Aims. The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA). Methods. This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC. Results. The mean 90-day revision rate for infection was 0.1% (0.1% to 0.2%) for TKA and 0.3% (0.1% to 0.5%) for THA. The mean 90-day PJI rates defined by T84.5 were 1.3% (1.1% to 1.7%) for TKA and 1.1% (0.8% to 1.3%) for THA. The mean 90-day PJI rates using the extended definition were 1.9% (1.5% to 2.2%) and 1.5% (1.3% to 1.7%) following TKA and THA, respectively. Conclusion. When reporting the revision arthroplasty for infection, the AOANJRR substantially underestimates the rate of PJI at 90 days. Using combinations of infection codes and PJI-related surgical procedure codes in linked hospital administrative databases could be an alternative way to monitor PJI rates. Cite this article: Bone Joint J 2022;104-B(9):1060–1066

Aims. The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone. Methods. This nationwide retrospective cohort study used data from the Diagnosis Procedure Combination database. We included patients aged ≥ 18 years who underwent surgery for hip fractures and received acetaminophen combined with NSAIDs (combination group), NSAIDs alone (NSAIDs group), or acetaminophen alone (acetaminophen group) preoperatively, between April 2010 and March 2022. Primary outcomes were in-hospital mortality and complications. Secondary outcomes were opioid use postoperatively; readmission within 90 days, one year, and two years; and total hospitalization costs. We used propensity score overlap weighting models, with the acetaminophen group as the reference group. Results. We identified 93,018 eligible patients, including 13,068 in the combination group, 29,203 in the NSAIDs group, and 50,474 in the acetaminophen group. Propensity score overlap weighting successfully balanced patient characteristics among the three groups, with no significant difference in in-hospital mortality rates observed among the groups (combination group risk difference 0.0% (95% CI -0.5 to 0.4%); NSAIDs group risk difference -0.2% (95% CI -0.5 to 0.2%)). However, the combination group exhibited a significantly lower risk of in-hospital complications than the acetaminophen group (risk difference -1.9% (95% CI -3.2 to -0.6%)) as well as a significantly lower risk of deep vein thrombosis (risk difference -1.4% (95% CI -2.2 to -0.7%)). Furthermore, total hospitalization costs were higher in the NSAIDs group than in the acetaminophen group (difference USD $438 (95% CI 249 to 630); p < 0.001). No significant differences in other secondary outcomes were observed among the three groups. Conclusion. The combination of acetaminophen with NSAIDs appears to be safe and advantageous in terms of reducing in-hospital complications. Cite this article: Bone Joint J 2024;106-B(8):849–857

Aims. In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods. This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results. The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion. Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies. Cite this article: Bone Jt Open 2023;4(10):791–800

Aims. Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. Methods. TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. Results. Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. Conclusion. This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536–542

Aims. Postoperative length of stay (LOS) and discharge dispositions following arthroplasty can be used as surrogate measurements for improvements in patients’ pathways and costs. With the increasing use of robotic technology in arthroplasty, it is important to assess its impact on LOS. The aim of this study was to identify factors associated with decreased LOS following robotic arm-assisted total hip arthroplasty (RO THA) compared with the conventional technique (CO THA). Methods. This large-scale, single-institution study included 1,607 patients of any age who underwent 1,732 primary THAs for any indication between May 2019 and January 2023. The data which were collected included the demographics of the patients, LOS, type of anaesthetic, the need for treatment in a post-anaesthesia care unit (PACU), readmission within 30 days, and discharge disposition. Univariate and multivariate logistic regression models were used to identify factors and the characteristics of patients which were associated with delayed discharge. Results. The multivariate model identified that age, female sex, admission into a PACU, American Society of Anesthesiologists grade > II, and CO THA were associated with a significantly higher risk of a LOS of > two days. The median LOS was 54 hours (interquartile range (IQR) 34 to 78) in the RO THA group compared with 60 hours (IQR 51 to 100) in the CO THA group (p < 0.001). The discharge dispositions were comparable between the two groups. A higher proportion of patients undergoing CO THA required PACU admission postoperatively, although without reaching statistical significance (7.2% vs 5.2%, p = 0.238). Conclusion. We found that among other baseline characteristics and comorbidities, RO THA was associated with a significantly shorter LOS, with no difference in discharge destination. With the increasing demand for THA, these findings suggest that robotic assistance in THA could reduce costs. However, randomized controlled trials are required to investigate the cost-effectiveness of this technology. Cite this article: Bone Joint J 2024;106-B(3 Supple A):24–30

Aims. The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA). Methods. In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered. Results. Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol. Conclusion. These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82–89

Aims. Open reduction in developmental dysplasia of the hip (DDH) is regularly performed despite screening programmes, due to failure of treatment or late presentation. A protocol for open reduction of DDH has been refined through collaboration between surgical, anaesthetic, and nursing teams to allow same day discharge. The objective of this study was to determine the safety and feasibility of performing open reduction of DDH as a day case. Methods. A prospectively collected departmental database was visited. All consecutive surgical cases of DDH between June 2015 and March 2020 were collected. Closed reductions, bilateral cases, cases requiring corrective osteotomy, and children with comorbidities were excluded. Data collected included demographics, safety outcome measures (blood loss, complications, readmission, reduction confirmation), and feasibility for discharge according to the Face Legs Activity Cry Consolidability (FLACC) pain scale. A satisfaction questionnaire was filled by the carers. Descriptive statistics were used for analysis. Results. Out of 168 consecutive DDH cases, 16 patients fit the inclusion criteria (age range 10 to 26 months, 13 female). Intraoperative blood loss ranged from "minimal" to 120 ml, and there were no complications or readmissions. The FLACC score was 0 for all patients. The carers satisfaction questionnaire expressed high satisfaction from the experience with adequate information and support provided. Conclusion. Open reduction in DDH, without corrective osteotomy, is safe and feasible to be managed as a day case procedure. It requires a clear treatment pathway, analgesia, sufficient counselling, and communication with carers. It is even more important during the COVID-19 pandemic when reduced length of hospital stay is likely to be safer for both patient and their parents. Cite this article: Bone Joint Open 2021;2(4):271–277

Aims. Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients. Methods. A retrospective cohort study was undertaken using data from the Scottish Hip Fracture Audit between May 2016 and December 2020. Only patients undergoing THA were included, with categorization according to surgical treatment within 36 hours of admission (≤ 36 hours = ‘acute group’ vs > 36 hours = ‘delayed’ group). Those with delays due to being “medically unfit” were excluded. The primary outcome measure was 30-day survival. Costs were estimated in relation to the differences in the lengths of stay. Results. A total of 1,375 patients underwent THA, with 397 (28.9%) having surgery delayed by > 36 hours. There were no significant differences in the age, sex, residence prior to admission, and Scottish Index of Multiple Deprivation for those with, and those without, delayed surgery. Both groups had statistically similar 30-day (99.7% vs 99.3%; p = 0.526) and 60-day (99.2% vs 99.0%; p = 0.876) survival. There was, however, a significantly longer length of stay for the delayed group (acute: 7.0 vs delayed: 8.9 days; p < 0.001; overall: 8.7 vs 10.2 days; p = 0.002). Delayed surgery did not significantly affect the rates of 30-day readmission (p = 0.085) or discharge destination (p = 0.884). The results were similar following adjustment for potential confounding factors. The estimated additional cost due to delayed surgery was £1,178 per patient. Conclusion. Delayed surgery does not appear to be associated with increased mortality in patients with an intracapsular hip fracture who undergo THA, compared with those who are treated with a hemiarthroplasty or internal fixation. Those with delayed surgery, however, have a longer length of stay, with financial consequences. Clinicians must balance ethical considerations, the local provision of orthopaedic services, and optimization of outcomes when determining the need to delay surgery in a patient with a hip fracture awaiting THA. Cite this article: Bone Joint J 2023;105-B(11):1201–1205

Aims. It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. Methods. We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m. 2. (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m. 2. , n = 512); obese (BMI 30 kg/m. 2. to 39.9 kg/m. 2. , n = 748); and morbidly obese (BMI > 40 kg/m. 2. , n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes. Results. Obese patients had a significantly increased rate of discharge to a rehabilitation facility compared with non-obese patients (38.7% (426/1,102) vs 26.0% (133/512), respectively; p < 0.001). When stratified by BMI, discharge to a rehabilitation facility remained significantly higher compared with non-obese (26.0% (133)) in both obese (34.2% (256), odds ratio (OR) 1.6) and morbidly obese (48.0% (170), OR 3.1) patients (p < 0.001). However, there was no significant difference in unexpected ICU transfer (0.4% (two) non-obese vs 0.9% (seven) obese (OR 2.5) vs 1.7% (six) morbidly obese (OR 5.4); p = 0.054), visits to the ED (8.6% (44) vs 10.3% (77) (OR 1.3) vs 10.5% (37) (OR 1.2); p = 0.379), readmissions (4.5% (23) vs 4.0% (30) (OR 1.0) vs 5.1% (18) (OR 1.4); p = 0.322), or reoperations (2.5% (13) vs 3.3% (25) (OR 1.2) vs 3.1% (11) (OR 0.9); p = 0.939). Conclusion. With the use of a preoperative RST, morbidly obese patients had similar rates of short-term postoperative adverse outcomes after primary TKA as non-obese patients. This supports the assertion that morbidly obese patients can safely undergo TKA with appropriate perioperative optimization and monitoring. Cite this article: Bone Joint J 2021;103-B(6 Supple A):45–50

Aims. The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR’s data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019. Methods. Structured Query Language was used to obtain data relating to patients who underwent total hip or knee arthroplasty (THA and TKA) from the hospital network’s electronic medical record (EMR) system to be included in the PAR. Data were stored in a secure database and visualized in dashboards. Quality assurance of PAR data was performed by review of the medical records. Capture rate was determined by comparing two months of PAR data with operating room schedules. Linear and binary logistic regression models were constructed to determine if length of stay (LOS), discharge to a care home, and readmission rates improved between 2016 and 2019. Results. The PAR captured 16,163 THAs and TKAs between April 2016 and March 2019, performed in seven hospitals by 110 surgeons. Manual comparison to operating schedules showed a 100% capture rate. Review of the records was performed for 2,603 random operations; 2,298 (88.3%) had complete and accurate data. The PAR provided the data for three abstracts presented at international conferences and has led to preoperative mental health treatment as a quality improvement initiative in the participating institutions. For primary THA and TKA surgeries, the LOS decreased significantly (p < 0.001) and the rate of home discharge increased significantly (p < 0.001) between 2016 and 2019. Readmission rates did not correlated with the date of surgery (p = 0.953). Conclusion. The PAR has high rates of coverage (the number of patients treated within the Partners healthcare network) and data completion and can be used for both research purposes and quality improvement. The same method of creating a registry that was used in the PAR can be applied to hospitals using similar EMR systems. Cite this article: Bone Joint J 2020;102-B(7 Supple B):90–98

Aims. The practice of overlapping surgery has been increasing in the delivery of orthopaedic surgery, aiming to provide efficient, high-quality care. However, there are concerns about the safety of this practice. The purpose of this study was to examine the safety and efficacy of a model of partially overlapping surgery that we termed ‘swing room’ in the practice of primary total hip (THA) and knee arthroplasty (TKA). Methods. A retrospective review of prospectively collected data was carried out on patients who underwent primary THA and TKA between 2006 and 2017 in two academic centres. Cases were stratified as partially overlapping (swing room), in which the surgeon is in one operating room (OR) while the next patient is being prepared in another, or nonoverlapping surgery. The demographic details of the patients which were collected included operating time, length of stay (LOS), postoperative complications within six weeks of the procedure, unplanned hospital readmissions, and unplanned reoperations. Fisher's exact, Wilcoxon rank-sum tests, chi-squared tests, and logistic regression analysis were used for statistical analysis. Results. A total of 12,225 cases performed at our institution were included in the study, of which 10,596 (86.6%) were partially overlapping (swing room) and 1,629 (13.3%) were nonoverlapping. There was no significant difference in the mean age, sex, body mass index (BMI), side, and LOS between the two groups. The mean operating time was significantly shorter in the swing room group (58.2 minutes) compared with the nonoverlapping group (62.8 minutes; p < 0.001). There was no significant difference in the rates of complications, readmission and reoperations (p = 0.801 and p = 0.300, respectively) after adjusting for baseline American Society of Anesthesiologists scores. Conclusion. The new ‘swing room’ model yields similar short-term outcomes without an increase in complication rates compared with routine single OR surgery in patients undergoing primary THA or TKA. Cite this article: Bone Joint J 2020;102-B(7 Supple B):112–115

Aims. Patients with metabolic syndrome (MetS) are known to be at increased risk of postoperative complications, but it is unclear whether MetS is also associated with complications after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Here, we perform a systematic review and meta-analysis linking MetS to postoperative complications in THA and TKA. Methods. The PubMed, OVID, and ScienceDirect databases were comprehensively searched and studies were selected and analyzed according to the guidelines of the Meta-analysis of Observational Studies in Epidemiology (MOOSE). We assessed the methodological quality of each study using the Newcastle-Ottawa Scale (NOS), and we evaluated the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Data were extracted and meta-analyzed or qualitatively synthesized for several outcomes. Results. Ten cohort studies involving 1,352,685 patients were included. Qualitative analysis suggested that MetS was associated with a higher incidence of cardiovascular events, and meta-analysis showed that MetS increased the risk of all-cause complications (risk ratio (RR) 1.55, 95% confidence interval (CI) 1.28 to 1.89), surgical site infection (SSI; RR 2.99, 95% CI 1.30 to 6.90), urinary tract infection (UTI; RR 2.58, 95% CI 1.03 to 6.43), and 30-day readmission (RR 1.45, 95% CI 1.33 to 1.59). There was insufficient evidence for assessing an association between MetS and venous thromboembolism events, pulmonary or gastrointestinal complications, or mortality. Conclusion. Patients with MetS undergoing THA and TKA are at increased risk of all-cause complications, cardiovascular complications, SSI, UTI, and 30-day readmission. Surgeons should be aware of the increased risk of these complications in MetS, and presurgical protocols for these complications should give special consideration to MetS patients. Cite this article:Bone Joint Res. 2020;9(3):120–129

Aims. Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. Methods. The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. Results. A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or ‘other’ race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. Conclusion. After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78–84

Aims. Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes. Methods. Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries. Results. In total, 1,312 Thompson’s hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%. Conclusion. The Thompson’s stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson’s implant as a cost-effective option for frail hip fracture patients. Cite this article: Bone Jt Open 2022;3(9):710–715

Aims. Antibiotic prophylaxis involving timely administration of appropriately dosed antibiotic is considered effective to reduce the risk of surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA). Cephalosporins provide effective prophylaxis, although evidence regarding the optimal timing and dosage of prophylactic antibiotics is inconclusive. The aim of this study is to examine the association between cephalosporin prophylaxis dose, timing, and duration, and the risk of SSI after THA/TKA. Methods. A prospective multicentre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected prior to and for one-year post surgery. Logistic regression was undertaken to explore associations between dose, timing, and duration of cephalosporin prophylaxis and SSI. Data were analyzed for 1,838 participants. There were 264 SSI comprising 63 deep SSI (defined as requiring intravenous antibiotics, readmission, or reoperation) and 161 superficial SSI (defined as requiring oral antibiotics) experienced by 249 (13.6%) participants within 365 days of surgery. Results. In adjusted modelling, factors associated with a significant reduction in any SSI and deep SSI included: correct weight-adjusted dose (any SSI; adjusted odds ratio (aOR) 0.68 (95% confidence interval (CI) 0.47 to 0.99); p = 0.045); commencing preoperative cephalosporin within 60 minutes (any SSI, aOR 0.56 (95% CI 0.36 to 0.89); p = 0.012; deep SSI, aOR 0.29 (95% CI 0.15 to 0.59); p < 0.001) or 60 minutes or longer prior to skin incision (aOR 0.35 (95% CI 0.17 to 0.70); p = 0.004; deep SSI, AOR 0.27 (95% CI 0.09 to 0.83); p = 0.022), compared to at or after skin incision. Other factors significantly associated with an increased risk of any SSI, but not deep SSI alone, were receiving a non-cephalosporin antibiotic preoperatively (aOR 1.35 (95% CI 1.01 to 1.81); p = 0.044) and changing cephalosporin dose (aOR 1.76 (95% CI 1.22 to 2.57); p = 0.002). There was no difference in risk of any or deep SSI between the duration of prophylaxis less than or in excess of 24 hours. Conclusion. Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSI in THA/TKA, whereas the duration of prophylaxis beyond 24 hours is unnecessary. Cite this article: Bone Jt Open 2022;3(3):252–260

Aims. Elective orthopaedic surgery was cancelled early in the COVID-19 pandemic and is currently running at significantly reduced capacity in most institutions. This has resulted in a significant backlog to treatment, with some hospitals projecting that waiting times for arthroplasty is three times the pre-COVID-19 duration. There is concern that the patient group requiring arthroplasty are often older and have more medical comorbidities—the same group of patients advised they are at higher risk of mortality from catching COVID-19. The aim of this study is to investigate the morbidity and mortality in elective patients operated on during the COVID-19 pandemic and compare this to a pre-pandemic cohort. Primary outcome was 30-day mortality. Secondary outcomes were perioperative complications, including nosocomial COVID-19 infection. These operations were performed in a district general hospital, with COVID-19 acute admissions in the same building. Methods. Our institution reinstated elective operations using a “Blue stream” pathway, which involves isolation before and after surgery, COVID-19 testing pre-admission, and separation of ward and theatre pathways for “blue” patients. A register of all arthroplasties was taken, and their clinical course and investigations recorded. Results. During a seven-month period, 340 elective arthroplasties were performed. There was zero mortality. One patient had a positive swab for COVID-19 while an inpatient, but remained asymptomatic. There were two readmissions within a 12-week period for hip dislocation. Patients had a mean age of 68 years (28 to 90), mean BMI of 30 kg/m. 2. (19.0 to 45.6), and mean American Society of Anesthesiologists grade of 2 (1 to 3). Conclusion. Results show no increased morbidity or mortality in this cohort of patients compared to the same hospital’s morbidity and mortality pre-COVID-19. The screened pathway for elective patients is effective in ensuring that patients can be safely operated on electively in an acute hospital. This study should reassure clinicians and patients that arthroplasties can be carried out safely when the appropriate precautions are in place. Cite this article: Bone Jt Open 2021;2(11):940–944

Aims. We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon. Methods. We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed. Results. Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit. Conclusion. Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA. Cite this article: Bone Jt Open 2021;2(2):93–102

Aims. As our population ages, the number of octogenarians who will require a total hip arthroplasty (THA) rises. In a value-based system where operative outcomes are linked to hospital payments, it is necessary to assess the outcomes in this population. The purpose of this study was to compare outcomes of elective, primary THA in patients ≥ 80 years old to those aged < 80. Methods. A retrospective review of 10,251 consecutive THA cases from 2011 to 2019 was conducted. Patient-reported outcome (PRO) scores (Hip disability and Osteoarthritis Outcome Score (HOOS)), as well as demographic, readmission, and complication data, were collected. Results. On average, the younger cohort (YC, n = 10,251) was a mean 61.60 years old (SD 10.71), while the older cohort (OC, n = 609) was 84.25 years old (SD 3.02) (p < 0.001). The OC had greater surgical risk based on their higher mean American Society of Anesthesiologists (ASA) scores (2.74 (SD 0.63) vs 2.30 (SD 0.63); p < 0.001) and Charlson Comorbidity Index (CCI) scores (6.26 (SD 1.71) vs 3.87 (SD 1.98); p < 0.001). While the OC stayed in the hospital longer than the YC (mean 3.5 vs 2.5 days; p < 0.001), there were no differences in 90-day emergency visits (p = 0.083), myocardial infarctions (p = 0.993), periprosthetic joint infections (p = 0.214), dislocations (p = 0.993), or aseptic failure (p = 0.993). The YC was more likely to be readmitted within 90 days (3.88% vs 2.18%, Β = 0.57; p = 0.048). There were no observed differences in 12-week (p = 0.518) or one-year (p = 0.511) HOOS scores. Conclusion. Although patients ≥ 80 years old have a greater number of comorbidities than younger patients, they had equivalent perioperative complication rates and PRO scores. This study demonstrates the safety and success of elective THA in octogenarians. Cite this article: Bone Jt Open 2021;2(7):535–539

Aims. The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic. Methods. Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months. Results. There were 167 elective procedures performed in the first three weeks of the study period, prior to the first national lockdown, and 57 emergency procedures thereafter. Three patients (1.3%) were readmitted within 30 days of discharge. There was one death (0.45%) due to SARS-CoV-2 infection after an emergency procedure. None of the patients developed complications of SARS-CoV-2 infection after elective arthroplasty. There was no observed spike in complications during in-hospital stay or in the early postoperative period. There was no statistically significant difference in survival between pre-COVID-19 and peri-COVID-19 groups (p = 0.624). We observed a higher number of emergency procedures performed during the pandemic within our institute. Conclusion. An international cohort has reported 30-day mortality as 28.8% following orthopaedic procedures during the pandemic. There are currently no reports on clinical outcomes of patients treated with lower limb reconstructive surgery during the same period. While an effective vaccine is developed and widely accepted, it is very likely that SARS-CoV2 infection remains endemic. We believe that this report will help guide future restoration planning here in the UK and abroad. Cite this article: Bone Jt Open 2021;2(5):323–329

Aims. The purpose is to determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person physiotherapy rehabilitation model. Methods. A multicentre prospective randomized controlled trial was conducted evaluating the use of a smartphone-based care management system for primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA). Patients in the control group (n = 244) received the respective institution’s standard of care with formal physiotherapy. The treatment group (n = 208) were provided a smartwatch and smartphone application. Early outcomes assessed included 90-day knee range of movement, EuroQoL five-dimension five-level score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score, 30-day single leg stance (SLS) time, Time up and Go (TUG) time, and need for manipulation under anaesthesia (MUA). Results. Overall, 90-day mean flexion was not significantly different between the control (121° (SD 11.7°)) and treatment groups (121. o. ; p = 0.559); 90-day mean SLS was 22.7 seconds (SD 9.8) in controls and 24.3 seconds (SD 20.8) in treatment (p = 0.519); 90-day mean TUG times were 10.1 seconds (SD 4.8) in control and 9.3 seconds (SD 3.3) in treatment (p = 0.139). Mean KOOS JR scores were significantly different between control group (73.6 (SD 13.4)) and treatment group (70.4 (SD 12.6); p = 0.026). MUAs were performed in nine (3.7%) patients in the control group and four (1.9%) in the treatment group (p = 0.398). Physiotherapy was performed by 230 (94.4%) of control group and 123 (59.3%) of treatment group (p < 0.001). There were no significant differences between groups in postoperative urgent care visits, or readmissions within 90 days, with significantly fewer emergency department visits in the treatment group (16 (8.2%) vs five (2.5%), p = 0.014). Conclusion. The use of the smartwatch/smartphone care platform demonstrated non-inferiority of clinically significant outcomes to traditional care models, while requiring significantly less postoperative physiotherapy and fewer emergency department visits. This platform could aid in decreasing postoperative costs, while improving patient engagement and communication with the healthcare team. Cite this article: Bone Joint J 2021;103-B(6 Supple A):3–12