The critical relationship between airborne microbiological contamination in an operating theatre and surgical site infection (SSI) is well known. The aim of this annotation is to explain the scientific basis of using settle plates to audit the quality of air, and to provide information about the practicalities of using them for the purposes of clinical audit. The microbiological quality of the air in most guidance is defined by volumetric sampling, but this method is difficult for surgical departments to use on a routine basis. Settle plate sampling, which mimics the mechanism of deposition of airborne microbes onto open wounds and sterile instruments, is a good alternative method of assessing the quality of the air. Current practice is not to sample the air in an operating theatre during surgery, but to rely on testing the engineering systems which deliver the clean air. This is, however, not good practice and microbiological testing should be carried out routinely during operations as part of clinical audit. Cite this article: Bone Joint J 2024;106-B(9):887–891

Aim. Peri-prosthetic joint infection is a serious and expensive complication of joint arthroplasty. Theatre discipline has infection prevention at its core with multiple studies correlating increased door opening with surgical site infection. The WHO, NICE and Philadelphia Consensus all advocate minimal theatre traffic. The Dutch Health Inspectorate consider >5 door openings per procedure excessive. Method. This prospective observational study over five weeks observed theatre door traffic during hip and knee arthroplasty within the eight laminar flow theatres at our institution. Two students attached to the department collected data. Half way through the study notices reminding people not to enter during arthroplasty were placed on the theatre doors. Results. The students observed 59 knees or hip arthroplasty 32 prior to notice's being placed on the theatre doors. The average number of door openings per case was 67 (25–130) prior to intervention and 70 (34–158) after intervention, although opening rates reduced from 1/min to 0.9/min (p=0.053). Reasons for door opening were drawing up medications, blood tests, delivery surgical equipment, general enquiries, staff breaks and “unknown” entries and exits. Conclusions. The rate of door opening was excessive and remained so after reminders were displayed. This deterioration in theatre discipline potentially has a significant negative impact on theatre hygiene and infection control. Individually wrapped components and screws along with the increasing component choice may have played some role in ‘legitimizing’ door opening. It will be challenging to reverse this behavioural trend but must be achieved

It was noted that in our spinal theatre a constant cause of delay was lack of an available radiographer. This work describes our solution to this problem by training theatre staff to operate the imaging equipment for the simple single plane images required in spinal surgery. Under the guidance of the trust's Radiation Protection Advisor to a training program for theatre staff was devised that encompassed the practical aspects of using the imaging equipment and the theoretical elements of radiation safety. All changes in practice complied with the radiation safety regulations IRR 99 and IRMER 2000. The trained staff now work as independent operators in the spinal theatre. They work to a ridge protocol and have to report directly to a Radiation Protection Supervisor (senior radiographer) at the end of each list so that the images taken and radiation dosage can be verified. Since the change of practice, the spinal theatre has been more efficient, performing up to one major case extra per list. The radiology department has benefited by having a radiographer freed to perform more complex procedures elsewhere. The operators have also commented on how they have found the whole process rewarding both professionally and personally. The training of theatre staff to operate the imaging equipment in our spinal theatre has been a successful endeavour and at present the trust is currently planning to expand the program to include other surgical fields such as urology and laparoscopic surgery

Purpose of Study. Discecomy is a common operation peformed for back pain at our hospital. We analysed the theatre register looking at demographic and health data for our patients to shed more light on this cases. Description of Methods. Entries in the spinal unit theatre registers from 2000–2012 were reviewed, and all patients undergoing discectomy for disc herniation recorded analysed regarding demographics and epidemiology. Summary Of Results. A total of 171 patients had operations in our theatres. Of these patients the large majority were females. The age distribution was 45 to 50 years. The lumbar spine was the commonest region operated, especially the lower lumbar spine. We had very low repeat operations from failed surgery or requiring herniation. Conclusion. Surgical registers are an important tool in understanding pathology in the communities we serve. We can track the type of patients treated and then plan appropriate intervention programmes. It also helps to follow-up patients and correlate outcomes, and we can use this data to correlate practices nationally and internationally. NO DISCLOSURES

We report the frequency of door-opening (“theatre traffic”) in orthopaedic operations at three metropolitan hospitals with different theatre policies. Published studies have correlated “theatre traffic” with airborne bacteria levels, which have been associated with raised wound infection rates. Hospital A had one scoliosis operation and two hip replacements, Hospital B had one knee revision and one knee replacement. Hospital C had one scoliosis operation. A second scoliosis operation was performed at Hospital C after “theatre traffic” education and door signage discouraging entry. One pair of surgeons performed the scoliosis operations and a different pair did the hips and knees. Hospital A is private and Hospitals B and C are public. The scoliosis operation in Hospital A (private) had an average door opening rate of 0.45/min compared to the same operation in Hospital C (public) with an average door opening rate of 1.0/min. The two hip replacements in Hospital A (private) had an average rate of 0.43/min and 0.51/min while the knee revision and knee replacement in Hospital B (public) had average rates of 0.91/min and 0.77/min respectively. Of concern is the total number of door openings that result from this rate of “theatre traffic”. In the Hospital C (public) operation the total number of door openings equalled 140 over the course of the scoliosis operation. In Hospital B the total number of door openings for the knee revision was 169 and the knee replacement was 72. In contrast, for Hospital A (private) the total number of door openings for the scoliosis operation was 73 and the two hip replacements equalled 30 and 36. The second study at Hospital C after staff education revealed a 35% decrease to 0.65/min. There was a difference in “theatre traffic” between private and public hospitals for the same or similar operations. Staff education and door signage dramatically reduced “theatre traffic” in Hospital C. Surgeons and theatre staff need to be aware of “theatre traffic” and its influence on infection rates

Aims. As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. Methods. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. Results. In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). Conclusion. Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886–892

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

The COVID-19 pandemic presented a significant impact on orthopaedic surgical operating. This multi-centre study aimed to ascertain what factors contributed to delays to theatre in patients with shoulder and elbow trauma. A retrospective cohort study of 621 upper limb (shoulder and elbow) trauma patients between 16/03/2020 and 16/09/2021 (18-months) was extracted from trauma lists in NHS Tayside, Highland and Grampian and Picture Archiving and Communication Systems (PACS). Median patient age =51 years (range 2-98), 298 (48%) were male and 323 (52%) female. The commonest operation was olecranon open reduction internal fixation (ORIF) 106/621 cases (17.1%), followed by distal humerus ORIF − 63/621 (10.1%). Median time to surgery was 2 days (range 0-263). 281/621 (45.2%) of patients underwent surgical intervention within 0-1 days and 555/621 patients (89.9%) had an operation within 14 days of sustaining their injury. 66/621 (10.6%) patients waited >14 days for surgery. There were 325/621 (52.3%) patients with documented evidence of delay to surgery; of these 55.6% (181/325) were due to amendable causes. 66/325 (20.3%) of these patients suffered complications; the most common being post-operative stiffness in 48.6% of cases (n=32/66). To our knowledge, this is the first study to specifically explore effect of COVID-19 pandemic on upper limb trauma patients. We suggest delays to theatre may have contributed to higher rates of post-operative stiffness and require more physiotherapy during the rehabilitation phase. In future pandemic planning, we propose dedicated upper-limb trauma lists to prevent delays to theatre and optimise patients’ post-operative outcomes

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499

The application of robotics in the operating theatre for knee arthroplasty remains controversial. As with all new technology, the introduction of new systems might be associated with a learning curve. However, guidelines on how to assess the introduction of robotics in the operating theatre are lacking. This systematic review aims to evaluate the current evidence on the learning curve of robot-assisted knee arthroplasty. An extensive literature search of PubMed, Medline, Embase, Web of Science, and Cochrane Library was conducted. Randomized controlled trials, comparative studies, and cohort studies were included. Outcomes assessed included: time required for surgery, stress levels of the surgical team, complications in regard to surgical experience level or time needed for surgery, size prediction of preoperative templating, and alignment according to the number of knee arthroplasties performed. A total of 11 studies met the inclusion criteria. Most were of medium to low quality. The operating time of robot-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is associated with a learning curve of between six to 20 cases and six to 36 cases respectively. Surgical team stress levels show a learning curve of seven cases in TKA and six cases for UKA. Experience with the robotic systems did not influence implant positioning, preoperative planning, and postoperative complications. Robot-assisted TKA and UKA is associated with a learning curve regarding operating time and surgical team stress levels. Future evaluation of robotics in the operating theatre should include detailed measurement of the various aspects of the total operating time, including total robotic time and time needed for preoperative planning. The prior experience of the surgical team should also be evaluated and reported. Cite this article: Bone Joint J 2020;102-B(4):407–413

Deep infection was identified as a serious complication in the earliest days of total hip arthroplasty. It was identified that airborne contamination in conventional operating theatres was the major contributing factor. As progress was made in improving the engineering of operating theatres, airborne contamination was reduced. Detailed studies were carried out relating airborne contamination to deep infection rates. In a trial conducted by the United Kingdom Medical Research Council (MRC), it was found that the use of ultra-clean air (UCA) operating theatres was associated with a significant reduction in deep infection rates. Deep infection rates were further reduced by the use of a body exhaust system. The MRC trial also included a detailed microbiology study, which confirmed the relationship between airborne contamination and deep infection rates. Recent observational evidence from joint registries has shown that in contemporary practice, infection rates remain a problem, and may be getting worse. Registry observations have also called into question the value of “laminar flow” operating theatres. Observational evidence from joint registries provides very limited evidence on the efficacy of UCA operating theatres. Although there have been some changes in surgical practice in recent years, the conclusions of the MRC trial remain valid, and the use of UCA is essential in preventing deep infection. There is evidence that if UCA operating theatres are not used correctly, they may have poor microbiological performance. Current UCA operating theatres have limitations, and further research is required to update them and improve their microbiological performance in contemporary practice. Cite this article: Bone Joint J 2018;100-B:1264–9

Increasing demands on our emergency department (ED) has resulted in the reduction of manipulations (MUAs) at the ‘front door’. We hypothesised that MUAs undertaken in theatre is rising with adverse financial implications. We performed a retrospective audit of operating lists in our institution from 2013–2016. Cost estimates were determined by our finance department. We used the NICE guidelines on management of non-complex fractures (NG38 Feb2016) as our audit standard. Data on 1372 cases performed over a three-month representative period during 2013–2016 was analysed. MUAs were 13% of the total theatre workload, with an annual increase in volume noted. Additionally, simple displaced distal radius fractures were routinely receiving a MUA (with or without K-wires) as a primary procedure in theatre. When this workload is combined it makes up 22% of the total theatre workload. Average theatre time was 57 minutes per case. Delays to definite procedure ranged from 8 to 120 hours. Cost of hospital admission and theatre utilisation was approximately £1000 per patient. Conversely, the cost of a MUA in the ED was estimated at £150. Given that we currently undertake around 15 manipulations in theatre a month, performing such work in the ED it would save approximately £153,000 a year to our health board. This audit identifies that MUAs of common orthopaedic injuries undertaken in theatre can lead too significant clinical and financial costs. We have proposed a strong financial argument to management for a twice weekly ‘manipulation list’ in the ED which is currently under review

Various studies have demonstrated that the necessity for reversal of Warfarin through the use of Vitamin K (Vit K) in neck of femur fracture patients introduces increased duration of stay and poorer outcomes as measured by operative complications and mortality rate. One reason for this delay may be the time latency between admission and the clinicians decision to investigate the INR. In this study we aim to explore the different causes of latency which contribute to a delay to theatre and ascertain whether point of care testing may negate this. We carried out an audit of a cohort of neck of femur fracture patients between 2012 and 2015. Between September 2011 and September 2013, paper notes of 25 patients who were on warfarin at the time of sustaining a Neck of femur fracture (NOF) was obtained within Addenbrookes hospital archives. An additional 80 patients records from the year 2015 were retrieved from EPIC digital records. Time intervals were recorded as follows (from time of A&E assessment by Medical doctor); Interval to orthopaedic specialist assessment, Interval to first INR order, Interval to first INR result seen by specialist, Interval to first Vit K prescribed, Interval to first Vit K given, Interval to Second INR ordered, Interval to second INR seen by specialist, Interval to operation time (as determined by time of team briefing). Analysis of the time intervals as a proportion of total time elapsed between A&E assessment and Time to theatre was performed. Point of care (POC) testing of INR on admission to A&E was introduced and a symmetrical time period was analysed for the same intervals. The latency generated by time taken for a NOF to be assessed by an orthopaedic specialist occupied 8.60% of the total time, the interval between ordering and recording an INR value accounted for 7.96% of time to theatre, the interval between an INR being recorded and subsequently seen by a clinician accounted for 13.4% of time to theatre, the time between orthopaedic specialist assessment and prescription of Vit K took up 7.83% of the total time and the percentage time between Vit K prescription and administration was 12.3%. The time between the first dose of Vit K prescription and arriving at theatre accounted for 76.1% of latency and the time between viewing a second INR and time to theatre occupied 33% of the total time. Following introduction of POC INR testing, there was a statistically significant decrease in time taken for warfarin reversal and consequently a reduction between time of admission to time to theatres. NOF patients who are on warfarin at time of injury introduces complexity to surgical management and planning for theatre. In our audit we demonstrate that causes of delay are distributed throughout the pathway of care and there are several stages. POC INR testing represents an effective method of reducing this latency and improves patient outcome

Aims. The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon’s cases and the total time spent in the operating theatre per day. Materials and Methods. A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. Results. A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days. Conclusion. The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081–1086

In patients with hand sepsis does bedside debridement compared to operating theatre debridement have similar clinical outcomes, hospital cost and time to discharge in a District Hospital setting in South Africa?. A case series of 130 adult patients presenting to a district level orthopaedic unit over 1 year with hand sepsis requiring debridement. All included patients were debrided at the bedside (i.e. the emergency room, ward, OPD) under wrist or digital block. Patients excluded from the study included patients with necrotising soft tissue infections that required debridement in theatre. A cost analysis was done based on operating theatre (OT) costs saved as defined by Samuel1 et al. If an average theatre time of 45 min is taken then the cost saved per patient is approximately R1500 and approximately R300000 for the patients included in the case series. This excludes ward and other hospital costs related to a longer hospital admission. The mean time to discharge for the included patients was 24 hours. This study suggests that bedside debridement can be a viable and cost effective option for selected cases of hand sepsis that can avoid the high cost and time associated with operating theatre debridement with similar outcomes. This has implications for the future treatment of hand sepsis in resource constrained settings were operating theatre time is not only very expensive but also very scarce

Aims. Hip hemiarthroplasty is a standard treatment for intracapsular proximal femoral fractures in the frail elderly. In this study we have explored the implications of early return to theatre, within 30 days, on patient outcome following hip hemiarthroplasty. Patients and Methods. We retrospectively reviewed the hospital records of all hip hemiarthroplasties performed in our unit between January 2010 and January 2015. Demographic details, medical backround, details of the primary procedure, complications, subsequent procedures requiring return to theatre, re-admissions, discharge destination and death were collected. Results. A total of 705 procedures were included; 428 Austin Moore and 277 Exeter Trauma Stems were used. A total of 34 fractures (in 33 patients) required early return to theatre within 30 days. Age, gender, laterality, time from admission to primary procedure, American Society of Anesthesiologists grade, and implant type were similar for those requiring early return to theatre and those who did not. Early return to theatre was associated with a significantly higher length of stay (mean 33.6 days (7 to 107) versus 18.6 days (0 to 152), p < 0.001), re-admission rate (38.2% versus 8.6%, p < 0.001), and subsequent revision rate (17.6% versus 1.3%, p < 0.001). We found no difference in level of care required on discharge or mortality. Conclusion. Proximal femoral fractures are common in the elderly population, with far-reaching medical and economic implications. Factors such as infection or dislocation may require early return to theatre, and this is associated with outcomes which may be both medically and economically detrimental. This illustrates the importance of avoiding early complications to improve longer term outcome. Return to theatre within 30 days is associated with longer length of stay, higher re-admission rate, and higher subsequent revision rate. It may be a useful short-term quality indicator for longer term outcome measures following hip hemiarthroplasty for intracapsular fractures of the proximal femur. Cite this article: Bone Joint J 2017;99-B:958–63

Aims. Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in temporary operating theatres. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates. Patients and methods. A total of 1223 primary hip and knee arthroplasties were performed between August 2012 and June 2013. A total of 539 (44%) were performed in temporary theatres. The two groups were matched for age, gender, body mass index and American Society of Anesthesiologists grade. Results. The deep infection rate for standard operating theatres was 0 of 684 (0%); for temporary theatres it was eight of 539 (1.5%) (p = 0.001). Conclusion. Use of a temporary operating theatre for primary hip and knee arthroplasty was associated with an unacceptable increase in deep infection. We do not advocate the use of these theatres for primary joint arthroplasty. Cite this article: Bone Joint J 2017;99-B:917–20

Patients who present with a fractured neck of femur (NOF) have a significant rate of morbidity and mortality. In 2011, the National Institute for Health and Care Excellence (NICE) published clinical guidelines in order to improve these rates. Within this guideline NICE state that surgery should be performed on all NOF fractures within 36 hours. Within ABMU Health board the 1000 Lives Campaign goes a step further and aims to operate on 90% of patients within 24 hours. This study investigates the effect of an additional NOF theatre list on compliance to these national guidelines. This retrospective study was performed between October-December 2013 and December-February 2015. The first period of data collection represents a daily trauma list whilst the second period allowed an additional NOF theatre list. Data was collected using the National Hip Fracture Database and the Trauma Theatre List. The number of patients meeting the national guidelines increased with the presence of an additional theatre list (75.19% v 60%). This represents a reduction to the average time to theatre of 4 hours and 30 minutes (29:47 v 34:17). The additional theatre list improved prioritisation of patients with NOF fractures on the list (29.46% v 13.33% listed first on list) and reduced the rate of cancellations (19.38 v 29.17%). During this study Morriston Hospital did not meet national guidelines, however an additional theatre list did significantly improve average time to theatre. This study highlights the significant impact a dedicated NOF fracture theatre list can have. Winner – Best Paper Award

The aim of this study was to investigate the effect of laboratory-based simulator training on the ability of surgical trainees to perform diagnostic arthroscopy of the knee. A total of 20 junior orthopaedic trainees were randomised to receive either a fixed protocol of arthroscopic simulator training on a bench-top knee simulator or no additional training. Motion analysis was used to assess performance objectively. Each trainee then received traditional instruction and demonstrations of diagnostic arthroscopy of the knee in theatre before performing the procedure under the supervision of a blinded consultant trainer. Their performance was assessed using a procedure-based assessment from the Orthopaedic Competence Assessment Project and a five-point global rating assessment scale. In theatre the simulator-trained group performed significantly better than the untrained group using the Orthopaedic Competence Assessment Project score (p = 0.0007) and assessment by the global rating scale (p = 0.0011), demonstrating the transfer of psychomotor skills from simulator training to arthroscopy in the operating theatre. This has implications for the planning of future training curricula

Background. Best practice tariff (BPT) for hip fracture was introduced in April 2010, offering financial incentive to encourage trusts to implement best practice and improve quality of care. This equates to £1335. An early indicator of a patient's outcome is the time to operation from admission, with best practice targets of <36hours as a key marker of quality. As well as being detrimental to patient experience, delays in the time to operation have clear links to increased mortality rates. Method. We performed a retrospective audit of neck of femur fracture patients from 01.01.14 for 12 months, investigating time to theatre, other BPT targets, and attainment of BPT. A cost analysis was also performed from financial data. Results. Of 471 patients, 461 operations were performed. Our median time to surgery was 24.9 hours. 140 (30%) of patients were not operated on within 36 hours. 134 of these (96%) would have met the BPT had they been operated on within the 36 hour target i.e. all other BPT targets were met. This equates to a loss of £178,890. Conclusions. We achieved time to theatre target for 70% of patients (compared to 71.7% reported nationally), which is suboptimal. A solution is to dedicate more theatre time to hip fractures on theatre lists or lengthened daily trauma lists. However, at £1200 per hour running theatre, this on its own would not be cost effective. Improved theatre utilisation by 10% can potentially save the trust £3,960,000 in a year. We have put forward plans to audit our current theatre usage, potentially improving utilisation and efficiency (e.g. planned hip fracture first on list from previous day to avoid start delay). Additionally we have introduced a “Time of breach” onto our trauma board to concentrate attention on this part of best practice. Level of Evidence. Level 3