Non-surgical osteoarthritis management includes analgesia escalation to oral opiates; however, tolerance can occur. This study aims to assess analgesic effects of opiate use pre-operatively and whether this influences outcome 1-year post-operatively in patients undergoing total hip/knee arthroplasty (THA/TKA). This prospective study assessed 1487 patients undergoing primary THA (n=729) or TKA (n=758) for osteoarthritis, with 95 respectively reporting pre-operative opiate use >1 month. THA opiate users had significantly higher BMI (p=0.007) and more likely to suffer associated comorbidities. TKA opiate users were significantly younger (p<0.001), with higher BMI (p=0.019) and more likely to suffer associated comorbidities. Pre-operative quality of life (QoL) and joint specific function were significantly worse (Hip EQ-5D 0.17 vs 0.41, p<0.001, OHS 14.6 vs 21.2, p<0.001; Knee EQ-5D 0.27 vs 0.44, p<0.001, OKS 16.4 vs 21.4, p<0.001). Pre-operative pain was significantly worse in those taking opioids (Hip Pain VAS 42.73 vs 50.70, p<0.001; Knee Pain VAS 50.93 vs 53.36, p=0.30). Post-operatively the THA opiate group had significant improvement in EQ-5D (0.175, p<0.001) and OHS (6.5, p<0.001) but were significantly less improved than opiate naïve patients after adjusting for confounding (EQ-5D 0.10, p<0.001; OHS 3.2, p<0.001). TKA opiate group also had significant improvement in EQ-5D (p<0.001) and OKS (p<0.001) but were significantly less (EQ-5D 0.089, p<0.001; OKS 3.9, p<0.001) than opioid naïve patients. Pre-operative opiate use was associated with significantly worse pre-operative QoL, joint specific function and worse subjective pain. Post-operatively, the opiate group had significantly lower improvement in their QoL and joint specific function

Background

We compared pain relief after total hip arthroplasty using periarticular intraoperative injection along with single dose post operative injection of local anesthetic (THA) with the well-established practice of epidural infusion.

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

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period. Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year. 388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p<0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p<0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276). Of the surgical management group, those that underwent fixation <72 hours post injury were significantly less likely to develop pneumonia than those who were delayed >72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856). Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain. This impedes early mobilization and delays hospital discharge. A prospective audit of 1081 patients undergoing primary TKA during 2008 was completed. All patients followed a programme including preoperative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, postoperative high volume ropivacaine boluses with an intra-articular catheter and early mobilization. Primary outcome measure was length of stay. Secondary outcomes were verbal analogue pain scores on movement, time to mobilization, nausea and vomiting scores, urinary catheterization for retention, need for rescue analgesia, range of motion at discharge and six weeks postoperatively. The median day of discharge was postoperative day four. Median pain score on mobilization was three for first postoperative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterization rate was 6.9%. Rescue analgesia was required in 5% of cases. The median day of discharge was postoperative day four. Median range of motion was 85° on discharge and 93° at six weeks postoperatively. This comprehensive care plan provides satisfactory postoperative analgesia allowing early safe ambulation and discharge

Introduction. The peri-operative analgesic management of patients having either Total Knee Replacement (TKR) or Unicompartmental Knee Replacement (UKR) is an area that continues to have prominence, driven in part by the desire to reduce hospital stay, while maintaining high patient satisfaction. This is particularly relevant in the current climate of healthcare cost savings. We evaluated the role of “top up” intra-articular local anaesthetic injection after identifying that an appreciable number of patients in the unit suffered “breakthrough pain” on the first post-op day, when the effects of local analgesia are wearing off. Method. 43 patients, who were scheduled to have a cemented Oxford UKR, were prospectively recruited and randomised. All patients had the same initial anaesthetic regime of general anaesthesia, femoral nerve block and intra-operative intra-articular infiltration of the cocktail. All patients had a 16G multi-holed epidural catheter placed intra-articularly prior to wound closure. Patients had the same operative technique, post operative rehabilitation and rescue analgesia. An independent observer recorded post-operative pain scores using a visual analogue score (1–10) every 6 hours and any rescue analgesia that was required. On the morning after surgery, 22 patients, (Group I), received 20 mls of 0.5% bupivicaine through the catheter whilst 21 patients, (Group II), had 20 mls of normal saline by the same observer, (who was blinded to the contents of the solution being injected), after which the catheter was removed. Results. When comparing these two groups there was no statistical difference found in their pain scores on the day of operation. However, patients in Group I had a significantly better pain score initially post top up and then at 6 hours (2.4 (0–8) vs 5.7 (2–9), Mann-Whitney p<0.001). This cohort of patients required less rescue analgesia (22% vs 75%, Mann-Whitney p<0.001). In addition, Group I had statistically significant higher patient satisfaction outcome scores after the infiltration, (p<0.001), with 16 reporting very good satisfaction in comparison to 1 in Group II. There were no complications in either group. Discussion. Our study has shown that injection of local anaesthesia via an intra-articular catheter does reduce pain scores when compared to placebo. This implies that this technique may have a role in providing optimal pain relief after UKR

Elevated fat pads on a paediatric elbow radiograph may represent an intraarticular fracture. If no obvious fracture is visible, the injury may be treated with a collar and cuff until discomfort resolves. In some centres these patients are discharged directly from A&E, easing the load on fracture clinics and reducing the number of visits required by the patient. A retrospective study was carried out to review patient journey for children referred to clinic with elevated fat pads only and to investigate whether such a protocol could be established locally. Notes for all children attending fracture clinic in May 2018 were reviewed. X-rays for patients with any elbow injury were then reviewed. Patients with raised fat pads only were included in the study. Outcome following clinic review was recorded. 818 patients (315 new referrals) attended 15 clinics. 31 were referred with raised fat pads only. Mean age was 7.7 years with mean time to clinic of 4 days. 74.2% required no further treatment and were discharged at first clinic appointment. 8 patients were kept in cast for another 1–2 weeks due to parental apprehension, patient apprehension or patient being uncomfortable without cast. None of our patients required surgical intervention or re-attended following discharge. This study showed that patients with raised fat pads only can be treated with collar and cuff, analgesia and discharged from A&E with an advice leaflet. This would reduce the number of patients unnecessarily attending clinics thereby reducing patient distress and enabling more efficient use of clinic appointments

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.

Aims

Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.

The CALEDonian Technique™, promoting enhanced recovery after surgery, is a multimodal multidisciplinary technique. This has demonstrated excellent analgesic control allowing early mobilisation and discharge following TKA, whilst maintaining patient safety. All patients follow a planned programme beginning with pre-operative out-patient education at the pre-assessment visit. An anaesthetic regimen consisting of pre-emptive analgesia is combined with a spinal/epidural with propofol sedation. Intra-articular local anaesthetic soft tissue wound infiltration by the surgeon under direct vision is supplemented by post-operative high volume intermittent boluses via an intra-articular catheter. Early active mobilisation is positively encouraged. A prospective audit of over 1000 patients demonstrated 35% of patients mobilised on day 0 and 95% by day 1, with rescue analgesia required in only 5% of cases. 79% of patients experienced no nausea or vomiting helping reduce length of stay from six to four postoperative days. A catheterisation rate of 7%, a DVT rate of 0.6% and a PE rate of 0.5% remained within or below previously published levels. Laboratory studies examining the performance of the epidural filter and injection technique used for the post-operative intra-articular injections demonstrated this to be robust and effective at preventing bacterial ingress. This in-vitro data is supported by clinical results demonstrating no increase in the deep infection rate of 0.7% since the implementation of the technique at our institution. We conclude that the CALEDonian Technique™ effectively and safely improves patient post-operative recovery following TKA

Background. For some time, optimized perioperative pathway protocols have been implemented in orthopedic surgery. In our hospital an accelerated clinical pathway has been successfully in effect for several years, focused on safely decreasing patients' length of stay and increasing their function at the time of discharge. The aim of the present project was to evaluate whether a further optimization is even more promising regarding early postoperative outcome parameters. Materials and Methods. Prospective, parallel group design in an Orthopaedic University Medical Centre. 143 patients, scheduled for unilateral primary total knee replacement (TKR) under perioperative regional analgesia were included. 76 patients received a Standard Accelerated Clinical Pathway (SACP). 67 patients received an Optimized Accelerated Clinical Pathway (OACP) including patient-controlled regional analgesia pumps, ultra-early/doubled physiotherapy and motor driven continuous passive motion machine units. Main measures were early postoperative pain on a visual analogue scale, consumption of regional anaesthetics, knee range of motion, time out of bed, walking distance/stair climbing, circumference measurements and Knee Society Scores of the operated leg. Patients in both groups were checked for a possible discharge by a blinded orthopedic surgeon on the 5th and 8th postoperative (po) day, using a discharge checklist including the KATZ Index of Independence in Activities of Daily Living, standard requirements for pain at rest/mobilization, walking distance and regular wound healing. A potential discharge was only approved if the patient was able to meet all six criteria from the discharge checklist. Re-admission within 6 weeks after discharge from hospital was registered. Results. Patients within the OACP had significant benefits regarding stair climbing/walking distance/time-out-of bed/circumference measurements of the thigh/Knee Society function score on the 5th po day and stair climbing/circumference measurements of the thigh on the 8th po day, and reduction of the consumption of regional anaesthetics. No significant reduction in length of stay was observed. Discussion. Early postoperative functional process indicators tended to be higher within the OACP group, but the main effects flatten in the course of the first eight postoperative days. Further, prospective randomised clinical trials with uniform, objective discharge criteria are needed

Aims

This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma.

Background:. Developing a successful outpatient service for Ilizarov frame removal provides both patient and cost benefits. Misinformation and patient trepidation can be detrimental to recovery and influence choices. Education may play an important role in tailoring an efficacious service. Objective:. Review Belfast Regional Limb Reconstruction frame removal practice, introduce changes aimed at improving care and evaluate effects. Methods:. 1 year retrospective review of Ilizarov frame removal. Evaluation of service prior to and following provision of a new patient information leaflet, alongside a test wire removal technique. Subsequent service evaluation supplemented via patient reported feedback questionnaire. Results:. Retrospectively 85% Ilizarov frames removed in clinic, 54% required Entonox. Annual cost £19000. 46% patients unaware of process, gathering information from unprofessional sources. General anaesthetic and analgesic requirements related to psychosocial influences; no correlation between fracture configuration, elective reconstructive cases and operative techniques. Prospectively 96% patients found information leaflet educational and beneficial. 87% Ilizarov frames removed in clinic. 100% patients who had outpatient removal recommend this method. Entonox use reduced to 15% with average pain score 4.6/10 without analgesia. Patients felt happier. Projected annual cost savings £3000. 100% rated service excellent. Discussion:. Professional education and a standardised outpatient removal process for Ilizarov frames, delivered by a dedicated specialist team, reduces morbidity and positively impacts service provision

Aims

Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture.

Aims

Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation.

Achilles tendinopathy is characterised by chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. Extracorporeal shockwave treatment (ESWT) is of potential benefit in refractory cases where conservative management with analgesia, physiotherapy and corticosteroid injection have been unsuccessful. Patients with refractory Achilles tendinopathy enrolled between October 2010 and October 2011 received three sessions of ESWT over three weeks. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale were reassessed at six and 16 weeks post treatment. 51 patients completed follow up. Mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. Significant improvement (p<0.05) in VAS scores (rest and activity) and VISA-A scores was observed between baseline and 16 weeks. Mean Likert score was 3 (somewhat improved) at 16 weeks. Patients suffering Achilles tendinopathy for longer than 25 months had significantly less improvement than those affected for a shorter period. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy

In this review, we present the data of one of the largest non-designer, mid- to long-term follow ups of the AGC. We present a total of 1538 AGC knees during a 15 year period, of which 902 were followed up by postal or telephone questionnaire focused on Oxford Knee Scores, Visual analogues of function and pain and survival analyses performed. Mean length of follow up was 10.4 years. 85.7% of patients had an Oxford knee score of between 0 and 40, with 71.2% scoring between 0–30. 65.6% of patients responded with a Visual Analogue Score (VAS) of 0 or 1 at rest (minimum pain 0) and 53.9% reporting VA scores of 0 or 1 while walking. 87.5% of patients reported Excellent or good functional reports at final follow up and 90.3% reporting excellent or good pain control compared to per-operative levels. Survival analysis confirms excellent survivorship. This large cohort and multi-surgeon trial reproduces the excellent results as demonstrated by the designer centre (Ritter et al.). Mid to long term outcome sows excellent function and analgesia. Complication rates are low and the necessity for revision remains low

Aims

We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial.

Aims

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.

Aim To develop a militarily relevant complex extremity wounding model. Study Design Controlled laboratory study with New Zealand White Rabbits. Method Phase One: Injury Development. Under general anaesthesia, the flexor carpi ulnaris of the right forelimb was exposed and high energy, short duration impact delivered via drop test rig. Anaesthesia was maintained for three hours, the animal was recovered and saline soaked gauze and supportive bandaging applied. 48 hrs later, the animal was culled and muscle harvested for histological analysis. Analgesia was administered daily, animals checked by experienced staff at least twice daily and temperatures recorded by subcutaneous transponder. Phase Two: Contamination. Sequential groups of animals had inoculums of 1×102, 1×106 and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered as phase one. At 48 hours, animals were culled, muscle harvested and axillary lymph nodes sampled. Quantitative microbiological analysis was performed on the muscle. Results: Six animals given a loading of 0.5kg yielded consistent injury with 20% of the muscle becoming necrotic. Representative of injury from ballistic trauma, this was adopted as standard. Twenty-two subsequent animals were exposed to the injury and inoculated with the challenge doses. 1×106/100μl S.aureus provided the greatest consistency in recovered yield. There were no adverse effects on animal welfare and body temperatures were always within normal limits. Discussion. This model enables a consistent, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management including wound coverage and fracture fixation