In the current austere financial climate within the NHS where local healthcare Trusts are reimbursed in a Payment by Results system it is important that we accurately identify the costs associated with surgical procedures.

We retrospectively reviewed data of 589 consecutive patients undergoing lower limb arthroplasty surgery and recorded their age, BMI and co-morbidities. The effect of these parameters on operative duration and length of stay (LOS) was analysed.

We demonstrate that for a 1 point increase in BMI we expect LOS to increase by a factor of 2.9% (p<0.0001) and mean theatre time to increase by 1.46 minutes (p<0.0001). We also show that for a l-year increase in age, we expect LOS to increase by a factor of 1.2% (p<0.0001).

We have calculated the extra financial costs associated with this and believe that the current OPCS coding system for obesity underestimates the financial impact of increasing BMI and age on lower limb arthroplasty Trusts are being inadequately reimbursed.

The results of this study have been used to produce a chart that allows prediction of LOS following lower limb arthroplasty based on BMI and age. We also believe that the data produced is of use in planning operating lists.

Recent NICE guidelines have suggested abandoning the Thompson hemiarthroplasty (TH) in favour of a ‘proven prosthesis’ such as the Exeter Trauma Stem (ETS). This is controversial because of significant cost implications and limited research assessing outcomes of the ETS. The aim of this study was to assess the treatment of intracapsular neck of femur fractures with the TH.

Between 2002 and 2006 (minimum 5 year follow-up), 431 cemented TH's were performed. Death rate at 1 year and 5 years were 26.0% and 67.7% respectively. Dislocation (1.4%) and infection (0.2%) rates were low and revision rate was 1.2%. Comparison was made to Bipolar hemiarthroplasties over the same period (total 194). These had lower rates of dislocation (0.5%) and infection (0.5%) with a significantly higher (3.6%) revision rate.

We feel that the TH remains the current gold standard treatment for intracapsular fractures, in appropriate patients, due to low complication and revision rates. Modern implants may provide better function or longevity, but there is no evidence in the literature to support abandoning the TH. Surgeons should assess patients and decide on its use, despite NICE guidelines, as it remains a cost effective treatment method, particularly for older, less mobile and cognitively impaired patients.

We designed this study to determine the clinical evidence to support use of the five degree tibial extra-medullary cutting block over the zero degree cutting block.

We identified three groups of patients from the databases and clinical notes at St Michaels Hospital, Toronto. Group one were primary total knees performed using the five degree cutting block, group two were primary total knees performed using the zero degree cutting block and the third group were computer navigated primary total knees. Patients in all three groups were age and sex matched. The senior author advocating use of the five degree block aimed to obtain a five degree posterior slope. The senior author who advocated the use of computer navigation, or the traditional zero degree cutting block, aimed to obtain a three degree posterior slope. All operations were performed by residents or clinical fellows, under the supervision of the senior authors. Patient radiographs were assessed to obtain the optimal direct lateral view obtained and they were saved on a database. Two independent blinded researchers assessed the posterior slope using Siemens Magicweb Software Version VA42C_0206. Two methods were used and the results averaged. The average posterior slope for the navigated total knee replacements was 0.1 degrees (−2 to 4). The average posterior slope for the five degree cutting block was 5.2 degrees (−2 to 16). The average posterior slope for the zero degree block was 3.79 degrees (−2 to 13). Computer navigated knee arthroplasty patients had significantly less variation in outlier measurements compared to the traditionally jigged arthroplasty patients. They were however, less accurate. The five degree cutting block tended to provide a more consistent posterior slope angle, but both the five degree and zero degree cutting blocks had variability in outliers. Computer Navigated Total Knee replacement provides a more consistent and reproducible tibial cut with less variability in alignment than extra-medullary jigs. The traditional five degree cutting block tended to provide a more reliable five degree posterior slope than the zero degree block, but was still subject to outliers.

Introduction

Paediatric hip fracture accounts for less than one percent of paediatric fractures. Previous studies report complication rates between 20 and 92%.

We reported the first single surgeon series comparing outcome of microscopic and open primary single level unilateral lumbar decompression or discectomy. We aimed to determine any difference in outcomes between the two techniques.

Forty-six decompressions were performed with use of an operating microscope (microscopic), and forty without (open) at two different hospitals. All procedures were performed by the senior author. Information was obtained by analysis of the patients' notes. The average age of the patients in both groups was comparable. Operating time was shorter in the microscopic group (68min, range 30-130) compared to the open group (83 mins, range 30-180). Dural tear rate was 4.3% with use of a microscope (0% symptomatic dural tear rate) and 7.5% without (2.5% symptomatic dural tear rate). Nerve damage incidence was 0% with use of a microscope and 5% (two patients) without. One of these was a neurapraxia and the patient made a full recovery. Wound infection rates, diagnosed on grounds of clinical suspicion, were 4.3% and 2.5% for microscopic and open respectively. There were no incidences of deep infection or post-operative discitis. Average inpatient stay was under 48 hours in both groups.

Using the modified Macnab criteria, results using the microscope were 0% poor, 14% fair, 32% good, and 55% excellent. The results for the open group were 0% poor, 10% fair, 37% good and 53% excellent. Average follow-up was six months (1-19) for the microscope group, and seven months (2-16) for the open group.

We conclude that primary single level unilateral lumbar decompressive surgery, performed without the use of a microscope, has a higher dural tear rate than the same surgery performed with the benefit of an operating microscope. Surgical time and incidence of nerve damage are also reduced by use of the microscope.