In March 2020, the World Health Organisation declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this and this pandemic has tested their adaptability. This study is aimed at assessing the impact of covid-19 on the demographics, presentation and clinical management of patients with proximal femoral (hip) fractures.

This retrospective multi-centre cohort study compared all patients admitted with hip fractures, between 1^st March and 30th May 2019 (Group PC: Pre-Covid) with hip fracture patients admitted over the same time period during the pandemic in 2020 (Group C: Covid). The data was obtained from the hospitals' local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality.

580 patients were included (304 PC, 276 C). Patient Charlson comorbidity index and Nottingham Hip Fracture scores were broadly similar across the two cohorts. There was a significant reduction in percentage of total hip replacements in Group C (11% to 5%, p=0.006). There was an increase in conservative management in group C (1% to 5%, p=0.002). The time to theatre was significantly delayed in Group C (43.7 hours C versus 34.6 hours PC, p<0.001). Overall length of hospital stay was similar in both groups (16.6 days PC versus 15 days C, p=0.089). 30-day mortality rate in Group C was 9.8% compared to 8.2% in Group PC (p=0.431), but for covid (+) patients it was significantly higher at 38.2% versus 5.8% in covid (−) patients (p<0.001).

This is one of the largest multi-centre comparative cohort study in the literature to date, examining the impact of the covid-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, covid patients were almost seven times more likely to die, reflecting the seriousness of the covid-19 infection and its sequelae in such elderly, vulnerable patients.

Purpose

The purpose of this study was to prospectively evaluate the rehabilitation outcome of children following operative and non-operative stabilisation of long bone fractures sustained in conjunction with an acquired brain injury (ABI).

Background

The aim of this study was to identify and quantify any benefits of early active treatment of paediatric femoral shaft fractures for patients, their families, and the hospital.

Aim: To assess the safety and efficacy of a mini-incision surgical (MIS) approach to knee arthroplasty (TKA) compared to a traditional standard approach.

Background: TKA through less invasive approaches have become increasingly popular in recent years. These range from smaller skin incisions to the ‘quadriceps-sparing’ procedures. Claims of improved recovery time and other clinical/economic advantages have been tempered by concerns about the safety of such procedures. This study was designed to evaluate any potential advantages of a specific approach (MIS) whilst studying peri-operative, radiological and outcome data to examine procedural safety.

Patients and Methods: 80 patients undergoing TKA were randomised to a standard or MIS (mini-midvastus) approach. The latter involved patella subluxation, rather than eversion. The operative, anaesthetic and post-operative treatments were standardised including rehabilitation protocols. Strict discharge criteria were established and independently verified and patients were discharged directly to their homes capable of independent care. Specifically the study evaluated patient demographics, operative time, blood loss and hospital stay. Outcome data including Knee Society Scores, Oxford Knee Scores and SF36 were recorded regularly in the early recovery period and up to 1 year post-operatively. Independent radiological review of implant positioning and alignment was obtained.

Results: There were no significant differences in operative time, blood loss, or other intra-operative data. Accelerated discharge was achieved in both groups (compared to historic data), however the length of stay (LOS) was significantly shorter in the MIS patients (mean – 3.5 days compared with 4.4 days in the standard patients). There was no statistical difference in clinical outcome analyses between the groups.

Discussion: Less invasive approaches to TKA have been reported over recent years but most studies have been anecdotal comparing patient recovery with historic controls which potentially can exaggerate clinical and economic benefits. Concerns have also been raised regarding the safety of these modified procedures. This study demonstrates a reduction in hospital stay and recovery in all patients as a result of accelerated rehabilitation. The MIS patients benefited from an additional significant reduction length of stay compared to controls with no evidence of compromise in terms of safety or efficacy.

Conclusions: This study has demonstrated the safety of the MIS mini-midvastus approach and a clear reduction in hospital length of stay. MIS surgery can offer substantial clinical and economic benefits but procedures must be closely evaluated to ensure equivalent or enhanced outcomes are achieved.

Introduction: The use of simultaneous bilateral knee replacement surgery remains controversial–several studies have reported increased rates of complications, and the use of the technique remains in question. However, many of these procedures are not truly simultaneous, meaning it is difficult to draw accurate conclusions on the safety of this technique from the published literature.

Method: A retrospective notes based review of all those patients undergoing bilateral knee replacement surgery between 2000 and 2005 at Harrogate District Hospital was performed. Patients undergoing both unicompartmental (UNI) and total knee replacement (TKR) were included. Procedures were performed by a consultant orthopaedic surgeon and his knee fellow with one scrub team. The post operative morbidity and mortality was assessed both 30 days post operatively and also at six month follow up.

Results: A total of 112 procedures were performed over the five year period. There were no deaths reported within the study group. Within the group there were 3 DVT’s, 2 superficial wound infections and one case of aseptic loosening at six months. Average tourniquet time was 76 minutes for the TKR group and 82 minutes for the UNI group. Average length of stay over the five year period was 8.6 nights (TKR) and 6.6 nights (UNI).

Conclusion: Bilateral truly simultaneous knee replacement surgery is a safe technique with favourable rates of complications. It offers the benefit of improved efficiency with regard to both theatre time and length of hospital stay, which is valuable in the modern climate of economic strain within health services worldwide. It also offers an excellent opportunity to the trainee to operate independently within a controlled environment, and is favoured by patients–offering a single admission and rehabilitation period.

Introduction: Reported incidence of dislocation following dislocation of hip replacements varies from less than 1% to 8%, the majority (59%) being in the first 3 months and 77% within a year. Recurrent dislocation of total hip arthroplasty is a serious problem for both patient and surgeon. Revision of the components does not guarantee success and there is significant comorbidity associated with major revision surgery. Early techniques of cup augmentation were complicated by screw and augment failure, hence cup augmentation evolved into a low profile polyethylene wedge with a separate metal backing and five screw fixation called the Posterior Lip Augmentation device (PLAD).

Methods: 33 patients in Leeds and Inverness underwent PLAD placement between 1995 and 2000. They were followed up at a minimum of 5 years postoperatively (5–9 years). Where patients had died the cause of death and status of the PLAD at time of death was determined from the notes.

Results: The mean age at time of PLAD insertion was 73 years(43–94). The longest survival was 102 months, the shortest 8 days. Of the 33 patients undergoing PLAD insertion, 3 were lost to follow up, 13 had died by the time of follow up, 7 had been revised and 10 had survived revision free.

Discussion: When considering the revision as an end point, PLAD insertion compares favourably with total revision. As shown by the mortality of the patients in the cohort, a less invasive option for the patient with significant comorbidities is useful to have in the surgical armamentarium.

The aim of this study was to compare the modern treatments for femoral fractures in children to see if they have any advantages over traditional treatments. The modern treatments are mainly operative with the objective is to get the children mobilising early and to minimise the time spent in hospital. We studied 66 children who had sustained a traumatic femoral shaft fracture, over a six-year period with a minimum follow up of two years. A protocol using early hip spicas for under 5 year olds, flexible intramedullary nails for over 5 year olds, and external fixation for the polytrauma cases was started in 1999. Over a three-year period there were 25 children who sustained a fracture (Early active group). These were prospectively reviewed with a minimum follow up of 24 months. The outcome measures being, length of hospital stay, degree of mal-union, range of movement of the hip and knee, leg length discrepancy, pain and functional restrictions. This modern patient group was compared with all the fractures in the three years prior to the new protocol commencing. This group were treated usually with in patient traction (Traditional group). There were 41 children in this group who had sustained a fracture between 1996 and 1999.

The mean length of hospital stay was 32 nights in the traditional group and 19 nights in the early active group (p less than 0.001). If we exclude the children who were severely injured with multiple injuries the mean stay is 29 nights and 10 nights (p less than 0.001). There was no significant difference in the mal-union rate between the two groups. Very few had pain and at 2 years they all had good clinical and functional results. The only significant complication rate was with the fractures that were treated with an external fixator. These were mainly pin site infections. In our population there has been a 40% reduction in the incidence of femoral fractures over the six-year period for which we have no explanation.

These modern treatments have resulted in a shorter hospital stay that has many advantages for the child and family as well as financial savings.

Aims: To review the effectiveness of the Posterior Lip Augmentation Device (P.L.A.D.) in treating recurrent prosthetic total hip dislocation. Method: We reviewed 36 patients from 2 hip revision surgeons from 2 UK centres who underwent cup augmentation using this device since October 1995. Data were collected from case notes, X-rays and clinical review. All dislocations were posterior (minimum of 3 dislocations). In the majority of cases the abductors were poor or detached, and 35 of the 36 patients had undergone at least one major operation on their hip before a P.L.A.D. was þtted (mean 2.2 operations). Results: The mean age at the time of P.L.A.D. was 73 years (range 47–94). The longest P.L.A.D. follow up is 72 months, and is working well without problems reported by the patient or visible changes on x-ray. A total of 26 out of 36 patients (72.2%) have had a successful correction of their dislocation over this mean period of 21 months (range 8 days Ð 72 months). 10 patients (27.8%) developed signiþcant problems of which 7 (19.4%) required removal of the implant. There were 4 unrelated deaths in our cohort. Conclusions: We feel it has a place in the treatment of recurrent dislocation, particularly in the frail patient, with well-þxed and orientated components, where risks of revision surgery are high and there will be less loading postoperatively

This study reports the outcome of using the Posterior Lip Augmentation Device (PLAD) for recurrent dislocation of total hip replacement. Twenty-seven patients (16 in Inverness, 11 in Leeds) were treated with the device. The indication for its use was recurrent dislocation of the hip in a patient who had a well-orientated and well-fixed cemented acetabular component. The patients had had between 2 and 14 dislocations before using the PLAD. 24 of the 27 patients had satisfactory control of the dislocations after surgery. The operation was found to be straightforward in most cases with few complications, although one case in the Inverness series has a partial sciatic nerve palsy which is recovering. Of the three failures, two had recurrent dislocation after the use of the PLAD. In one of these, in whom the dislocation followed acetabular reconstruction with impaction grafting, the cup also pulled out due to the semi-captive state after use of the PLAD. Both of these cases were treated by a Girdlestone excision arthroplasty. There was one final failure in whom there has been no further dislocation but following an abduction injury some four months after surgery, progressive cup loosening developed and he awaits revision of the cup. One patient complains of an occasional click in the hip joint and a broken screw is visible on x-ray but there has been no loss of position of the device and no further evidence of dislocation. Overall, we have found that this device gives satisfactory control of recurrent dislocations of the hip but the failures have stressed the need to ensure that the cup fixation is sound before inserting the device.