Aims. Due to widespread cancellations in elective orthopaedic procedures, the number of patients on waiting list for surgery is rising. We aim to determine and quantify if disparities exist between inpatient and day-case orthopaedic waiting list numbers; we also aim to determine if there is a ‘hidden burden’ that already exists due to reductions in elective secondary care referrals. Methods. Retrospective data were collected between 1 April 2020 and 31 December 2020 and compared with the same nine-month period the previous year. Data collected included surgeries performed (day-case vs inpatient), number of patients currently on the orthopaedic waiting list (day-case vs inpatient), and number of new patient referrals from primary care and therapy services. Results. There was a 52.8% reduction in our elective surgical workload in 2020. The majority of surgeries performed in 2020 were day case surgeries (739; 86.6%) with 47.2% of these performed in the independent sector on a ‘lift and shift’ service. The total number of patients on our waiting lists has risen by 30.1% in just 12 months. As we have been restricted in performing inpatient surgery, the inpatient waiting lists have risen by 73.2%, compared to a 1.6% rise in our day-case waiting list. New patient referral from primary care and therapy services have reduced from 3,357 in 2019 to 1,722 in 2020 (49.7% reduction). Conclusion. This study further exposes the increasing number of patients on orthopaedic waiting lists. We observed disparities between inpatient and day-case waiting lists, with dramatic increases in the number of inpatients on the waiting lists. The number of new patient referrals has decreased, and we predict an influx of referrals as the pandemic eases, further adding to the pressure on inpatient waiting lists. Robust planning and allocation of adequate resources is essential to deal with this backlog. Cite this article: Bone Jt Open 2021;2(7):530–534

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. Methods. A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory. Results. A total of 888 patients responded. Better health, pain, and mood scores were reported by upper limb patients. The longest waiters reported better health but poorer mood and anxiety scores. Overall, 82% had tried self-help measures to ease symptoms; 94% wished to proceed with their intervention; and 21% were prepared to tolerate deferral. Qualitative analysis highlighted the overall patient mood to be represented by the terms ‘understandable’, ‘frustrated’, ‘pain’, ‘disappointed’, and ‘not happy/depressed’. COVID-19-mandated health and safety measures and technology solutions were felt to be implemented well. However, patients struggled with access to doctors and pain management, quality of life (physical and psychosocial) deterioration, and delay updates. Conclusion. This is the largest study to hear the views of this ‘hidden’ cohort. Our findings are widely relevant to ensure provision of better ongoing support and communication, mostly within the constraints of current resources. In response, we developed a reproducible local action plan to address highlighted issues. Cite this article: Bone Jt Open 2021;2(8):583–593

Currently 180 days is the target maximum wait time set by all Canadian provinces for elective joint replacement surgery. In Nova Scotia however, only 34% of Total Knee Arthroplasties (TKA) and 51% of Total Hip Arthroplasties (THA) met this benchmark in 2017. Surgery performed later in the natural history of disease is shown to have significant impact on pain, function and Health related Quality of Life at the time of surgery and potentially affect post-operative outcomes. The aim of this study is to describe the association between wait time and acute hospital Length of Stay (LOS) during elective hip and knee arthroplasty in province of Nova Scotia. Secondarily we aim to describe risk factors associated with variations in LOS. Data from Patient Access Registry Nova Scotia (PAR-NS) was linked to the hospital Discharge Access Database (DAD) for primary hip and knee arthroplasty spanning 2009 to 2017. There were 23,727 DAD observations and 21,329 PARNS observations identified. Observations were excluded based on missing variables, missing linkages, revision status and emergency cases. Percentage difference in LOS, risk factors and outcomes were analyzed using Poisson regression for those waiting more than 180 days compared to those waiting equal or less than 180 days. For primary TKA, 11,833 observations were identified with mean age of 66 years, mean wait time of 348 days and mean LOS of 3.6 days. After adjusting for controls, patients waiting more than 180 days for elective TKA have a 2.5% longer acute care LOS (p < 0.028). Risk factors identified for prolonged LOS are advanced age, female gender, higher surgical priority indicator, required blood transfusion, dementia, peptic ulcer disease, cerebrovascular disease, heart failure, chronic kidney disease, malignancy, ischemic heart disease and diabetes. Factors associated with decreased LOS are surgical year, use of local anesthetic, peripheral location of hospital and admission to hospital from home. For primary THA, 6626 observations were identified with mean age of 66 years, mean wait time of 267 days and mean LOS of 4 days. Patients waiting more than 180 days for THA did not show a statistically significant association with LOS. Risk factors and protective factors are the same with exception of CVD and use of local anesthetic. Our findings suggest a positive and statistically significant association for patients waiting more than 180 days for TKA and longer acute care LOS. Longer LOS may be due to deteriorating health status while placed on a surgical waitlist and may represent a delayed and indirect cost to the patient and the healthcare system. Ultimately with projected increase in demand for elective joint replacement surgeries, our findings are aimed to inform physicians and policy makers in management of surgical waitlist efficiency and cost effectiveness. For any reader inquiries, please contact . shahriar-s@hotmail.com

Aim. The aim of this study is to evaluate the value of inflammatory parameters normalization and/or increased time between stages necessary in predicting healing and preventing infection recurrence. Method. We retrospectively studied all cases of total hip and knee arthroplasty that underwent revision for infection in our institution between 2011 and 2014. We revised the clinical and laboratory information from 55 patients (27 hips: 28 knees) with a mean age of 68 years. The average values before the first stage were 88.6 mm/h (15–134) and 59.1 mg/L (2–279) for the erythrocyte sedimentation rate(ESR) and C-reactive protein(CRP) serum respectively. In 10 cases (18.2%) it was not possible to perform the second stage. Moreover, in the other 45 cases of re- arthroplasty, the mean follow-up was 32 months (1 year). Results. Among the 45 cases in which the two stages were completed, only 3(6.7%) had recurrence of infection. No significant differences between the two groups regarding the absolute values of ESR and/or CRP before the second stage or variation between the first and second stage of revision were seen. Interestingly, in the group of cases where there was recurrence of infection, the average values of CPR and ESR before the second stage were even lower: 6.0 vs. 11.8 mg/L and 19.3 vs. 28.7 mm/h respectively. Analysing the temporal influence on the recurrence rate, we find that the 17 cases in which the second stage was performed in less than 90 days, there were no recurrences. The three recurrences occurred in the group of patients with an interval > 90 days (3/28 – 11%). Conclusions. Knowing when to perform the second stage safely is one of the most difficult decision in two-stage procedures. Tradition mandates waiting for complete normalization of inflammatory parameters sometimes for a long period of time in order to identify cases at risk. However, this approach involves an increased disability time and significant quality of life decrease for patients and lacks adequate scientific support. This study confirms that this traditional approach does not increase the chances of success. The authors argue that there is no advantage in waiting for the normalization of inflammatory parameters before advancing to the second stage time and this practice should be definitively abandoned

Aim

An instrumented blood culture system automatically flags when growth within the culture medium has been detected (‘work in progress’), and subsequently when the organism has been identified.

We explore using this data to switch patients to oral therapy within 72 hours post-surgery, reducing costs and improving antimicrobial stewardship.

Most acetabular defects can be treated with a cementless acetabular cup and screw fixation. However, larger defects with segmental bone loss and discontinuity often require reconstruction with augments, a cup-cage, or triflange component – which is a custom-made implant that has iliac, ischial, and pubic flanges to fit the outer table of the pelvis. The iliac flange fits on the ilium extending above the acetabulum. The ischial and pubic flanges are smaller than the iliac flange and usually permit screw fixation into the ischium and pubis. The custom triflange is designed based on a pre-operative CT scan of the pelvis with metal artifact reduction, which is used to generate a three-dimensional image of the pelvis and triflange component. The design of the triflange involves both the manufacturing engineer and surgeon to determine the most appropriate overall implant shape, screw fixation pattern, and cup location and orientation.

A plastic model of the pelvis, and triflange implant can be made in addition to the triflange component to be implanted, in order to assist the surgeon during planning and placement of the final implant in the operating room. A wide surgical exposure is needed including identification of the sciatic nerve. Proximal dissection of the abductors above the sciatic notch to position the iliac flange can risk denervation of the abductor mechanism. Blood loss during this procedure can be excessive.

Implant survivorship of 88 to 100% at 53-month follow-up has been reported. However, in a series of 19 patients with Paprosky type 3 defects, only 65% were considered successful. The custom triflange also tends to lateralise the hip center which may adversely affect hip mechanics. The use of a triflange component is indicated in cases with massive bone loss or discontinuity in which other reconstructive options are not considered suitable.

Although the introduction of ultraporous metals in the forms of acetabular components and augments has substantially improved the orthopaedic surgeon's ability to reconstruct severely compromised acetabuli, there remain some revision THAs that are beyond the scope of cups, augments, and cages. In situations involving catastrophic bone loss, allograft-prosthetic composites or custom acetabular components may be considered. Custom components offer the potential advantages of immediate, rigid fixation with a superior fit individualised to each patient. These custom triflange components require a pre-operative CT scan with three-dimensional (3-D) reconstruction using rapid prototyping technology, which has evolved substantially during the past decade. The surgeon can fine-tune exact component positioning, determine location and length of screws, modify the fixation surface with, for example, the addition of hydroxyapatite, and dictate which screws will be locked to enhance fixation. The general indications for using custom triflange components include: (1) failed prior salvage reconstruction with cage or porous metal construct augments, (2) large contained defects with possible discontinuity, (3) known pelvic discontinuity, and (4) complex multiply surgically treated hips with insufficient bone stock to reconstruct using other means. The general indications for using custom triflange components include: (1) failed prior salvage reconstruction with cage or porous metal construct augments, (2) large contained defects with possible discontinuity, (3) known pelvic discontinuity, and (4) complex multiply surgically treated hips with insufficient bone stock to reconstruct using other means.

We previously reported on our center's experience with 23 patients (24 hips) treated with custom triflange components with minimum 2-year follow-up. This method of reconstruction was used in a cohort of patients with Paprosky Type 3B acetabular defects, which represented 3% (30 of 955) of the acetabular revisions we performed during the study period of 2003 to 2012. At a mean follow-up of 4.8 years (range, 2.3–9 years) there were 4 subsequent surgical interventions: 2 failures secondary to sepsis, and 1 stem revision and 1 open reduction internal fixation for periprosthetic femoral fracture. There were 2 minor complications managed nonoperatively, but all of the components were noted to be well-fixed with no obvious migration or loosening observed on the most recent radiographs. Harris hip scores improved from a mean of 42 (SD ± 16) before surgery to 65 (SD ± 18) at latest follow-up (p<0.001). More recently, we participated in a multi-center study of 95 patients treated with reconstruction using custom triflange components who had a mean follow-up of 3.5 years. Pelvic defects included Paprosky Type 2C, 3A, 3B and pelvic discontinuity. Concomitant femoral revision was performed in 21 hips. Implants used a mean of 12 screws with 3 locking screws. Twenty of 95 patients (21%) experienced at least one complication, including 6% dislocation, 6% infection, and 2% femoral-related issues. Implants were ultimately removed in 11% of hips. One hip was revised for possible component loosening. Survivorship with aseptic loosening as the endpoint was 99%,

Custom acetabular triflange components represent yet another tool in the reconstructive surgeon's armamentarium. These devices can be helpful in situations of catastrophic bone loss, achieving reliable fixation. Clinical results are inferior to both primary THA and more routine revision THA. Patients and surgeons should be aware of the increased complications associated with these complex hip revisions.

Acetabular defects often result from osteolysis with or without component loosening. The goals of acetabular reconstruction in the face of significant rim or column deficiencies are to create a stable acetabular construct, which will facilitate acetabular component biologic fixation and long-term stability. Four reconstructive techniques have emerged to treat these defects: 1) Large allografts, 2) Cup / Cage constructs, 3) Metallic augments and uncemented hemispherical cups, and 4) Triflange custom implants.

While all of these techniques have demonstrated success, we have elected to pursue triflange implants to improve fixation on host bone, allow modular liner options, facilitate enhanced fixation surfaces, match patient complex geometries, opportunity to utilise locking screws, and possibly reduce surgical operative time. Furthermore, screw paths and lengths can be planned pre-operatively along with custom pelvic model generation which makes surgical exposure and reconstructive more understandable.

Multiple studies have shown excellent survivorship in series of the most challenging acetabular reconstructions.

Introduction

The Two Week Waiting Time Standard, which requires that patients with suspected cancer referred by general practitioners should be seen within 2 weeks, was introduced in 2000. We reviewed the performance of this standard with regards to proportion of patients seen and tumour detection rates.

Aim. To investigate the impact of waiting for surgical treatment for bone and joint infection (BJI) on patient self-reported quality of life (QoL). Method. Patients presenting to clinic between January 2019 and February 2020 completed the EuroQol EQ-5D-5L questionnaire. Patients were divided into three groups: surgery performed; on the waiting list for surgery; or decision for non-operative management. All patients were followed-up for 2 years. The EQ-index score was calculated and change from presentation to 1-year and 2-year follow-up was compared across the 3 groups. Mortality at final follow-up was measured in all groups. Results. 188 patients were included. Of these, 98 had an operation performed, 50 were on the waiting list for surgery but did not receive an operation and 40 were treated non-operatively. At presentation, all three groups had similar EQ-5D-5L index scores (surgery:0.412 SD0.351; waiting list:0.510 SD0.320; non-operative management: 0.467 SD0.354; p=0.269). There was a significant improvement in QoL in patients who underwent surgery when compared to their pre-operative state (mean increase of EQ-index score +0.241 in the first year (SD0.333, p<0.001) and +0.259 (SD0.294, p<0.001) in the second year. Patients on the waiting list for surgery had a small time-dependent decrease in EQ-index score at 1 year (−0.077, SD0.282, p=0.188) and 2 years (−0.140, SD0.359, p=0.401). Patients treated non-operatively had similar changes in EQ-index scores at 1 year (−0.052, SD0.309, p=0.561) and 2 years (−0.146, SD 0.234, p=0.221). Patients who had surgery had significantly better QoL at 2-years after treatment compared to other groups (mean EQ-index scores: surgery performed 0.671 vs. waiting list 0.431, p<0.001; surgery performed vs. non-operative management 0.348, p<0.001). Mortality in the operated group was 3.1%, which was similar to patients who were on the waiting list for surgery (6.5%, p=0.394) but lower than patients who were non-operatively managed (14.7%, p=0.014). Conclusions. The Covid-19 pandemic created long waiting times for some patients. Selecting patients with BJI who can safely wait for surgery is difficult. QoL for patients with BJI deteriorates over time if surgery is delayed or not performed. When patients decline surgery, they should be counselled that their QoL is likely to be impaired over time. The relationship between waiting time and mortality merits further study

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. Methods. Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’. Results. The least deprived cohort were older (mean 65.95 years (SD 13.33)) than the most deprived (mean 59.48 years (SD 13.85)). Mean symptom duration was lower in the least deprived areas (68.59 months (SD 112.26)) compared to the most deprived (85.85 months (SD 122.50)). Mean pain visual analogue scores (VAS) were poorer in the most compared to the least deprived cohort (7.11 (SD 2.01) vs 5.99 (SD 2.57)), with mean mood scores also poorer (6.06 (SD 2.65) vs 4.71 (SD 2.78)). The most deprived areas exhibited lower mean quality of life (QoL) scores than the least (0.37 (SD 0.30) vs 0.53 (SD 0.31)). QoL findings correlated with health VAS and Generalized Anxiety Disorder 2-item (GAD2) scores, with the most deprived areas experiencing poorer health (health VAS 50.82 (SD 26.42) vs 57.29 (SD 24.19); GAD2: 2.94 (SD 2.35) vs 1.88 (SD 2.07)). Least-deprived patients had the highest self-reported activity levels and lowest sedentary cohort, with the converse true for patients from the most deprived areas. Conclusion. The most deprived patients experience poorer physical and mental health, with this most adversely impacted by lengthy waiting list delays. Interventions to address inequalities should focus on prioritizing the most deprived. Cite this article: Bone Jt Open 2022;3(10):777–785

Aims. The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers. Methods. A model of referral, waiting list, and eventual surgery was created and calibrated using historical data from NHS England (April 2017 to March 2020) and was used to investigate the possible consequences of unmet demand resulting from fewer patients entering the treatment pathway and recovery strategies. NJR data were used to estimate the deficit of hip and knee arthroplasty by August 2020 and NHS tariff costs were used to calculate the financial burden. Results. By November 2020, the elective waiting list in England is predicted to be between 885,286 and 1,028,733. If reduced hospital capacity is factored into the model, returning to full capacity by November, the waiting list could be as large as 1.4 million. With a 30% increase in productivity, it would take 20 months if there was no hidden burden of unreferred patients, and 48 months if there was a hidden burden, to return to pre-COVID-19 waiting list numbers. By August 2020, the estimated deficits of hip and knee arthroplasties from NJR data were 18,298 (44.8%) and 16,567 (38.6%), respectively, compared to the same time period in 2019. The cost to clear this black log would be £198,811,335. Conclusion. There will be up to 1.4 million patients on elective orthopaedic waiting lists in England by November 2020, approximate three-times the pre-COVID-19 average. There are various strategies for recovery to return to pre-COVID-19 waiting list numbers reliant on increasing capacity, but these have substantial cost implications. Cite this article: Bone Jt Open 2021;2(2):103–110

Orthopaedic paediatric deformities, globally, are often corrected later than initial identification due to resource constraints (bed availability, investigative modalities, surgical skill set). The study aims to analyse experiences and challenges met with running a flagship scoliosis surgery week in a tertiary public health care facility, with the goal of reducing patient waiting time on the waiting list. In this retrospective study, patients from an existing deformity correction waiting list were selected for a 5 day scoliosis surgery week. Investigations relevant to clinical findings were carried out and patients were scheduled on a “one patient per day” surgery list. Inclusion criteria was any patient with adolescent idiopathic scoliosis of varying degree that was symptomatic. Exclusion criteria was any other deformity of any age. Outcomes measured include: Administrative hurdles (obtaining funding, organising ward and ICU beds, getting nursing staff), Surgical challenges (severity of the curve, intraoperative time, approach chosen) and perioperative management (anaesthesia, pain management, cost of equipment) will be looked at to better define the experiences and challenges. All scheduled surgeries were completed. This meant more cases were carried out than what was done in the last 2 years at the facility combined. Lack of Nursing staff availability and few ICU beds delayed starting cases. Anterior fusion took a shorter surgical time in comparison to posterior and cost far less to carry out owing to deformity severity. Intra and post operative management also varied due to daily changes in theatre staff and a lack of standardized protocols. Running a scoliosis surgery week helps to lower the waiting time for deformity correction in public health care facilities. Pre organising resources results in more successful outcomes and an increase in the number of cases done over a shorter period

Aboriginal and Torres Strait Islander (ATSI) people have higher elective wait times compared to non-ATSI population in Australia. The Murrumbidgee Local Health District (MLHD) in southern New South Wales services 125,242km. 2. and a population of 287,000 people, with 5.8% identifying as ATSI. The aim of this study is to investigate the arthroplasty waitlist time of ATSI, and the impact of rurality on joint replacement, within the MLHD and compared to the Australian national data. 1435 consecutive patients who underwent elective hip or knee arthroplasty from July 2018 to June 2021 were collated. Demographics, ATSI status, total wait time, readiness for care, and rurality were collected. Rurality was measured by distance from the arthroplasty hospital within MLHD. 1,151 patients were included after excluding patients with missing data or underwent emergent surgery. Within this cohort, 72 of 1,151 patients (6.2%) identified as ATSI. ATSI were younger than non-ATSI population (60.7y v 66.4y). There was no difference between Aboriginal status and ready for care wait time (368.0 v 349.9 days; p=0.116). The rurality of the groups was similar and increasing rurality did not affect total wait time (ATSI 103.1km v 98.6km; p=0.309). There was no difference in total or not-ready-for-care time between the groups (p: 0.68). Findings suggest equitable access to joint arthroplasty in the MLHD between ATSI and non-ATSI populations, which differs from the national experience. There is no significant difference between rurality and accessibility in the MLHD. This may be a result of the increased focus to ATSI and rural health within the district. A state or national study would be beneficial in identifying high performing regions and reviewing processes that enable equitable and accessible care. MLHD provides equitable access to arthroplasty surgery between ATSI and non-ATSI, as well as patients from rural areas within the LHD

Hip and knee joint arthroplasty wait list has been getting outrageously long in South Africa with some tertiary hospital reporting more than 5 years of waiting time. This has been further compounded by covid 19 pandemic. There is plateau of ideas on how best to address the backlogs in high volume tertiary centers, with catchup list, out reach program, private partnership seeming unsustainable. We sought to look for sustainable solution to the problem and we looked not far but inside the system. Method. Triggered by the fire that engulfed part of the hospital, we found ourself refuged at the sister tertiary hospital with no access to theatre time. We visited districts hospitals within the cluster and discovered state of the art facility underutilized. We presented a plan to establish a satellite arthroplasty center which was greatly embraced by the management. We partnered with the trade to setup an arthroplasty service in this district hospital. Employed 3 retired nurses and 2 parttime anaesthetist all on yearly contract. We developed pathways for patient selection according to American Society of Anaesthesiologist(ASA). 232 total joint arthroplasties were performed in 15-month, 33%Hips and 67%Knees. The average hospital stay was 2,3± 2days. We had 1 mortality(# NOF) and 2 cases of PJI treated successfully with debridement antibiotic and implant retention. We had 5 cases of intraoperative calcar femur fracture managed with cables and all stable at 6weeksand 3month. Over 76% of the cases were performed by fellows as the primary surgeons. Primary hip and knee total joint replacement can be safely performed in a district hospital. Employing motivated retired staff was key to the success of this project. Fellowship trainees performed most of the operations. We suggest that other academic hospitals with long waiting list can look at emulating this model within their district

The progressive painful and disabling predicament of patients with severe osteoarthritis awaiting a total hip or knee arthroplasty (THA/TKA) results in a decline in muscle mass, strength and function also known as Sarcopenia. We conducted a cross-sectional, prospective study of patients on the waiting-list for a THA/TKA in the South Australian public healthcare system and compared the findings to healthy participants and patients newly referred from their general practitioners. Participants with a history of joint replacements, pacemakers and cancers were excluded from this study. Outcomes of this study included (i) sarcopenia screening (SARC-F ≥4); (ii) sarcopenia, defined as low muscle strength (hand grip strength M<27kg; F<16kg), low muscle quality (skeletal muscle index M<27%, F<22.1%) and low physical performance (short physical performance battery ≤8). Additional outcomes include descriptions of the recruitment feasibility, randomisation and suitability of the assessment tools. 29 healthy controls were recruited; following screening, 83% (24/29) met the inclusion criteria and 75% (18/24) were assessed. 42 newly referred patients were recruited; following screening, 67% (30/45) met the inclusion criteria and 63% (19/30) were assessed. 68 waiting list patients were recruited; following recruitment, 24% (16/68) met the inclusion criteria and 75% (12/16) were assessed. Preliminary data shows increasing waiting time is associated with higher SARC-F scores, lower hand grip strength and lower muscle quality. As a pilot study, preliminary data demonstrate that: (1) study subjects’ willingness to participate will enable a larger study to be conducted to establish the prevalence of sarcopenia and the diagnostic cut-off points for this patient group. (2) SARC-F is a suitable tool to screen for sarcopenia. (3) There is a positive correlation between waiting time for a THA/TKA and sarcopenia

Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget. In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears. In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model. Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits. The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects

Extended patient waiting lists for assessment and treatment are widely reported for planned elective joint replacement surgery. The development of regionally based Elective Orthopaedic Centres, separate from units that provide acute, urgent or trauma care has been suggested as one solution to provide protected capacity and patient pathways. These centres will adopt protocolised care to allow high volume activity and increased day-case care. We report the plan to establish a new elective orthopaedic centre serving a population of 2.4 million people. A census conducted in 2022 identified that 15000 patients were awaiting joint replacement surgery with predictions for further increases in waiting times. The principle of care will be to offer routine primary arthroplasty surgery for low risk (ASA 1 and 2) patients at a new regional centre. Pre-operative assessment and preparation will be undertaken digitally, virtually and/or in person at local centres close to the where patients live. This requires new and integrated pathways and ways of working. Predicting which patients will require perioperative transfusion of blood products is an important safety and quality consideration for new pathways. We reviewed all cases of hip and knee arthroplasty surgery conducted at our centre over a 12-month period and identified pre-operative patient related predictive factors to allow us to predict the need for the perioperative transfusion of blood products. We examined patient sex, age, pre-operative haemaglobin and platelet count, use of anti-coagulants, weight and body mass index to allow us to construct the Imperial blood transfusion tool. We have used the results of our study and the transfusion tool to propose the patient pathway for the new regional elective orthopaedic centre which we present

Aims. The primary aim was to assess the rate of patient deferral of elective orthopaedic surgery and whether this changed with time during the coronavirus disease 2019 (COVID-19) pandemic. The secondary aim was to explore the reasons why patients wanted to defer surgery and what measures/circumstances would enable them to go forward with surgery. Methods. Patients were randomly selected from elective orthopaedic waiting lists at three centres in the UK in April, June, August, and September 2020 and were contacted by telephone. Patients were asked whether they wanted to proceed or defer surgery. Patients who wished to defer were asked seven questions relating to potential barriers to proceeding with surgery and were asked whether there were measures/circumstances that would allow them to go forward with surgery. Results. There was a significant decline in the rate of deferral for surgery from April (n = 38/50, 76%), June (n = 68/233, 29%), to August (n = 6/50, 12%) and September (n = 5/100, 5%) (p < 0.001). Patients wishing to defer were older (68 years (SD 10.1) vs 65 (SD 11.9)), more likely to be female (65% (44/68) vs 53% (88/165)) and waiting for a knee arthroplasty (65% (44/68) vs 41% (67/165); p < 0.001). By September 2020, all patients that deferred in June at one centre had proceeded or wanted to proceed with surgery due to a perceived lower risk of acquiring COVID-19 perioperatively (68%, n = 15) or because their symptoms had progressed (32%, n = 7). The most common reason (n = 14/17, 82%) for patients deferring surgery in September was the perceived risk of acquiring COVID-19 while as an inpatient. When asked what measures or circumstances would enable them to proceed with surgery, the most common (n = 7, 41%) response was reassurance of a COVID-19 free hospital. Conclusion. The rate of deferral fell to 5% by September, which was due to a lower perceived risk of contracting COVID-19 perioperatively or worsening of symptoms while waiting. The potential of a COVID-19-free hospital and communication of mortality risk may improve a patient’s willingness to go forward with surgery. Cite this article: Bone Joint Open 2020;1-10:663–668

Aims. Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre. Methods. A retrospective cohort study was performed. Patients undergoing primary or revision hip or knee arthroplasty over a six-month period, from 1 July to 31 December 2020, were compared to the same period in 2019 before the COVID-19 pandemic. Demographic data, American Society of Anesthesiologists (ASA) grade, wait to surgery, COVID-19 status, and length of hospital stay were recorded. Results. A total of 1,311 patients underwent hip or knee arthroplasty in the six-month period following recommencement of elective services in 2020 compared to 1,527 patients the year before. Waiting time to surgery increased in post-COVID-19 group (137 days vs 78; p < 0.001). Length of stay also significantly increased (0.49 days; p < 0.001) despite no difference in age or ASA grade. There were no cases of postoperative COVID-19 infection. Conclusion. Time to surgery and length of hospital stay were significantly higher following recommencement of elective orthopaedic services in the latter part of 2020 in comparison to a similar patient cohort from the year before. Longer waiting times may have contributed to the clinical and radiological deterioration of arthritis and general musculoskeletal conditioning, which may in turn have affected immediate postoperative rehabilitation and mobilization, as well as increasing hospital stay. Cite this article: Bone Jt Open 2021;2(8):655–660