Background

Revision total knee arthroplasty (rTKA) is a high stakes procedure with complex equipment and multiple steps. For rTKA using the ATTUNE system revising femoral and tibial components with sleeves and stems, there are over 240 pieces of equipment that require correct assembly at the appropriate time. Due to changing teams, work rotas, and the infrequency of rTKR, scrub nurses may encounter these operations infrequently and often rely heavily on company representatives to guide them. In turn, this delays and interrupts surgical efficiency and can result in error. This study investigates the impact of a fully immersive virtual reality (VR) curriculum on training scrub nurses in technical skills and knowledge of performing a complex rTKA, to improve efficiency and reduce error.

The purpose of this prospective audit was to assess the efficacy of local infiltration analgesia in relieving postoperative pain following knee replacement surgery.

Methods and materials: Data was collected on 61 consecutive patients undergoing knee replacement. They formed 2 groups. Patients in Group I (n=33) had 30 mls of Bupivacaine 0.5%, Ketoralac 30 mg, 0.75ml of adrenaline 1:1000 concentration made up to100mls with normal saline while patients in Group II (n=28) had either patient controlled analgesia (PCA) or regional nerve blocks. The group I patients had the local analgesia cocktail infiltrated into the soft tissues before wound closure. Majority of these patients had spinal anaesthesia supplemented with sedation while some had general anaesthesia supplemented with regional nerve blocks. All the patients were prescribed morphine as rescue analgesia and patacetamol/co-codamol and/or naproxene as supplemental analgesia. Pain was assessed with Numerical Rating Scale (NRS 0 – 10) at 1 hr, 3 hr, 6 hr and 8 hrs post-operatively.

Results: The two groups were well matched for age, sex, ASA grade and body mass index. Pain control was generally satisfactory for group I (NRS range 0 – 2) compared to group II (NRS range 0 – 7). Most patients did not require morphine for post-operative pain control in group I (18/27 pts) while additional analgesics were not needed until 6 hours in this group. They were able to mobilise with assistance earlier compared to the other group. Moreover the pain levels as assessed by pain scores were lower with group I patients compared to group II patients. The nursing level of intensity was lower in group I patients as monitoring of PCA was not required compared to group II patients.

Conclusion: Local infiltration analgesia is practical, simple and safe procedure with good efficacy in relieving pain after knee surgery. Moreover monitoring levels are reduced relieving nursing staff to concentrate on other duties.

Introduction: We undertook an audit study to find out patient perception of being seen by a nurse practitioner in the clinic for a follow up appointment instead of a consultant and satisfaction with the joint clinic.

Methods and materials: 100 patients were surveyed following their post-operation review with the nurse. Data was collected prospectively over a period of 6 months. Patients were asked to complete the questionnaire on the day of their appointment and to hand the survey prior to leaving. Hence we had 100% response rate.

Results: Majority of the respondents were female (61%) with 50 % having had total hip replacements and the rest had knee replacements. 99% of respondents (94/95) felt that enough time was spent with them during the appointment. All respondents (100%) reported that they were able to ask questions and were answered satisfactorily. The consultant saw 26% of respondents; further 6% was seen by a registrar and the rest 68% were seen by the nurse specialist. Reasons for being seen by a doctor included check up or assessment, reviewing stitches and infection. 42% of respondents (33/79) were referred for further treatment either by the consultant (33%), nurse (64%) or registrar (3%). Reasons for further treatment included physiotherapy, plaster room, and further follow up (check up) appointment at 3–6 months to review the patient following surgery. 100% of respondents (97/97) were satisfied with the combined consultant/nurse clinic. 3 did not record their response. The vast majority of respondents (80%, 79/99) reported that they ‘don’t mind’ who they would have been seen by in the clinic.

Discussion: The results indicate that patients are satisfied with the current clinic arrangements i.e. nurse-led clinic with the consultant being available. Hence there is a definite role for nurse led clinics for joint replacement surgery follow-ups.

Introduction: A posterior entry point, a neutral tip position and stem alignment are recommended for an even cement mantle and an optimal outcome in total hip arthroplasty (THA). Our aim was to highlight any differences between the two approaches in obtaining a neutral stem tip position, particularly in the saggital plane.

Methods: We examined the post op, digitised radiographs of 100 (50 each group) polished, tapered Exeter THA, inserted via the antero-lateral or posterior approaches. The stem tip position was defined as the distance, in millimetres, between the centre of the femoral canal and the centre of the stem tip, in both the coronal and saggital planes.

Results: There was a significant difference between the two approaches in the saggital stem tip position only (p= 0.01), but not in coronal tip position (p=0.1). When not in neutral, stems inserted by the antero-lateral approach showed a marked deviation towards the posterior cortex. This was not the case with the posterior approach.

Discussion: Our results illustrate that a neutral stem tip position in THA, and subsequently an even cement mantle, is significantly more difficult to obtain with an antero-lateral approach than a posterior approach. A posterior approach to the hip avoids the cuff of glutei that can lever the proximal stem anteriorally causing an anterior entry point and a posterior stem tip position. It also illustrates how the anatomy of the proximal femur in the saggital plane makes a neutral stem alignment difficult to achieve with either approach.