The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway. The probability of SARS-CoV-2 infection with a false negative test was calculated using a lower-end RT-PCR sensitivity of 71%, specificity of 95%, and the UK disease prevalence of 0.24% reported in May 2020. Subsequently, a case fatality rate of 20.5% was applied as a worst-case scenario.Aims
Methods
The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in
The transition from shutdown of
We present a retrospective review of 167 patients aged 18 years and under who were treated for chronic haematogenous osteomyelitis at our
Aims. The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common
We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5594 admissions were cross-referenced with 22 810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative. In 2004, we screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1122 of 1447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p <
0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p <
0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p <
0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1084) to 0.69% in 2004 (10 of 1447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1257) to 0.17% in 2004 (3 of 1806), p = 0.06). The cost of preventing one MRSA infection was £3200. Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to £13 972 per patient. From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and
We cultured human osteoblasts from trabecular bone explants and confirmed their phenotype by alkaline phosphatase assay, increased cyclic adenosine monophosphate production in response to prostaglandin E2 and radiographic micro-analysis of nodules of calcification. The osteoblasts were seeded on to demineralised human bone fragments and examined at ten-day intervals over a 50-day period by scanning electron microscopy. During this time the bank bone became progressively repopulated by the cultured osteoblasts. This system may offer a means of graft enhancement in
In the light of EEC proposals on the avoidance of damage to hearing caused by noise, a study was undertaken to determine the risk posed by powered orthopaedic instruments. The noise levels from a number of air-powered and electric tools were measured and analysed and found to exceed the recommended levels. The predicted daily personal noise exposure was calculated and the potential for hearing damage confirmed. Twenty-seven senior orthopaedic staff were then assessed by audiometry; evidence of noise-induced hearing loss was found in half the subjects. The increasing use of powered instruments in
Cite this article:
Weightbearing instructions after musculoskeletal injury or orthopaedic surgery are a key aspect of the rehabilitation pathway and prescription. The terminology used to describe the weightbearing status of the patient is variable; many different terms are used, and there is recognition and evidence that the lack of standardized terminology contributes to confusion in practice. A consensus exercise was conducted involving all the major stakeholders in the patient journey for those with musculoskeletal injury. The consensus exercise primary aim was to seek agreement on a standardized set of terminology for weightbearing instructions.Aims
Methods
The primary aim was to assess change in health-related quality of life (HRQoL) of patients as they waited from six to 12 months for a total hip (THA) or total or partial knee arthroplasty (KA). Secondary aims were to assess change in joint-specific function, mental health, quality of sleep, number living in a state worse than death (WTD), wellbeing, and patient satisfaction with their healthcare. This prospective study included 142 patients awaiting a THA (mean age 66.7 years (SD 11.4); 71 female) and 214 patients awaiting KA (mean age 69.7 years (SD 8.7); 117 female). Patients completed questionnaires (EuroQol five-dimension health questionnaire (EQ-5D), Oxford Hip and Knee Scores (OHS/OKS), Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Score (HADS), University of California, Los Angeles Activity Scale, wellbeing assessment, and satisfaction with their healthcare) at six and 12 months while awaiting surgery.Aims
Methods
To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome. This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients’ odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates.Aims
Methods
Total knee arthroplasty (TKA) with a highly congruent condylar-stabilized (CS) articulation may be advantageous due to increased stability versus cruciate-retaining (CR) designs, while mitigating the limitations of a posterior-stabilized construct. The aim was to assess ten-year implant survival and functional outcomes of a cemented single-radius TKA with a CS insert, performed without posterior cruciate ligament sacrifice. This retrospective cohort study included consecutive patients undergoing TKA at a specialist centre in the UK between November 2010 and December 2012. Data were collected using a bespoke electronic database and cross-referenced with national arthroplasty audit data, with variables including: preoperative characteristics, intraoperative factors, complications, and mortality status. Patient-reported outcome measures (PROMs) were collected by a specialist research team at ten years post-surgery. There were 536 TKAs, of which 308/536 (57.5%) were in female patients. The mean age was 69.0 years (95% CI 45.0 to 88.0), the mean BMI was 32.2 kg/m2 (95% CI 18.9 to 50.2), and 387/536 (72.2%) survived to ten years. There were four revisions (0.7%): two deep infections (requiring debridement and implant retention), one aseptic loosening, and one haemosiderosis.Aims
Methods
The primary aim of this study was to assess whether patients waiting six months or more for a total hip (THA) or knee (KA) arthroplasty had a deterioration in their health-related quality of life (HRQoL). Secondary aims were to assess changes in frailty and the number of patients living in a state considered to be worse than death (WTD), and factors associated with changes in HRQoL and frailty. This cross-sectional study included 326 patients, 150 males (46.0%) and 176 females (54.0%), with a mean age of 68.6 years (SD 9.8) who were randomly selected from waiting lists at four centres and had been waiting for six months or more (median 13 months, interquartile range 10 to 21) for a primary THA (n = 161) or KA (n = 165). The EuroQol five-dimension questionnaire (EQ-5D) and visual analogue scores (EQ-VAS), Rockwood Clinical Frailty Scale (CFS), and 36-Item Short Form Survey subjective change in HRQoL were assessed at the time and recalled for six months earlier. A state that was WTD was defined as an EQ-5D of less than zero.Aims
Methods
The primary aim was to assess the rate of postoperative COVID-19 following hip and knee arthroplasty performed in March 2020 in the UK. The secondary aims were to assess whether there were clinical factors associated with COVID-19 status, the mortality rate of patients with COVID-19, and the rate of potential COVID-19 in patients not presenting to healthcare services. A multicentre retrospective study was conducted of patients undergoing hip or knee arthroplasty during the first wave of the COVID-19 pandemic (1 March 2020 to 31 March 2020) with a minimum of 60 days follow-up. Patient demographics, American Society of Anesthesiologists grade, procedure type, primary or revision, length of stay (LOS), COVID-19 test status, and postoperative mortality were recorded. A subgroup of patients (n = 211) who had not presented to healthcare services after discharge were contacted and questioned as to whether they had symptoms of COVID-19.Aims
Methods
Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion.Aims
Methods
Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost. In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA.Aims
Methods
The aim of this study was to assess the quality of life of patients on the waiting list for a total hip (THA) or knee arthroplasty (KA) during the COVID-19 pandemic. Secondary aims were to assess whether length of time on the waiting list influenced quality of life and rate of deferral of surgery. During the study period (August and September 2020) 843 patients (THA n = 394, KA n = 449) from ten centres in the UK reported their EuroQol five dimension (EQ-5D) scores and completed a waiting list questionnaire (2020 group). Patient demographic details, procedure, and date when listed were recorded. Patients scoring less than zero for their EQ-5D score were defined to be in a health state “worse than death” (WTD). Data from a retrospective cohort (January 2014 to September 2017) were used as the control group.Aims
Methods
The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period. A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1 March 2020 to 19 April 2020) with a minimum of 50 days follow-up. Patient demographics, American Society of Anesthesiologists (ASA) grade, priority (urgent or elective), procedure type, COVID-19 status, and postoperative mortality were recorded.Aims
Methods
The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors.Aims
Methods
To benchmark the radiation dose to patients during the course of treatment for a spinal deformity. Our radiation dose database identified 25,745 exposures of 6,017 children (under 18 years of age) and adults treated for a spinal deformity between 1 January 2008 and 31 December 2016. Patients were divided into surgical (974 patients) and non-surgical (5,043 patients) cohorts. We documented the number and doses of ionizing radiation imaging events (radiographs, CT scans, or intraoperative fluoroscopy) for each patient. All the doses for plain radiographs, CT scans, and intraoperative fluoroscopy were combined into a single effective dose by a medical physicist (milliSivert (mSv)).Aims
Methods
The purpose of this study was to develop a personalized outcome prediction tool, to be used with knee arthroplasty patients, that predicts outcomes (lengths of stay (LOS), 90 day readmission, and one-year patient-reported outcome measures (PROMs) on an individual basis and allows for dynamic modifiable risk factors. Data were prospectively collected on all patients who underwent total or unicompartmental knee arthroplasty at a between July 2015 and June 2018. Cohort 1 (n = 5,958) was utilized to develop models for LOS and 90 day readmission. Cohort 2 (n = 2,391, surgery date 2015 to 2017) was utilized to develop models for one-year improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score, KOOS function score, and KOOS quality of life (QOL) score. Model accuracies within the imputed data set were assessed through cross-validation with root mean square errors (RMSEs) and mean absolute errors (MAEs) for the LOS and PROMs models, and the index of prediction accuracy (IPA), and area under the curve (AUC) for the readmission models. Model accuracies in new patient data sets were assessed with AUC.Aims
Methods
A pragmatic, single-centre, double-blind randomized clinical trial was conducted in a NHS teaching hospital to evaluate whether there is a difference in functional knee scores, quality-of-life outcome assessments, and complications at one-year after intervention between total knee arthroplasty (TKA) and patellofemoral arthroplasty (PFA) in patients with severe isolated patellofemoral arthritis. This parallel, two-arm, superiority trial was powered at 80%, and involved 64 patients with severe isolated patellofemoral arthritis. The primary outcome measure was the functional section of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 12 months. Secondary outcomes were the full 24-item WOMAC, Oxford Knee Score (OKS), American Knee Society Score (AKSS), EuroQol five dimension (EQ-5D) quality-of-life score, the University of California, Los Angeles (UCLA) Physical Activity Rating Scale, and complication rates collected at three, six, and 12 months. For longer-term follow-up, OKS, EQ-5D, and self-reported satisfaction score were collected at 24 and 60 months.Aims
Methods
Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery. A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed.Aims
Methods
Infection following total hip or knee arthroplasty is a serious
complication. We noted an increase in post-operative infection in
cases carried out in temporary operating theatres. We therefore
compared those cases performed in standard and temporary operating
theatres and examined the deep periprosthetic infection rates. A total of 1223 primary hip and knee arthroplasties were performed
between August 2012 and June 2013. A total of 539 (44%) were performed
in temporary theatres. The two groups were matched for age, gender,
body mass index and American Society of Anesthesiologists grade.Aims
Patients and methods
The aim of this study was to determine and compare the congruency of the articular surface contact area of the patellofemoral joint (PFJ) during both active and passive movement of the knee with the use of an MRI mapping technique in both the stable and unstable PFJ. A prospective case-control MRI imaging study of patients with a history of PFJ instability and a control group of volunteers without knee symptoms was performed. The PFJs were imaged with the use of an MRI scan during both passive and active movement from 0° through to 40° of flexion. The congruency through measurement of the contact surface area was mapped in 5-mm intervals on axial slices. In all, 40 patients were studied. The case group included 31 patients with symptomatic patellofemoral instability and the control group of nine asymptomatic volunteers. The ages were well matched between the case and control groups. The mean age was 25 years (16 to 42; Aims
Patients and Methods
The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures. The Kids’ Inpatient Database (KID) was used to evaluate children between birth and 17 years of age, from 1997 and 2012, who had undergone open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. Demographics, hospital charges, lengths of stay (LOS), and complications were analyzed.Aims
Patients and Methods
To investigate whether elective joint arthroplasty performed
at the weekend is associated with a different 30-day mortality We examined the 30-day cumulative mortality rate (Kaplan-Meier)
for all elective hip and knee arthroplasties performed in England
and Wales between 1st April 2003 and 31st December 2014, comprising
118 096 episodes undertaken at the weekend and 1 233 882 episodes
performed on a weekday. We used Cox proportional-hazards regression
models to assess for time-dependent variation and adjusted for identified
risk factors for mortality.Aims
Patients and Methods
Methicillin-resistant Staphylococcus aureus (MRSA) has become a ubiquitous bacterium in both the hospital and community setting. There are two major subclassifications of MRSA, community-acquired and healthcare-acquired, each with differing pathogenicity and management. MRSA is increasingly responsible for infections in otherwise healthy, active adults. Local outbreaks affect both professional and amateur athletes and there is increasing public awareness of the issue. Health-acquired MRSA has major cost and outcome implications for patients and hospitals. The increasing prevalence and severity of MRSA means that the orthopaedic community should have a basic knowledge of the bacterium, its presentation and options for treatment. This paper examines the evolution of MRSA, analyses the spectrum of diseases produced by this bacterium and presents current prevention and treatment strategies for orthopaedic infections from MRSA.
The aim of this study was to re-assess whether the use of a ‘one-knife technique’ can be considered as safe as the alternative practice of using separate skin and inside knives for elective orthopaedic surgery. A total of 609 knife blades from 203 elective orthopaedic operations, with equal numbers of skin, inside and control blades, were cultured using direct and enrichment media. We found 31 skin blades (15.3%), 22 inside blades (10.8%), and 13 control blades (6.4%) gave bacterial growth. Of the 31 contaminated skin blades only three (9.7%) had growth of the same organism as found on the corresponding inside blade. It is not known whether contamination of deeper layers in the remaining 90% was prevented by changing the knife after the skin incision. The organisms cultured were predominantly coagulase-negative staphylococci and proprionibacterium species; both are known to be the major culprits in peri-prosthetic infection. Our study suggests that the use of separate skin and inside knives should be maintained as good medical practice, since the cost of a single deep infection in human and financial terms can be considerable.
The Control of Infection Committee at a specialist orthopaedic hospital prospectively collected data on all episodes of bacteriologically-proven deep infection arising after primary hip and knee replacements over a 15-year period from 1987 to 2001. There were 10 735 patients who underwent primary hip or knee replacement. In 34 of 5947 hip replacements (0.57%) and 41 of 4788 knee replacements (0.86%) a deep infection developed. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Of the infections, 29% (22) arose in the first three months following surgery, 35% between three months and one year (26), and 36% (27) after one year. Most cases were detected early and treated aggressively, with eradication of the infection in 96% (72). There was no significant change in the infection rate or type of infecting micro-organism over the course of this study. These results set a benchmark, and importantly emphasise that only 64% of peri-prosthetic infections arise within one year of surgery. These results also illustrate the advantages of conducting joint replacement surgery in the isolation of a specialist hospital.
We have investigated iatrogenic popliteal artery
injuries (PAI) during non arthroplasty knee surgery regarding mechanism
of injury, treatment and outcomes, and to identify successful strategies
when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients
during knee surgery other than knee arthroplasty were identified
from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011.
Prospective registry data were supplemented with case-records, including
long-term follow-up. In total, 13 patients suffered PAI during elective surgery
and eight during urgent surgery such as fracture fixation or tumour
resection. Nine injuries were detected intra-operatively, five within
12 to 48 hours and seven >
48 hours post-operatively (two days to
23 years). There were 19 open vascular and two endovascular surgical repairs.
Two patients died within six months of surgery. One patient required
amputation. Only six patients had a complete recovery of whom had
the vascular injury detected at time of injury and repaired by a
vascular surgeon. Patients sustaining vascular injury during elective
procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of
diagnosis and treatment, and that orthopaedic surgeons should develop
strategies to detect PAI early and ensure rapid access to vascular
surgical support. Cite this article:
The aim of this study was to define return to
theatre (RTT) rates for elective hip and knee replacement (HR and
KR), to describe the predictors and to show the variations in risk-adjusted
rates by surgical team and hospital using national English hospital
administrative data. We examined information on 260 206 HRs and 315 249 KRs undertaken
between April 2007 and March 2012. The 90-day RTT rates were 2.1%
for HR and 1.8% for KR. Male gender, obesity, diabetes and several
other comorbidities were associated with higher odds for both index
procedures. For HR, hip resurfacing had half the odds of cement fixation
(OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR,
unicondylar KR had half the odds of total replacement (OR = 0.49,
95% CI 0.42 to 0.56), and younger ages had higher odds (OR = 2.23,
95% CI 1.65 to 3.01) for ages <
40 years compared with ages 60
to 69 years). There were more funnel plot outliers at three standard deviations
than would be expected if variation occurred on a random basis. Hierarchical modelling showed that three-quarters of the variation
between surgeons for HR and over half the variation between surgeons
for KR are not explained by the hospital they operated at or by
available patient factors. We conclude that 90-day RTT rate may
be a useful quality indicator for orthopaedics. Cite this article:
In a time of limited resources, the debate continues
over which types of hip prosthesis are clinically superior and more
cost-effective. Orthopaedic surgeons increasingly need robust economic
evidence to understand the full value of the operation, and to aid
decision making on the ‘package’ of procedures that are available
and to justify their practice beyond traditional clinical preference. In this paper we explore the current economic debate about the
merits of cemented and cementless total hip replacement, an issue
that continues to divide the orthopaedic community. Cite this article:
Popliteal artery injury (PAI) is a feared complication
during knee replacement. Our aim was to investigate those injuries
that occurred in association with knee replacement in terms of the
type of injury, treatment and outcomes. From our national vascular registry (Swedvasc) and the Swedish
Patient Insurance databases a total of 32 cases were identified.
Prospective data from the registries was supplemented with case-records,
including long-term follow-up. We estimated the incidence during 1998 to 2010 to be 0.017%.
In our series of 32 patients with PAI occurring between 1987 and
2011, 25 (78%) were due to penetrating trauma and seven were caused
by blunt trauma. The patients presented in three ways: bleeding
(14), ischaemia (7) and false aneurysm formation (11), and five
occurred during revision surgery. A total of 12 injuries were detected
intra-operatively, eight within 24 hours (3 to 24) and 12 at more
than 24 hours post-operatively (2 to 90 days). Treatment comprised
open surgery in 28 patients. Patency of the vascular repair at 30
days was 97% (31 of 32, one amputation). At the time of follow-up
(median 546 days, mean 677 days (24 to 1251)), 25 patients had residual
symptoms. Of seven patients with a complete recovery, six had had
an early diagnosis of the PAI during the procedure, and were treated
by a vascular surgeon in the same hospital. PAI is a rare adverse event during knee replacement surgery.
The outcome following such events is often adversely affected by
diagnostic and therapeutic delay. Bleeding and false aneurysm were
the most common clinical presentations. Cite this article:
We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Methicillin-resistant
In order to assess the efficacy of inspection and accreditation by the Specialist Advisory Committee for higher surgical training in orthopaedic surgery and trauma, seven training regions with 109 hospitals and 433 Specialist Registrars were studied over a period of two years. There were initial deficiencies in a mean of 14.8% of required standards (10.3% to 19.2%). This improved following completion of the inspection, with a mean residual deficiency in 8.9% (6.5% to 12.7%.) Overall, 84% of standards were checked, 68% of the units improved and training was withdrawn in 4%. Most units (97%) were deficient on initial assessment. Moderately good rectification was achieved but the process of follow-up and collection of data require improvement. There is an imbalance between the setting of standards and their implementation. Any major revision of the process of accreditation by the new Post-graduate Medical Education and Training Board should recognise the importance of assessment of training by direct inspection on site, of the relationship between service and training, and the advantage of defining mandatory and developmental standards.
Cite this article:
We obtained pre-operative and six-month post-operative
Oxford hip (OHS) and knee scores (OKS) for 1523 patients who underwent
total hip replacement and 1784 patients who underwent total knee
replacement. They all also completed a six-month satisfaction question. Scatter plots showed no relationship between pre-operative Oxford
scores and six-month satisfaction scores. Spearman’s rank correlation
coefficients were -0.04 (95% confidence interval (CI) -0.09 to 0.01)
between OHS and satisfaction and 0.04 (95% CI -0.01 to 0.08) between
OKS and satisfaction. A receiver operating characteristic (ROC) curve
analysis was used to identify a cut-off point for the pre-operative
OHS/OKS that identifies whether or not a patient is satisfied with
surgery. We obtained an area under the ROC curve of 0.51 (95% CI
0.45 to 0.56) for hip replacement and 0.56 (95% CI 0.51 to 0.60)
for knee replacement, indicating that pre-operative Oxford scores
have no predictive accuracy in distinguishing satisfied from dissatisfied
patients. In the NHS widespread attempts are being made to use patient-reported
outcome measures (PROMs) data for the purpose of prioritising patients
for surgery. Oxford hip and knee scores have no predictive accuracy
in relation to post-operative patient satisfaction. This evidence
does not support their current use in prioritising access to care.
The incidence of deep-vein thrombosis (DVT) and
pulmonary embolism (PE) is thought to be low following foot and ankle
surgery, but the routine use of chemoprophylaxis remains controversial.
This retrospective study assessed the incidence of symptomatic venous
thromboembolic (VTE) complications following a consecutive series
of 2654 patients undergoing elective foot and ankle surgery. A total
of 1078 patients received 75 mg aspirin as routine thromboprophylaxis
between 2003 and 2006 and 1576 patients received no form of chemical
thromboprophylaxis between 2007 and 2010. The overall incidence
of VTE was 0.42% (DVT, 0.27%; PE, 0.15%) with 27 patients lost to follow-up.
If these were included to create a worst case scenario, the overall
VTE rate was 1.43%. There was no apparent protective effect against
VTE by using aspirin. We conclude that the incidence of VTE following foot and ankle
surgery is very low and routine use of chemoprophylaxis does not
appear necessary for patients who are not in the high risk group
for VTE.
We present a comparison of patient-reported outcomes
(PROMs) in relation to patient age, in patients who had received
a total (TKR) or unicompartmental knee replacement (UKR). The outcome
was evaluated using the Oxford knee score (OKS), EuroQol (EQ-5D)
and satisfaction scores. Patients aged 65 to 84 years demonstrated
better pre-operative function scores than those aged <
65 years
(OKS, p = 0.03; EQ-5D, p = 0.048) and those aged
≥ 85 years (OKS, p = 0.03). Post-operative scores were comparable
across age groups, but a linear trend for greater post-operative
improvement in OKS and EQ-5D was seen with decreasing age (p <
0.033). The overall mean satisfaction score at six months was 84.9,
but those aged <
55 years exhibited a lower mean level of satisfaction (78.3)
compared with all other age groups (all p <
0.031). The cumulative
overall two-year revision rate was 1.3%. This study demonstrates
that good early outcomes, as measured by the OKS and EQ-5D, can
be anticipated following knee replacement regardless of the patient’s
age, although younger patients gain greater improvement. However,
the lower satisfaction in those aged
<
55 years is a concern, and suggests that outcome is not fully
encapsulated by the OKS and EQ-5D evaluation, and raises the question
whether the OKS alone is an appropriate measure of pain and function
in younger, more active individuals. Cite this article:
We performed a retrospective study of a departmental database to assess the efficacy of a new model of orthopaedic care on the outcome of patients with a fracture of the proximal femur. All 1578 patients admitted to a university teaching hospital with a fracture of the proximal femur between December 2007 and December 2009 were included. The allocation of Foundation doctors years 1 and 2 was restructured from individual teams covering several wards to pairs covering individual wards. No alterations were made in the numbers of doctors, their hours, out-of-hours cover, or any other aspect of standard patient care. Outcome measures comprised 30-day mortality and cause, complications and length of stay. Mortality was reduced from 11.7% to 7.6% (p = 0.007, Cox’s regression analysis); adjusted odds ratio was 1.559 (95% confidence interval 1.128 to 2.156). Reductions were seen in These findings may have implications for all specialties caring for patients on several wards, and we believe they justify a prospective trial to further assess this effect.
Infection remains a significant and common complication after joint replacement and there is debate about which contributing factors are important. Few studies have investigated the effect of the operating time on infection. We collected data prospectively from 5277 hip and knee replacements which included the type of procedure, the operating time, the use of drains, the operating theatre, surgeon, age and gender. In a subgroup of 3449 knee replacements further analysis was carried out using the tourniquet time in place of the operating time. These variables were assessed by the use of generalised linear modelling against superficial, deep or joint-space post-operative infection as defined by the Australian Surgical-Site Infection criteria. The overall infection rate was 0.98%. In the replacement data set both male gender (z = 3.097, p = 0.00195) and prolonged operating time (z = 4.325, p <
0.001) were predictive of infection. In the knee subgroup male gender (z = 2.250, p = 0.02447), a longer tourniquet time (z = 2.867, p = 0.00414) and total knee replacement ( These findings support the view that a prolonged operating time and male gender are associated with an increased incidence of infection. Steps to minimise intra-operative delay should be instigated, and care should be exercised when introducing measures which prolong the duration of joint replacement.
We have compared the outcome of hemiarthroplasty of the shoulder in three distinct diagnostic groups, using survival analysis as used by the United Kingdom national joint registers, patient-reported outcome measures (PROMs) as recommended by Darzi in the 2008 NHS review, and transition and satisfaction questions. A total of 72 hemiarthroplasties, 19 for primary osteoarthritis (OA) with an intact rotator cuff, 22 for OA with a torn rotator cuff, and 31 for rheumatoid arthritis (RA), were followed up for between three and eight years. All the patients survived, with no revisions or dislocations and no significant radiological evidence of loosening. The mean new Oxford shoulder score (minimum/worst 0, maximum/best 48) improved significantly for all groups (p <
0.001), in the OA group with an intact rotator cuff from 21.4 to 38.8 (effect size 2.9), in the OA group with a torn rotator cuff from 13.3 to 27.2 (effect size 2.1) and in the RA group from 13.7 to 28.0 (effect size 3.1). By this assessment, and for the survival analysis, there was no significant difference between the groups. However, when ratings using the patient satisfaction questions were analysed, eight (29.6%) of the RA group were ‘disappointed’, compared with one (9.1%) of the OA group with cuff intact and one (7.7%) of the OA group with cuff torn. All patients in the OA group with cuff torn indicated that they would undergo the operation again, compared to ten (90.9%) in the OA group with cuff intact and 20 (76.9%) in the RA group. The use of revision rates alone does not fully represent outcome after hemiarthroplasty of the shoulder. Data from PROMs provides more information about change in pain and the ability to undertake activities and perform tasks. The additional use of satisfaction ratings shows that both the rates of revision surgery and PROMs need careful interpretation in the context of patient expectations.
As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection. If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading.
This paper describes the presence of tenodesis effects in normal physiology and explores the uses of operative tenodesis in surgery of the upper limb.
We have conducted a case-control study over a period of ten years comparing both deep infection with methicillin-resistant Risk factors associated with deep infection were vascular diseases, chronic obstructive pulmonary disease, admission to a high-dependency or an intensive-care unit and open wounds. Those for colonisation were institutional care, vascular diseases and dementia. Older age was a risk factor for any MRSA infection. The length of hospital stay was dramatically increased by deep infection. These risk factors are useful in identifying higher-risk patients who may be more susceptible to MRSA infection. A strategy of early identification and isolation may help to control its spread in trauma units.
We audited the relationship between obesity and the age at which hip and knee replacement was undertaken at our centre. The database was analysed for age, the Oxford hip or knee score and the body mass index (BMI) at the time of surgery. In total, 1369 patients were studied, 1025 treated by hip replacement and 344 by knee replacement. The patients were divided into five groups based on their BMI (normal, overweight, moderately obese, severely obese and morbidly obese). The difference in the mean Oxford score at surgery was not statistically significant between the groups (p >
0.05). For those undergoing hip replacement, the mean age of the morbidly obese patients was ten years less than that of those with a normal BMI. For those treated by knee replacement, the difference was 13 years. The age at surgery fell significantly for those with a BMI >
35 kg/m2 for both hip and knee replacement (p >
0.05). This association was stronger for patients treated by knee than by hip replacement.
We analysed which pre-operative factors could be used to predict the length of in-patient stay following unilateral primary total hip replacement undertaken for osteoarthritis. Data were collected prospectively from 2302 patients undergoing primary total hip replacement over a nine-year period. The relationships between the various pre-operative factors and length of stay were studied separately using either Student’s t-test or Pearson’s correlation, and then subjected to multiple linear regression analysis. The mean length of stay was 8.1 days (median 7; 3 to 58). After adjusting for the effects of other pre-operative factors, younger age, male gender, higher combined Harris hip function and activity score, higher general health perception dimension of the Short-Form 36 score, and non-steroidal anti-inflammatory drug use were all found to be significantly associated with a reduced length of stay.
The risk of venous thromboembolism in patients following arthroplasty may be reduced by continuing chemical thromboprophylaxis for up to 35 days post-operatively. This prospective cohort study investigated the compliance of 40 consecutive consenting patients undergoing lower limb arthroplasty with self-administration of a recommended subcutaneous chemotherapeutic agent for six weeks after surgery. Compliance was assessed by examination of the patient for signs of injection, number of syringes used, and a self-report diary at the end of the six-week period. A total of 40 patients, 15 men and 25 women, were recruited. One woman was excluded because immediate post-operative complications prevented her participation. Self-administration was considered feasible in 87% of patients (95% confidence interval (CI) 76 to 98) at the time of discharge. Among this group of 34 patients, 29 (85%) were compliant (95% CI 73 to 97). Patients can learn to self-administer subcutaneous injections of thromboprophylaxis, and compliance with extended prophylaxis to six weeks is good.
Hip resurfacing is a bone-conserving procedure with respect to proximal femoral resection, but there is debate in the literature as to whether the same holds true for the acetabulum. We have investigated whether the Birmingham hip resurfacing conserves acetabular bone. Between 1998 and 2005, 500 Birmingham hip resurfacings were performed by two surgeons. Between 1996 and 2005 they undertook 700 primary hip replacements, with an uncemented acetabular component. These patients formed the clinical material to compare acetabular component sizing. The Birmingham hip resurfacing group comprised 350 hips in men and 150 hips in women. The uncemented total hip replacement group comprised 236 hips in men and 464 hips in women. Age- and gender-matched analysis of a cohort of patients for the sizes of the acetabular components required for the two types of replacement was also undertaken. Additionally, an analysis of the sizes of the components used by each surgeon was performed. For age-matched women, the mean outside diameter of the Birmingham hip resurfacing acetabular components was 2.03 mm less than that of the acetabular components in the uncemented total hip replacements (p <
0.0001). In similarly matched men there was no significant difference (p = 0.77). A significant difference was also found between the size of acetabular components used by the two surgeons for Birmingham hip resurfacing for both men (p = 0.0015) and women (p = 0.001). In contrast, no significant difference was found between the size of acetabular components used by the two surgeons for uncemented total hip replacement in either men or women (p = 0.06 and p = 0.14, respectively). This suggests that variations in acetabular preparation also influence acetabular component size in hip resurfacing.
We conducted a randomised, controlled trial to determine whether changing gloves at specified intervals can reduce the incidence of glove perforation and contamination in total hip arthroplasty. A total of 50 patients were included in the study. In the study group (25 patients), gloves were changed at 20-minute intervals or prior to cementation. In the control group (25 patients), gloves were changed prior to cementation. In addition, gloves were changed in both groups whenever there was a visible puncture. Only outer gloves were investigated. Contamination was tested by impression of gloved fingers on blood agar and culture plates were subsequently incubated at 37°C for 48 hours. The number of colonies and types of organisms were recorded. Glove perforation was assessed using the water test. The incidence of perforation and contamination was significantly lower in the study group compared with the control group. Changing gloves at regular intervals is an effective way to decrease the incidence of glove perforation and bacterial contamination during total hip arthroplasty.
In May 2012, in airports across the globe, seven
orthopaedic surgeons bravely said goodbye to their loved ones, and
slowly turned towards their respective aircraft. Filled with expectation
and mild trepidation they stepped into the unknown… the ABC fellowship
of 2012.
The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme in order to standardise the collection of information about infections acquired in hospital in the United Kingdom and provide national data with which hospitals could measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by the Center for Disease Control (CDC), should meet at least one of the defined criteria which would confirm the diagnosis and determine the need for specific treatment. We have assessed the interobserver reliability of the criteria for superficial incisional infection set by the CDC in our current practice. The incisional site of 50 patients who had an elective primary arthroplasty of the hip or knee was evaluated independently by two orthopaedic clinical research fellows and two orthopaedic ward sisters for the presence or absence of surgical-site infection. Interobserver reliability was assessed by comparison of the criteria for wound infection used by the four observers using kappa reliability coefficients. Our study demonstrated that some of the components of the current CDC criteria were unreliable and we recommend their revision.
Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.
Our aim was to determine the total blood loss associated with surgery for fracture of the hip and to identify risk factors for increased blood loss. We prospectively studied 546 patients with hip fracture. The total blood loss was calculated on the basis of the haemoglobin difference, the number of transfusions and the estimated blood volume. The hidden blood loss, in excess of that observed during surgery, varied from 547 ml (screws/ pins) to 1473 ml (intramedullary hip nail and screw) and was significantly associated with medical complications and increased hospital stay. The type of surgery, treatment with aspirin, intra-operative hypotension and gastro-intestinal bleeding or ulceration were all independent predictors of blood loss. We conclude that total blood loss after surgery for hip fracture is much greater than that observed intra-operatively. Frequent post-operative measurements of haemoglobin are necessary to avoid anaemia.
We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance score clinical scale, the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Short-Form (SF-36) General Health Survey. In total, five questions were considered inappropriate, which resulted in the final 12-item questionnaire, which has been referred to as the Oxford elbow score. This comprises three unidimensional domains, ‘elbow function’, ‘pain’ and ‘social-psychological’; with each domain comprising four items with good measurement properties. This new 12-item Oxford elbow score is a valid measure of the outcome of surgery of the elbow.
This prospective five-year study analyses the impact of methicillin-resistant Encouragingly, overall infection rates have not risen significantly over the five years of the study despite increased prevalence of MRSA. However, the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively.