Aims. The aim of this study was to surveil whether the standard operating procedure created for the NHS Golden Jubilee sufficiently managed COVID-19 risk to allow safe resumption of elective orthopaedic surgery. Methods. This was a prospective study of all elective orthopaedic patients within an elective unit running a green pathway at a COVID-19 light site. Rates of preoperative and 30-day postoperative COVID-19 symptoms or infection were examined for a period of 40 weeks. The unit resumed elective orthopaedic services on 29 June 2020 at a reduced capacity for a limited number of day-case procedures with strict patient selection criteria, increasing to full service on 29 August 2020 with no patient selection criteria. Results. A total of 2,373 cases were planned in the 40-week study period. Surgery was cancelled in 59 cases, six (10.2%) of which were due to having a positive preoperative COVID-19 screening test result. Of the remaining 2,314, 996 (43%) were male and 1,318 (57%) were female. The median age was 67 years (interquartile range 59.2 to 74.6). The median American Society of Anesthesiologists grade was 2. Hip and knee arthroplasties accounted for the majority of the operations (76%). Six patients tested positive for COVID-19 preoperatively (0.25%) and 39 patients were tested for COVID-19 within 30 days after discharge, with only five patients testing positive (0.22%). Conclusion. Through strict application of a COVID-19 green pathway, elective orthopaedic surgery could be safely delivered to a large number of patients with no selection criteria. Cite this article: Bone Jt Open 2021;2(11):951–957

Abstract. Background. During COVID-19 pandemic, there has been worldwide cancellation of elective surgeries to protect patients from nosocomial transmission and peri-operative complications. With unfolding situation, there is definite need for exit strategy to reinstate elective services. Therefore, more literature evidence supporting exit plan to elective surgical services is imperative to adopt a safe working principle. This study aims to provide evidence for safe elective surgical practice during pandemic. Methods. This single centre, prospective, observational study included adult patients who were admitted and underwent elective surgical procedures in the trust's COVID-Free environment at Birmingham Treatment Centre between 19th May and 14th July’2020. Data collected on demographic parameters, peri-operative variables, surgical specialities, COVID-19 RT-PCR testing results, post-operative complications and mortality. The study also highlighted the protocols it followed for the elective services during pandemic. Results. 303 patients were included with mean age of 49.9 years (SD 16.5) comprising of 59% (178) female and 41% (125) male. They were classified according to American Society of Anaesthesiologist Grade, different surgical specialities and types of anaesthesia used. 96% patients were discharged on the same day. 100% compliance to pre-operative COVID-19 testing was maintained. There was no 30-day mortality or major respiratory complications. Conclusion. Careful patient selection, simultaneous involvement of the pre-assessment and anaesthetic team, strict adherence to peri-operative protocols and delivering vigilant post-operative care for COVID-19 infection can help providing safe elective surgical services if the community transmission under reasonable control. However, it is particularly important to maintain COVID-free safe environment for such procedures

The significance of ring-fencing orthopaedic beds and protected elective sites have recently been highlighted by the British Orthopaedic Association & Royal College of Surgeons. During the pandemic many such elective setups were established with various degrees of success. This study aimed to compare the functioning and efficiency of a Orthopaedic Protected Elective Surgical Unit (PESU) instituted during the pandemic with the pre-pandemic elective service at our hospital (Pre-Pandemic ward or PPW). We retrospectively collected data of all patients who underwent elective Orthopaedic procedures in a protected elective unit during the pandemic (March 2020 – July 2020) and a similar cohort of patients operated via the routine elective service immediately prior to the pandemic (October 2019 – February 2020). Various parameters were compared and analysed. To minimise the effect of confounding factors a secondary analysis was undertaken comparing total hip replacements (THR) by a single surgeon via PESU (PESU-THR) and PPW (PPW-THR) over 5 months each from March-July 2021 and March-July 2019 respectively. A total of 192 cases were listed on PESU during the studied period whereas this number was 339 for PPW. However more than half (52%) of those listed for a surgery on PPW were cancelled and only 162 cases (48%) were actually performed. PESU had a significantly better conversion rate with only 12.5% being cancelled and 168 (87.5%) cases performed. 49% (87 out of 177) of the cases cancelled on PPW were due to a ‘bed unavailability’. A further 17% (30/177) and 16% (28/177) were cancelled due to ‘emergency case prioritisation’ and ‘patient deemed unfit’ respectively. In contrast only 3 out of the 24 patients cancelled on PESU were due to bed unavailability and the main reason for cancellation here was ‘patient deemed unfit’ (9/24). Single surgeon THR, showed similar demographic features for the 25 patients on PESU and 37 patients on PPW. The average age for these patients was 63 on PESU and 69 on PPW whereas the BMI was 33 and 30 respectively. The patients on PESU also demonstrated a decrease in length of hospital stay with an average of 3 days in comparison to 4.8 days for those admitted to PPW. PROMS scores were comparable at 6 weeks with an average improvement of 16.4/48 in the PESU-THR cohort and of 18.8/48 in the PPW-THR cohort. There were no readmissions or revisions recorded in the PESU-THR cohort while the PPW-THR cohort had 1 readmission and revision. Our study shows how a small ring fenced Orthopaedic elective unit in a district general hospital, even during a global pandemic, can function more efficiently than a routine elective facility with many shared services

Aims. There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019. Methods. A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019. Results. A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery. Conclusion. Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery. Level of evidence: III. Cite this article: Bone Jt Open 2022;3(1):42–53

The presence of metastatic bone disease (MBD) often necessitates major orthopaedic surgery. Patients will enter surgical care either through emergent or electively scheduled care pathways. Patients in a pain crisis or with an acute fracture are generally admitted via emergent care pathways whereas patients with identified high-risk bone lesions are often booked for urgent yet scheduled elective procedures. The purpose of this study is to compare the post-operative outcomes of patients who present through emergent or electively scheduled care pathways in patients in a Canadian health care system. We have conducted a retrospective, multicenter cohort study of all patients presenting for surgery for MBD of the femur, humerus, tibia or pelvis in southern Alberta between 2006 and 2021. Patients were identified by a search query of all patients with a diagnosis of metastatic cancer who underwent surgery for an impending or actual pathologic fracture in the Calgary, South and Central Alberta Zones. Subsequent chart reviews were performed. Emergent surgeries were defined by patients admitted to hospital via urgent care mechanisms and managed via unscheduled surgical bookings (“on call list”). Elective surgeries were defined by patients seen by an orthopaedic surgeon at least once prior to surgery, and booked for a scheduled urgent, yet elective procedure. Outcomes include overall survival from the time of surgery, hospital length of stay, and 30-day hospital readmission rate. We have identified 402 patients to date for inclusion. 273 patients (67.9%) underwent surgery through emergent pathways and 129 patients (32.1%) were treated through urgent, electively scheduled pathways. Lung, prostate, renal cell, and breast cancer were the most common primary malignancies and there was no significant difference in these primaries amongst the groups (p=0.06). Not surprisingly, emergent patients were more likely to be treated for a pathologic fracture (p<0.001) whereas elective patients were more likely to be treated for an impending fracture (p<0.001). Overall survival was significantly shorter in the emergent group (5.0 months, 95%CI: 4.0-6.1) compared to the elective group (14.9 months 95%CI: 10.4-24.6) [p<0.001]. Hospital length of stay was significantly longer in the emergent group (13 days, 95%CI: 12-16 versus 5 days, 95%CI: 5-7 days). There was a significantly greater rate of 30-day hospital readmission in the emergent group (13.3% versus 7.8%) [p=0.01]. Electively managed MBD has multiple benefits including longer post-operative survival, shorter length of hospital stay, and a lower rate of 30-day hospital readmission. These findings from a Canadian healthcare system demonstrate clinical value in providing elective orthopaedic care when possible for patients with MBD. Furthermore, care delivery interventions capable of decreasing the footprint of emergent surgery through enhanced screening or follow-up of patients with MBD has the potential to significantly improve clinical outcomes in this population. This is an ongoing study that will justify refinements to the current surgical care pathways for MBD in order to identify patients prior to emergent presentation. Future directions will evaluate the costs associated with each care delivery method to provide opportunity for health economic efficiencies

Aims. As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment. Methods. This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery. Results. Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p = 0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p = 0.03). Conclusion. Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services. Cite this article: Bone Joint Open 2020;1-6:267–271

Abstract. Background. The COVID-19 pandemic has strongly impacted elective orthopaedic surgery. At our trust, a geographically discrete elective site deals with planned orthopaedic surgery. There was a need to define a green pathway to deliver surgical care safely and efficiently, and tackle mounting waiting lists. Methods. Records of patients operated at our elective site, between 1. st. July 2020 and 14. th. January 2021, under a green pathway, including pre-operative self-isolation, COVID screening and segregating perioperative patients, were reviewed, and analysed retrospectively. Patients who did not attend (DNA) their post-operative follow-up appointments were identified. Finally, regional COVID incidence was compared with that in our centre. Results. During this period, 2466 patients were admitted for elective orthopaedic surgery, of which sixteen (0.6%) tested COVID-positive. Among these, two tested positive during asymptomatic in-patient screening, five tested positive within two weeks of discharge, while six tested positive beyond two weeks. One patient tested positive on the day of surgery, which was then postponed. Fourteen (87.5%) patients who tested positive recovered, with two COVID-related mortalities. We identified 34 (1.4%) DNA patients. The COVID incidence in our centre closely paralleled the regional incidence. There were no major COVID outbreaks and no definite evidence of in-hospital transmission. Conclusion. This green pathway has helped streamline patient flow for continuing elective surgery safely through the pandemic, under cautionary monitoring. Modulating elective activity in response to regional COVID rates is vital for addressing waiting lists. Given the encouraging results, this pathway is an effective measure for maintaining elective activity through the pandemic

Aims. Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre. Methods. A retrospective cohort study was performed. Patients undergoing primary or revision hip or knee arthroplasty over a six-month period, from 1 July to 31 December 2020, were compared to the same period in 2019 before the COVID-19 pandemic. Demographic data, American Society of Anesthesiologists (ASA) grade, wait to surgery, COVID-19 status, and length of hospital stay were recorded. Results. A total of 1,311 patients underwent hip or knee arthroplasty in the six-month period following recommencement of elective services in 2020 compared to 1,527 patients the year before. Waiting time to surgery increased in post-COVID-19 group (137 days vs 78; p < 0.001). Length of stay also significantly increased (0.49 days; p < 0.001) despite no difference in age or ASA grade. There were no cases of postoperative COVID-19 infection. Conclusion. Time to surgery and length of hospital stay were significantly higher following recommencement of elective orthopaedic services in the latter part of 2020 in comparison to a similar patient cohort from the year before. Longer waiting times may have contributed to the clinical and radiological deterioration of arthritis and general musculoskeletal conditioning, which may in turn have affected immediate postoperative rehabilitation and mobilization, as well as increasing hospital stay. Cite this article: Bone Jt Open 2021;2(8):655–660

Introduction. The purpose of this study was to compare implant survivorship and functional outcomes in patients undergoing reverse total shoulder arthroplasty (RTSA) for acute proximal humeral fracture (PHF) with those undergoing elective RTSA in a population-based cohort study. Methods. Prospectively collected data from the New Zealand Joint Registry from 1999 to 2021 and identified 7,277 patients who underwent RTSA. Patients were categorized by pre-operative indication, including acute PHF (10.1%), rotator cuff arthropathy (RCA) (41.9%), osteoarthritis (OA) (32.2%), rheumatoid arthritis (RA) (5.2%) and old traumatic sequelae (4.9%). The PHF group was compared with elective indications based on patient, implant, and operative characteristics, as well as post-operative outcomes (Oxford Shoulder Score [OSS], and revision rate) at 6 months, 5 and 10 years after surgery. Survival and functional outcome analyses were adjusted by age, sex, ASA class and surgeon experience. Results. Implant survivorship at 10 years for RTSA for PHF was 97.3%, compared to 96.1%, 93.7%, 92.8% and 91.3% for OA, RCA, RA and traumatic sequelae, respectively. When compared with RTSA for PHF, the adjusted risk of revision was higher for traumatic sequelae (hazard ratio = 2.29; 95% CI:1.12–4.68, p=0.02) but not for other elective indications. At 6 months post-surgery, OSS were significantly lower for the PHF group compared to RCA, OA and RA groups (31.1±0.5 vs. 35.6±0.22, 37.7±0.25, 36.5±0.6, respectively, p<0.01), but not traumatic sequelae (31.7±0.7, p=0.43). At 5 years, OSS were only significantly lower for PHF compared to OA (37.4±0.9 vs 41.0±0.5, p<0.01), and at 10 years, there were no differences between groups. Discussion and Conclusion. RTSA for PHF demonstrated reliable long-term survivorship and functional outcomes compared to other elective indications. Despite lower functional outcomes in the early post-operative period for the acute PHF group, implant survivorship rates were similar to patients undergoing elective RTSA

The purpose of this study was (1) to evaluate the adequacy of informed consent documentation in the trauma setting for distal radius fracture surgery compared with the elective setting for total knee arthroplasty (TKA) at a large public hospital and (2) to explore the relevant guidelines in New Zealand relating to consent documentation. Consecutive adult patients (≥16 years) undergoing operations for distal radius fractures and elective TKA over a 12-month period in a single-centre were retrospectively identified. All medical records were reviewed for the risks and complications recorded. The consent form was analysed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) index readability scores. A total of 133 patients undergoing 134 operations for 135 distal radius fractures and 239 patients undergoing 247 TKA were included. Specific risks of surgery were recorded significantly less frequently for distal radius fractures than TKA (43.3% versus 78.5%, P < 0.001). Significantly fewer risks were recorded in the trauma setting compared to the elective (2.35 ± 2.98 versus 4.95 ± 3.33, P < 0.001). The readability of the consent form was 40.5 using the FRES and 10.9 using the SMOG index, indicating a university undergraduate level of reading. This study has shown poor compliance in documenting risks of surgery during the informed consent process in an acute trauma setting compared to elective arthroplasty. Institutions must prioritise improving documentation of informed consent for orthopaedic trauma patients to ensure a patient-centred approach to healthcare

Aims. The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers. Methods. A model of referral, waiting list, and eventual surgery was created and calibrated using historical data from NHS England (April 2017 to March 2020) and was used to investigate the possible consequences of unmet demand resulting from fewer patients entering the treatment pathway and recovery strategies. NJR data were used to estimate the deficit of hip and knee arthroplasty by August 2020 and NHS tariff costs were used to calculate the financial burden. Results. By November 2020, the elective waiting list in England is predicted to be between 885,286 and 1,028,733. If reduced hospital capacity is factored into the model, returning to full capacity by November, the waiting list could be as large as 1.4 million. With a 30% increase in productivity, it would take 20 months if there was no hidden burden of unreferred patients, and 48 months if there was a hidden burden, to return to pre-COVID-19 waiting list numbers. By August 2020, the estimated deficits of hip and knee arthroplasties from NJR data were 18,298 (44.8%) and 16,567 (38.6%), respectively, compared to the same time period in 2019. The cost to clear this black log would be £198,811,335. Conclusion. There will be up to 1.4 million patients on elective orthopaedic waiting lists in England by November 2020, approximate three-times the pre-COVID-19 average. There are various strategies for recovery to return to pre-COVID-19 waiting list numbers reliant on increasing capacity, but these have substantial cost implications. Cite this article: Bone Jt Open 2021;2(2):103–110

Background. Deciding how to allocate scarce surgical resources is a worldwide issue. These decisions are difficult when considering procedures aimed primarily at improving functional quality of life, such as lower extremity joint replacement (LEJR) surgery, and procedures perceived as life preserving which also have impacts on physical function, such as coronary artery bypass graft (CABG) surgery. Comparing functional outcomes of these two procedures may provide further evidence to guide resource allocation decisions. Methods. We compared patient-reported functional outcomes following CABG and LEJR surgery using standardised, validated outcome metrics. A retrospective review of prospectively collected pre- and post-operative health related quality of life (SF-36) measures were conducted from 105 patients undergoing elective CABG and 105 elective LEJR surgery patients. Patients were matched based on gender and age. Results. Pre-operatively, CABG patients reported statistically superior (p< 0.05) Physical Functioning, Bodily Pain, and Physical Component summary SF-36 scores compared to LEJR patients. However, their pre-operative General Health scores were lower. Surgery resulted in improvements in SF-36 scores for all patients, with statistically significant improvements in Bodily Pain and Physical Component scores occurring in both groups. Interestingly, improvements in 8 out of 10 SF-36 index scores were greater in the LEJR group, with the exception of Vitality and the Mental Component Summary. The pre-operative pattern of statistically better Physical Functioning in the CABG group, and superior General Health scores in the LEJR group remained following surgery. Conclusion. It appears that, despite being matched for age and gender, significant pre-operative general health differences exist between CABG and LEJR patients that persist post-operatively. While surgery results in significant improvements for both groups, CABG patients enjoy greater improvement in General Health scores while LEJR patients benefit from greater improvements in Bodily Pain scores. Further research is underway, examining how these differences reflect disease-specific scores and health care resource utilisation

Chronic postsurgical pain (CPSP) can occur after elective mid/hindfoot and ankle surgery. Effective treatment approaches for CPSP in this population have not been extensively investigated. The impact of multimodal strategies on CPSP following elective mid/hindfoot surgery is unknown due to both the heterogeneity of acute pain management and the lack of a recognized definition specific to this type of surgery. This study aimed to identify and evaluate current pain management strategies after elective mid/hindfoot and ankle surgery. We conducted a systematic review under Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases (MEDLINE, Embase and Cochrane Library) were electronically searched for English studies published between 1990 and July 2017. Reference lists of relevant systematic reviews were also manually searched. Comparative studies of adults undergoing elective mid/hindfoot and ankle surgery were included. Two reviewers independently reviewed studies and assessed their methodological quality. Of 1,159 studies, seven high-quality randomized controlled trials met our inclusion criteria. Though all studies examined regional anesthesia techniques, intervention heterogeneity precluded meta-analysis. Participants were typically followed up to 48 hours post-operatively. Interventions effective at reducing postoperative pain and/or opioid consumption included inserting popliteal catheters under ultrasound instead of nerve stimulation guidance, infusing perineural dexamethasone, bupivacaine, or ropivacaine perioperatively, and adding a femoral catheter infusion to a popliteal catheter infusion. Only one study assessed pain six months following elective mid/hindfoot and ankle surgery, demonstrating significant pain reduction with activity with the addition of a femoral to popliteal catheter infusion. There is an overwhelming lack of evidence regarding CPSP and its management for patients undergoing elective mid/hindfoot and ankle surgery. Although specific regional anesthesia techniques and adjuncts may be effective at reducing in-hospital pain and opioid consumption after elective mid/hindfoot and ankle surgery, our systematic review identified only seven studies addressing multimodal pain management in this population. Further comparative studies with longer-term follow-up are required

Aims. The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic. Methods. A prospective cohort study was undertaken between 17 March 2020 and 30 April 2020 and compared with retrospective data from same time period in 2019. We compared the number of patients requiring acute hospital admission or orthopaedic referrals and indications of referrals from our admission sheets and obtained operative data from our theatre software. Results. Between 17 March to 30 April 2020, there were 48 acute spine referrals as compared to 68 acute referrals during the same time period last year. In the 2019 period, 69% (47/68) of cases referred to the on-call team presented with back pain, radiculopathy or myelopathy compared to 43% (21/48) in the 2020 period. Almost 20% (14/68) of spine referrals consisted of spine trauma as compared to 35% (17/48) this year. There were no confirmed cases of cauda equine last year during this time. Overall, 150 spine cases were carried out during this time period last year, and 261 spine elective cases were cancelled since 17 March 2020. Recommendations. We recommend following steps can be helpful to deal with similar situations or new pandemics in future:. 24 hours on-call spine service during the pandemic. Clinical criteria in place to prioritize urgent spinal cases. Pre-screening spine patients before elective operating. Start of separate specialist trauma list for patients needing urgent surgeries. Conclusion. This paper highlights the impact of COVID-19 pandemic in a district general hospital of England. We demonstrate a decrease in hospital attendances of spine pathologies, despite an increase in emergency spine operations. Cite this article: Bone Joint Open 2020;1-6:281–286

Chronic postoperative pain (CPP) can occur in elective mid/hindfoot and ankle surgery patients. Multimodal pain management has been reported to reduce postoperative pain and opioid use, which may prevent the development of CPP. However, few studies have examined the impact of multimodal pain management strategies on CPP following complex elective mid/hindfoot and ankle surgery. The purpose of this study was to 1) evaluate current pain management strategies and 2) determine current definitions, incidence, and prevalence of CPP after elective mid/hindfoot and ankle surgery. Three databases (MEDLINE, Embase and Cochrane Library) were manually and electronically searched for English language studies published between 1990 and July 2017. For the first aim, we included comparative studies of adults undergoing elective mid/hindfoot and ankle surgery that investigated pre-, peri- or postoperative pain management. For the second aim, we included observational studies examining CPP definition, incidence, and prevalence. Two reviewers independently screened titles and abstracts, followed by full texts. Conflicts were resolved through discussion with a third reviewer. Reviewers also independently assessed the quality of studies meeting inclusion criteria using the Joanna Briggs Institute Critical Appraisal Checklist. For the first aim, 1159 studies were identified by the primary search, and seven high quality randomized controlled trials were included. Ankle arthroplasty or fusion and calcaneal osteotomy were the most common procedures performed. The heterogeneity of study interventions, though all regional anesthesia techniques, precluded meta-analysis. Most investigated continuous popliteal, sciatic and/or femoral nerve blockade. Participants were typically followed up to 48 hours postoperatively to examine postoperative pain levels and morphine consumption in hospital. Interventions effective at reducing postoperative pain and/or morphine consumption included inserting popliteal catheters using ultrasound instead of nerve stimulation guidance, perineural dexamethasone, and adding continuous femoral blockade to continuous popliteal blockade. Using more than one analgesic was generally more effective than using a single agent. Only two studies examined longer term pain management. One found no difference in pain levels and opioid consumption at two weeks with perineural or systemic dexamethasone use. The other found that pain with activity was significantly reduced at six months postoperatively with the addition of a femoral catheter infusion to a popliteal catheter infusion. For the second aim, only two studies of the 747 identified were selected. One prospective observational study defined CPP as moderate-to-severe pain at one year after foot and ankle surgery, and reported 21% and 43% of patients as meeting their definition at rest and with activity, respectively. The other study was a systematic review that reported 23–60% of patients experienced residual pain after total ankle arthroplasty. There is no standardized definition of CPP in this population, and incidence and prevalence are rarely reported and vary largely based on definition. Although regional anesthesia may be effective at reducing in-hospital pain and opioid consumption, evidence is very limited regarding longer-term pain management and associated outcomes following elective mid/hindfoot and ankle surgery

Aims. 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. Methods. 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. Results. During the study period, 1,659 procedures were performed in 1,569 patients. There were 68 (4.3%) patients who were diagnosed with COVID-19. There were 85 (5.4%) deaths postoperatively. Patients who had COVID-19 had a significantly lower survival rate when compared with those without a proven SARS-CoV-2 infection (67.6% vs 95.8%, p < 0.001). When adjusting for confounding variables (older age (p < 0.001), female sex (p = 0.004), hip fracture (p = 0.003), and increasing ASA grade (p < 0.001)) a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, 95% confidence interval (CI) 1.14 to 3.12; p = 0.014). A total of 62 patients developed COVID-19 postoperatively, of which two were in the elective and 60 were in the urgent group. Patients aged > 77 years (odds ratio (OR) 3.16; p = 0.001), with increasing ASA grade (OR 2.74; p < 0.001), sustaining a hip (OR 4.56; p = 0.008) or periprosthetic fracture (OR 14.70; p < 0.001) were more likely to develop COVID-19 postoperatively. Conclusion. Perioperative COVID-19 nearly doubled the background postoperative mortality risk following surgery. Patients at risk of developing COVID-19 postoperatively (patients > 77 years, increasing morbidity, sustaining a hip or periprosthetic fracture) may benefit from perioperative shielding. Cite this article: Bone Joint J 2020;102-B(12):1774–1781

Aims. The primary aim was to assess the rate of patient deferral of elective orthopaedic surgery and whether this changed with time during the coronavirus disease 2019 (COVID-19) pandemic. The secondary aim was to explore the reasons why patients wanted to defer surgery and what measures/circumstances would enable them to go forward with surgery. Methods. Patients were randomly selected from elective orthopaedic waiting lists at three centres in the UK in April, June, August, and September 2020 and were contacted by telephone. Patients were asked whether they wanted to proceed or defer surgery. Patients who wished to defer were asked seven questions relating to potential barriers to proceeding with surgery and were asked whether there were measures/circumstances that would allow them to go forward with surgery. Results. There was a significant decline in the rate of deferral for surgery from April (n = 38/50, 76%), June (n = 68/233, 29%), to August (n = 6/50, 12%) and September (n = 5/100, 5%) (p < 0.001). Patients wishing to defer were older (68 years (SD 10.1) vs 65 (SD 11.9)), more likely to be female (65% (44/68) vs 53% (88/165)) and waiting for a knee arthroplasty (65% (44/68) vs 41% (67/165); p < 0.001). By September 2020, all patients that deferred in June at one centre had proceeded or wanted to proceed with surgery due to a perceived lower risk of acquiring COVID-19 perioperatively (68%, n = 15) or because their symptoms had progressed (32%, n = 7). The most common reason (n = 14/17, 82%) for patients deferring surgery in September was the perceived risk of acquiring COVID-19 while as an inpatient. When asked what measures or circumstances would enable them to proceed with surgery, the most common (n = 7, 41%) response was reassurance of a COVID-19 free hospital. Conclusion. The rate of deferral fell to 5% by September, which was due to a lower perceived risk of contracting COVID-19 perioperatively or worsening of symptoms while waiting. The potential of a COVID-19-free hospital and communication of mortality risk may improve a patient’s willingness to go forward with surgery. Cite this article: Bone Joint Open 2020;1-10:663–668

Abstract. Aim. With resumption of elective spine surgery services following the first wave of COVID-19 pandemic, we conducted a multi-centre BASS collaborative study to examine the clinical outcomes of surgeries. Methods. Prospective data was collected from eight spinal centres in the first month of operating following restoration of elective spine surgery following the first wave. Primary outcomes measures were the 30-day mortality rate and postoperative Covid-19 infection rate. Secondary outcomes analysed were the surgical, medical adverse events and length of inpatient stay. Results. 257 patients (128 Male) with an age range of 2–88 years formed the study cohort. The average workload from each unit was 32(range 16–101) with 118 procedures (46%) done as category 3 prioritisation level (Procedures performed in < 3 month). 87% of patients were low-medium “risk stratification” category. 195 patients (75.8%) isolated for two weeks preoperatively and all but four patients had COVID-19 negative test prior to surgery. None of the patients were diagnosed with COVID-19 infection nor was any mortality related to COVID-19 in the 30 day follow up period, with 25 patients having been tested for symptoms. 32 patients (12%) developed a total of 34 complications with 19/34 being grade 1–2 Clavien-Dindo classification of surgical complications. Median LOS 5.2 days and 78.4 % patients stayed less than a week. Conclusions. As per our study safe and effective planned spinal surgical services can be restored avoiding viral transmission, with adherence to national guidelines and COVID-secure pathways tailored according to the resources of the individual spinal units

Smoking is negatively implicated in healing and may increase the risk of surgical complications in orthopaedic patients. Carbon monoxide (CO) breath testing provides a rapid way of measuring recent smoking activity, but so far, to our knowledge, this has not been studied in elective orthopaedic patients. We studied whether CO-testing can be performed preoperatively in elective orthopaedic patients and whether testing accurately correlates with self-reported smoking status?. CO breath testing was performed on and a brief smoking history was obtained from 154 elective orthopaedic patients on the day of surgery. All patients admitted over 6 weeks for elective orthopaedic intervention were enrolled. 16.2% patients admitted to smoking. The mean CO levels were 15.2 ppm for self-reported smokers and 3.1 ppm for self-reporting non-smokers. One self-reporting non-smoker admitted to smoking after testing. 5 non-smoking patients had a CO breath of >=7, 1 had a CO level of >= 10 ppm. Using a cutoff of 7 ppm gave a sensitivity of 65.4% and a specificity of 96.1%, whilst a cutoff of 10 ppm gave a sensitivity of 57.6% and specificity of 99.2%. Whilst most patients are honest about smoking, CO testing can identify non-disclosing smokers undergoing elective orthopaedic procedures. Due to the high specificity, speed and cost-effectiveness, CO breath testing could be performed routinely to identify patients at risk from smoking-related complications in pre-assessment clinics. Smoking cessation services may reduce the risk of harm. CO testing on admission may demonstrate the efficacy of smoking cessation services

To review the effect of MRSA screening, ward ring-fencing and other significant factors on elective orthopaedic operation cancellations: and to study the effect of introducing a multi-disciplinary trauma management system on trauma operation cancellations, we carried out a study at the Royal Gwent Hospital, a district general hospital accepting general emergency admissions. It took the form of a prospective audit of all elective orthopaedic and trauma cancellations from 1 October to 10 November 2002, and in the same period of 2004. Definitions: an ‘elective cancellation’: deemed medically fit at SHO pre-admission assessment; MRSA swabbed with negative results then subsequently cancelled from an elective theatre list under the headings, ‘ward breech by other unscreened patients’, ‘unfit for surgery’ (anaesthetic decision), ‘lack of beds’ and ‘other’ (lack of surgical assistant, theatre time, theatre staff and operation not required). A ‘trauma cancellation’: acute admission with allocation of theatre space; subsequently cancelled under the headings, ‘unfit for surgery’ (anaesthetic decision), ‘lack of theatre time’, ‘surgery not required’ and ‘other’ (patient refused surgery, absconded, incorrect listing, no surgical assistant or theatre staff). Results. In the six week period 198 and 226 elective patients were listed in 2002 and 2004 respectively. 52% were cancelled in 2002 and 35% in 2004, most frequently by ‘ward breech by other unscreened patient’. 234 and 269 trauma cases were listed in 2002 and 2004 respectively. 26% were cancelled in 2002 and 16% in 2004, most frequently in 2002 by ‘unfit for surgery’, and ‘surgery not required’; and in 2004 ‘lack of theatre time’. The MRSA ring-fencing policy was breached frequently by unscreened emergency patients. An elective unit separate from the main hospital may prevent these cancellations. The multi-disciplinary trauma management scheme reduced trauma cancellations, but other factors have reduced theatre efficiency