Reduced length of stay (LOS) is logistically, economically and physiologically beneficial. Although a high proportion of total joint arthroplasty (TJA) patients are suitable for same day admission (SDA), removable barriers persist in many centres. This study aimed to determine factors limiting SDA and quantify the impact of implementing both SDA and a targeted enhanced recovery programme on length of stay.

This single-centre retrospective cohort study collected data on elective TJA patients aged <60. Qualitative service reviews identified opportunities for optimisation. Improvements were implemented in 2017, including: obtaining consent at the pre-assessment clinic and robustly assessing suitability for SDA. A targeted rapid recovery program was implemented in June 2018. Data was collected prior to changes in 2017, and following changes in 2018.

106 of 108 screened patients were eligible for inclusion. There were no significant between-year differences in baseline health characteristics. Significantly greater proportions of 2018 patients were consented at their pre-assessment clinic (56% vs 8.9%, p<0.001) and assessed as suitable for SDA (94% vs 57.1%, p<0.001). Pre-operative LOS was significantly reduced in 2018 for both total hip replacements (median [IQR]: 0[0,0] vs 1[1,1], p<0.001) and total knee replacements (median [IQR]: 0[0,0] vs 0[0,1], p=0.002). The departmental mean LOS improved from 4.7 days to 3.7 days following SDA. This was further shortened to 3.2 days after introduction of the rapid recovery program.

When a larger proportion of patients were deemed suitable for SDA, this correlated with reduction of LOS. The department now performs above national standards in both of these parameters.

Introduction: Polymodal anaesthesia has become the core approach for the modern anaesthetist. Femoral, sciatic and obturator nerve blockade, individually or in combination, by means of either single shot or continuous infusion, are often used as adjuncts to general anaesthesia in knee arthroplasty.

Methods: We examine the outcome of 2 groups of 100 patients from 2 surgeons and their anaesthetists. All patients received a general anaesthetic. The first group receive a single shot femoral and sciatic nerve block, the second group a standard GA and local infiltration of the surgical field. Post operatively, both groups received identical analgesic regimes and rehabilitation programmes.

Results: Length of stay was prolonged in the nerve blockade group, with 21 of the 100 patients still in hospital on day 6 versus 9 patients in the local infiltration group. An initial advantage in flexion and extension in the nerve blockade group was reversed by day 2 and persisted thereafter. Motor dysfunction was seen to be more prevalent and of longer duration in the nerve blockade group. Muscle groups supplied by the sciatic nerve were 4 times more likely to be involved than those supplied by the femoral nerve. Dysaesthesia in the sciatic nerve dermatomes was 5 times more likely within the nerve blockade group, but less likely in the local infiltration group. No significant difference in rates of VTE. Pain control was superior and less analgesia was required in the nerve blockade group. Fewer patients required urethral catheterisation in the local infiltration group. One heel ulcer occurred in the nerve blockade group. Tourniquet time, significant as a possible contributor to nerve injury, was similar.

Conclusion: Nerve blockade in knee arthroplasty not recommended.

Regional anaesthesia, and the supplementation of either general or spinal anaesthesia with nerve block is well established and becoming increasingly more popular. Femoral, sciatic and obturator nerve blockade, in alone or in combination, by means of single shot or continuous infusion has been shown to significantly improve pain control and post operative nausea and vomiting (PONV). We identify equally significant morbidity associated with this practice, with delayed post operative rehabilitation, increase in length of stay, reduction in range of movement and local adverse symptoms at the site of injection and paraesthesia at 3 months post operatively.

2 surgeons were recruited to contribute 100 consecutive total knee replacements each to this study. Each worked exclusively with a one anaesthetist. Each had a predictable and different practice. One employed either spinal or general anaesthesia which the surgeon supplemented with end of operation infiltration of soft tissues in the surgical field including the capsule and skin incision with ropivacaine 300mg, adrenaline 500μg and ketorolac 30mg with normal saline added to make a volume of 100ml. The second employed either spinal or general anaesthesia but supplemented this with a single combined femoral and sciatic nerve block performed pre-operatively. Intravenous opiate analgesia administed via patient controlled analgesia pump for 24 hours post operatively, paracetamol 1g 6 hourly and ibuprofen 300mg 8 hourly where appropriate were prescribed by both anaesthetists. We recorded the incidence of insertion of urinary catheter, deep venous thrombosis diagnosed within 3 and 12 weeks, recovery of lower limb power to grade 5/5, range of movement achieved in each postoperative day and at 12 weeks post operatively, length of stay in addition to PONV and pain scores using the visual analogue scale (VAS) and collected every 6 hours. Localised pain and tenderness at the site of injection was noted at 12 weeks, and persistent paraesthesia.

As predicted patients in the group receiving nerve block has significantly less pain and post operative nausea and vomiting (p< 0.05). There was no statistically significant difference in the use of urinary catheters (p = 0.052) or the incidence of deep venous thrombosis (p=0.58). There was however a significant difference in the recovery of lower limb power (p = 0.023), range of movement recorded at 24hr intervals (p=0.038) (at 12 weeks p=0.54) and length of stay in hospital (0.038). One patient had an almost complete femoral nerve palsy at 12 weeks and required a manipulation under anaesthesia of her knee following recovery of same.

Nerve blockade is an increasingly popular method of controlling post-operative pain. We demonstrate some adverse effects on rehabilitation following this practice in addition to the increased financial and logistical burden of a longer inpatient stay.

Aims: To study prospectively the characteristic migration of four different cemented femoral stems using Radiostereometry. Methods: 96 patients undergoing cemented femoral hip replacement for osteoarthritis were randomised to receive an Exeter (Howmedica Stryker), Ultima Tapered Polished Stem [TPS], Ultima straight stem [USS] (Johnson and Johnson) or Charnley Elite (Depuy/Johnson and Johnson) stem. RSA migration measurements were performed postoperatively and at 6,12,18 and 24 months post surgery using the UMRSA system. Results: Two signiþcantly distinct patterns of distal migration in the y direction (subsidence) were seen, compatible with previous studies. Tapered stems subsided rapidly by six months, Exeter 0.85mm (±0.15) UTPS 0.85mm (±0.15), stabilising by 2 years, Exeter 1.3mm (±0.35), UTPS 1.2mm (±0.25). The USS and Elite designs showed lower migrations of 0.1mm (±0.1) and 0.15 (±0.15) mm at six and 0.25mm (±0.15) and 0.35mm (±0.15) at 24 months. For migrations and rotations in other directions, differences were seen between prostheses with the same design concept. Whilst both the UTPS and Exeter exhibited posterior migration of the head, by 24 months this was expressed as a rotation about the transverse axis for the TPS and the axial axis for the Exeter. The Elite and USS differed in rates of posterior migration and varus tilt. Conclusions: Patterns of migration for stems with the same design concept may vary due to subtle differences in prosthesis shape. These variations produce a distinct migration Ç signature È for each stem.

Aims: To study prospectively the characteristic migration of four different cemented femoral stems using Radiostereometry.

Methods: 96 patients undergoing cemented femoral hip replacement for osteoarthritis were randomised to receive an Exeter (Howmedica Stryker), Ultima Tapered Polished Stem [TPS], Ultima straight stem [USS] (Johnson and Johnson) or Charnley Elite (Depuy/Johnson and Johnson) stem. RSA migration measurements were performed at postoperatively and at 6,12,18 and 24 months post surgery using the UMRSA system enhanced with locally developed software.

Results: Two significantly distinct patterns of distal migration in the y direction (subsidence) were seen compatible with previous studies. Tapered stems subsided rapidly by six months Exeter 0.85mm (+/−0.15) UTPS 0.85mm (+/−0.15) stabilising by 2 years Exeter 1.3mm(+/−0.35), UTPS 1.2mm(+/−0.25). The USS and Elite designs showed lower migrations of 0.1mm (+/−0.1) and 0.15 (+/−0.15) mm at six and 0.25mm(+/−0.15) and 0.35mm (+/−0.15) 24 months. For migrations and rotations in other directions differences were seen between prostheses with the same design concept. Whilst both the UTPS and Exeter exhibited posterior migration of the head, by 24 months this was expressed as a rotation about the transverse axis for the TPS and the axial axis for the Exeter. The Elite and USS differed in rates of posterior migration and varus tilt.

Conclusions: Patterns of migration for stems with the same design concept may vary due to subtle differences in prosthesis shape. These variations produce a distinct migration “signature” for each stem.