCS (17.1 ± 12.5, p=0.02). At 2-years follow up, MR-TKA group fared slightly better for SF36-PCS (48 ± 10 vs. 46 ± 10, p=0.032), but the absolute difference was only 2 points. There were no significant differences between SR-TKA and MR-TKA for ROM (115º ± 16º vs. 117º ± 16º, p=0.218), KS-KS (81 ± 16 vs. 85 ± 12, p=0.795), KS-FS (74 ± 21 vs. 75 ± 20, p=0.627), OKS (20 ± 7 vs. 18 ± 6, p=0.099), and SF36-MCS (56 ± 10 vs. 55 ± 10, p=0.324). There were larger proportions of MR-TKA patients who achieved the minimum clinically important difference (MCID) for OKS (95% vs. 82%, p<0.001) and SF36-PCS (67% vs. 55%, p=0.011) at 2-years follow-up. Logistic regression, controlling for all preoperative variables, showed SR-TKA is less likely to achieve MCID for OKS with an odds ratio of 0.275 (95% confidence interval: 0.114 – 0.663, p=0.004), and SF36-PCS with an odds ration of 0.547 (0.316 – 0.946, p=0.031). Discussion and conclusion. SR-TKA and MR-TKA produced similar outcomes, in concordance with current literature. However, SR-TKA has lower odds of achieving MCID in OKS and SF36-PCS, possibly due to its smaller improvement in flexion over 2 years. This subtle difference has a greater impact in the context of Asian patients due to the cultural practice of kneeling and/or squating

Dual mobility (DM) cups have 2 points of articulation – between the shell and the polyethylene (external bearing) and between the polyethylene and the femoral head (internal bearing). Primary motion occurs at the inner bearing while the outer bearing moves only in cases of extreme range of motion. Dislocation is a top reason for revision surgery and a major cost burden on society. Instability is also a significant problem after revision THA. While a variety of factors are important in hip stability, DM cups provide the safety of larger femoral heads in virtually all patients. These larger heads increase jump distance (the distance the femoral must travel before dislocation occurs) and they also increase ROM before impingement occurs. ROM and impingement are competing with each in primary THA. Especially in the flexible female with small bone structure, their increased ROM significantly increases the risk of impingement during physiologic activities. While not necessarily leading to dislocation, subluxation can occur resulting in pain. Further, ongoing impingement reduces the longevity of the PE. The ability to increase head size and head-neck ration with the DM cups in these patients is both an immediate and long-term advantage. PE thickness still can compromise the integrity of the liner. DM cups have thicker PE, especially in the smaller size cups than standard PE inserts. Even with the dual articulation, PE wear in DM cups are less, or at worst, equivalent to standard cups while at the same time providing adequate PE thickness for PE integrity and longevity

In Denmark the most common postoperative pathogen is S. aureus (1), sensitive to dicloxacillin. These bacteria can cause a postoperative infection despite using prophylactic antibiotics. Whether the tissue concentration reached is above the minimal inhibitory concentration (MIC) for the pathogens is unknown, and if lower than expected could result in a postoperative infection. Thus a trial was conducted, measuring the actual tissue concentration of dicloxacillin in human muscle and adipose tissue and compared these to the plasma concentration. MIC for dicloxacillin against S. aureus was determined using the broth macrodilution method. Six healthy male volunteers aging 25 to 27 years (body-mass-index; 20–28), were recruited. A CMA63 (Mdialysis, Stockholm, Sweden) catheter was placed in the subcutaneous tissue of the abdomen and in the rectus muscle of the thigh and the volunteers given 2 g dicloxacillin intravenously over 5 minutes. In 10 min intervals for the following 6 hours, samples from blood and Microdialysis fluid (flowrate 5 ml/min) were collected. Recovery was determined in vitro. Plasma was isolated from blood samples. The unbound dicloxacillin was isolated from plasma using filter plates (AcroPrep 30K Omega, Pall Corporation, US) centrifuged for 30 minutes at 1000 × g and 37°C. All samples were analyzed with High Performance Liquid Chromatography. MIC was determined to be 0.125 µg/ml. Average recovery was 73,7 % Maximum concentrations were reached in muscle tissue after a median of 0.5 hours and adipose tissue after 0.8 hours. The geometric mean ration (GMR) of AUC0-6h for adipose tissue compared to plasma was 0.32 [0.15–0.71]. GMR of AUC0-6h for muscle tissue compared to plasma and adipose tissue compared to muscle showed no statistically significant differences. The tissue concentrations were above MIC for 3.4 hours for adipose tissue and 4.1 hours for muscle tissue. The administration of prophylactic dicloxacillin should be given at least 30 minutes prior to incision to ensure maximum tissue concentrations at the onset of surgery. A second dose should be given after 3.4 hours in case of long surgery time. Since the dicloxacillin concentration reached in the adipose tissue is lower than in plasma, it should be investigated whether this difference is more prominent in adipose patients or patients with impaired peripheral circulation, since these patients are at a greater risk of postoperative infections

Introduction. MRSA colonisation increases the risk of acquiring a surgical site infection (SSI). Screening identifies such patients and provides them with suitable eradication treatment prior to surgery to decrease their risk of infection. Our aim was to determine whether receiving effective eradication therapy decreases the risk of infection in a patient previously screening positive for MRSA to that of someone screening negative. Methods. 1061 patients underwent elective total knee or hip replacement between March 2008 and July 2010. 1047 had pre-operative screening for MRSA and MSSA using nasal and perineum swabs. If positive for MRSA they underwent a course of eradication treatment and were required to provide a negative swab result prior to undertaking surgery. However during the time of this study those screening positive for MSSA did not receive eradication treatment. Surgical site infections were recorded and the rate of infection, relative risk and odds ration were calculated. Results. Overall 24 (2.26%) SSIs were observed post-operatively. There were 15 infections (1.78%) in 851 patients screening negative. Twenty-five patients (2.4%) screened positive for MRSA with 2 (8%) suffering a post-operative infection (Relative Risk 4.49, Odds Ratio 4.79). 181 patients (17.3%) screened positive for MSSA with 7 (3.9%) suffering an SSI (Relative Risk 2.12, Odds Ratio 2.22). The group screening positive for MRSA was at a statistically significantly higher risk of suffering a post-operative infection (p=0.03). Conclusion. An increased rate of post-operative infection is observed in patients screening positive for MRSA pre-operatively in spite of the administration of eradication therapy and the provision of a negative swab prior to surgery. A second group of patients screening positive for MSSA are also at a higher risk of post-operative infection than those that screen negative. Further work is required to establish if eradication therapy would decrease the SSI rate amongst this group

Aims

Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Introduction. The design and manufacture of patient specific implants at Hospital for Special Surgery (HSS) was started in the fall of 1976. The first implant designed and manufactured was an extra large total knee. This effort expanded to include all arthroplasty devices including hips, knees, shoulders and elbows along with fracture fixation devices. In the 1980s, the hospital was designing and manufacturing over 100 custom implants per year. This reduced significantly in the 1990s due to the introduction of modular total knee replacements. In 1996, HSS ceased manufacture due to rising costs and a greater regulatory burden. However, implants are still designed at HSS with manufacturing outsourced to commercial companies. Since 1976, the hospital has designed over 2500 implants. Patient Population. Currently, we design implants for ∼30 cases per year, hips, knees, and upper extremity devices (mainly elbow). We've seen an increase in acetabular revision cases over the last few years and now design about 10 revision acetabular components each year. Regulatory Challenges. Patient specific implants can be provided under a variety of regulatory pathways. Some have received 510(k) clearance as the manufacturer has provided a matrix of sizes; if the device fits within the matrix, the device can be supplied commercially. For devices that fall outside of the 510(k) pathway, the process is more complex. The 2012 FDA Safety and Innovation Act attempts to clarify the ambiguous nature of the prior statute in which the number of custom implants allowed of a specific type was unclear, setting the limit to 5 units per year of a particular device type. However, such a low number has led to rationing by the device manufacturers and even cessation of manufacturing of custom implants by one of the major companies. Another option available for obtaining patient specific implants is the Compassionate Use process. This process has been used, for example, when a patient needs a replacement of a part for a device that is not approved for use in the United States. The surgeon can request an exemption from FDA to use the part. To obtain this exemption, the surgeon must provide to FDA a justification letter explaining why using this device is in the best interests of the patient, a letter from a second surgeon who agrees with this conclusion, a letter from the implant company agreeing to manufacture the device, IRB approval from the institution where the device will be implanted, and consent from the patient. Though gathering this information can be time consuming, once the application is submitted, FDA has rapidly responded in providing exemptions (in less than two weeks). Conclusion. Even with the increase in modular components and the variety of devices in the commercial market, the need still exists for patient specific implants at HSS. The regulatory environment creates additional challenges to obtaining these devices. In spite of these challenges, we are able to provide the devices required for our patients

INTRODUCTION. Tamura et al. proposed a new friction test to measure the maturity of surface gel-hydration-like lubrication using MPC-polymer (2-Methacryloyloxyethyl phos -phorylcholine polymer) grafted surface as aãζζcounter surface. They suggested that the MPC-polymer grafted surface makes it possible to mimic in-vivo-like condition. Therefore, we can evaluate a lubricating ability of cartilage surface except for the possible effects of deformation resistance. By the way, reduction of lubricating ability of articular cartilage surface has much to do with pathogenesis of primary osteoarthritis. On the other hand, intraarticular injections of hyaluronic acid (HA) has been reported to have some clinical effect, however, it has not been clearly supported that HA restores a lubricating ability of injured cartilage surface. In the present study, the short-term effect of HA on injured cartilage surface's frictional performance was examined by the friction test using MPC-polymer grafted surface. METHODS. Articular cartilage specimens were taken from porcine femoral condyle and cut into 5 mm diameter plugs. Their surfaces were wiped with particular papers soaked in saline solution. Thereafter, these specimens were preserved with 1 mL volume of HA and saline solution for 0, 3, 6, 9 hours. The concentration of HA was 1% (w/v) in saline solution (MW=9×10. 5. Daltons; Seikagaku corp., Tokyo, Japan). Friction test was carried out in saline solution under a constant pressure of 1.5 Mpa and a relative sliding velocity of 0.8 mm/s, with MPC-polymer grafted glass as counter surface. Besides, superficial layer of cartilage tissue was histologically observed by two kinds of staining method: Toluidine blue (pH7.0) staining and Toluidine blue (pH2.5) staining Then, the Toluidine blue (pH7.0) staining intensity on superficial tissue was quantitatively analyzed. As follows, images of the stained cartilage specimens were analyzed by ImageJ. Measure RGB program was used to average out luminance values of blue in 2.7 μm square area of superficial layer and middle layer. The ration of the mean value in superficial layer and it in middle layer was defined as Toluidine blue (pH7.0) Index. RESULTS & DISCUSSION. Results of the friction test showed that the friction coefficients were inclined to decline with preservation time in both of the preservative solutions, and that the inclination was more remarkable in the HA-preserved case (Fig. 1). It suggests that the preservation with HA solution accelerate the recovery of friction coefficient in the short term. Superficial layer of cartilage tissues was positively stained with both Toluidine blue (pH7.0) and (pH2.5) staining, and only the (pH7.0) staining was changed with preservation time. As hyaluronan, mucoitin sulfate and chondroitin sulfate were stained by the toluidine blue (pH7.0), and hyaluronan was not stained by the toluidine blue (pH2.5), the toluidine blue (pH7.0) Index is thought to be rough indication for amount of surface hyaluronan concentration. As sown in Fig. 2, the toluidine blue (pH7.0) Index was inclined to increase with preservation time in both of the preservative solutions. This suggested that the decline of friction coefficient in HA-preserved specimen was not caused by histological repair but by adsorption of exogenous hyluronan

Aims

COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms.

Aims

Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with ‘COVID’ and ‘COVID-free’ hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic.

Aims

The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era.