Aims

Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.

Osseous first ray surgery is a common day case procedure. Patients are often given regional blocks. We sought to find if there is a difference between ankle block and metatarsal block in this group of patients. After ethical approval was granted and power analysis performed, 25 patients were recruited into each arm of the study. These patients were having either an osteotomy or arthrodesis.

All patients had standardised general anaesthesia and received 20mls of 0.5% chirocaine for the blockade. The cohort having the ankle block had infiltration under ultrasound guidance in the anaesthetic room; and the cohort receiving the metatarsal block had infiltration at the end of the procedure. The timings of both the anaesthesia and the operation were recorded for each patient.

Patients scored their pain level at 2, 6 and 24 hours. The amount of post-operative analgesia used in the first 24 hours was also recorded by the research nurse. All patients were discharged home with a standardised prescription of analgesia.

Analysis of the pain scores showed that there was no difference between the two blocks at any measured time period. Nor was there a difference in the analgesic requirement in the first 24 hours. There was, however, a difference in the time taken for the whole procedure: with the ankle block taking an average of ten minutes more.

We conclude that metatarsal blocks are as effective as ankle blocks in providing pain relief after osseous first ray surgery, and may be a more efficient use of time.

The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club.

The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions.

It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development.

NICE published the guidelines ‘Selection of prostheses for primary hip replacement’ in 2000. Essentially these guidelines made two recommendations: firstly to use prostheses which had attained the ‘10 year benchmark’ of a revision rate of 10% or less at 10 years, or had a minimum of three years revision rate experience that was on target to reach this benchmark; and secondly to use cemented hip prostheses to the exclusion of uncemented and hybrid prostheses.

The information from the Trent Regional Arthroplasty Study (TRAS) has been used to retrospectively examine the types of hip prostheses used from 1990 – 2005, and assess the impact that the NICE guidelines have had on orthopaedic practice.

This study revealed that the percentage of prostheses used which attained the ‘ten year benchmark’ has increased since the guidelines were published. In 2001, of the ten cups, which constituted 80% of the acetabular components used, only three attained this NICE benchmark, but by 2005 this number had risen to eight. Similarly in 2001, of the eight stems, which constituted almost 80% of the femoral components used, only five attained this NICE benchmark. In 2005 seven out of these eight stems had attained the minimum standard.

However contrary to the recommendation made by NICE in 2000, to use cemented prostheses, the results indicate the use of uncemented prostheses has trebled (from 6.7% to 19.2%, n= 137 and 632 respectively), and the use of hybrid prostheses has more than doubled (from 8.8% to 22% of all prostheses, n= 181 and 722 respectively) since the guidelines were published.

Therefore the recommendations made by NICE are not being followed, which calls the value of NICE guidelines into question.