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

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

At our district general hospital in the southwest of England, around 694 total knee replacements (TKR) are performed annually. Since spring 2013 we have been using an enhanced recovery protocol for all TKR patients, yet we have neither assessed compliance with the protocol nor whether its implementation has made a discernible and measurable difference to the delivery of care in this patient population. Enhanced recovery after surgery (ERAS) protocols are multi-modal care pathways designed to aid recovery. They are based on best evidence and promote a multi-disciplinary approach which standardises care and encompasses nutrition, analgesia and early mobilisation throughout the pre, intra and postoperative phases of an inpatient stay. ERAS has been found to reduce length of stay (LOS), readmission rates and analgesic requirements following surgery. 1, 2, 3. Additionally, they have been shown to improve range of knee movement following TKR and improve mobility, patient satisfaction whilst reducing mortality and morbidity. 4, 5, 6. With these benefits in mind, we sought to investigate how well our trauma and orthopaedic department was complying with a local ERAS protocol and whether we could replicate the benefits seen within the literature. Following approval from our local audit office in September 2015 we generated a patient list of elective TKR patients under the same surgeon before and after the implementation of the ERAS protocol. Using discharge summaries and patient notes we extracted data for 39 patients operated on prior to the ERAS implementation between January 2011 and December 2012 and 27 patients following its introduction between January 2014 and September 2015. Data collected included length of stay, time to discharge from inpatient physiotherapy and use of analgesia and antiemetics. Alongside this we audited the compliance with all facets of the local ERAS protocol. There was no statistically significant difference between the 2 groups in terms of demographics or pre-operative morbidity. Overall compliance with the ERAS protocol was good but there was some variability, especially with intraoperative medication and type of anaesthesia which was likely due to individual patient factors. Compliance with postoperative analgesia was especially good with 93% of patients receiving all 4 suggested analgesics within the ERAS group. Length of stay (LOS) was significantly reduced by 0.5 days per patient (p value < 0.4). Overall compliance with the ERAS protocol was good but there was some variability, especially with intraoperative medication and type of anaesthesia, which was likely due to individual patient factors. Compliance with postoperative analgesia was especially good with 93% of patients receiving all suggested analgesics within the ERAS group. In terms of LOS, we found a statistically significant difference between the pre-ERAS and ERAS group of 0.5 days per patient. Within the context of our DGH, a 0.5 day reduction in LOS translates to around 350 bed days per year and a potential saving of GBP 105,000 (EUR 132,000) making this a clinically significant finding

Collection of new data for the Scottish hip fracture audit stopped in December 2008. The proposed standard of operating on 98% of all hip fractures within 24 hours of admission, subject to medical fitness and during safe operating hours should now be maintained. Methods. We prospectively collected data from 102 consecutive hip fracture patients documenting the patient's journey from admission to discharge from the orthopaedic ward to look at whether the standard had been maintained. Results. 50% of patients get to theatre 24hrs or earlier with 60% catheterised perioperatively.50% of patients were moved from the acute orthopaedic facility at a week with less than 20% of these getting back to their usual place of residence. 25% were still on the acute ward at two weeks and 3% died in the immediate post operative period. However, the number of co-morbidities did not seem to correlate with time to discharge. The majority of patients transferred to onward care moved to the geriatric rehabilitation ward within the hospital. Prioritisation of hip fracture patients on the trauma list needs to be continued along with improvements in the availability of rehabilitation beds. Pre-operative medical work up for patients with reversible illness and post-operative geriatric care will improve the outcomes for these frail patients