The majority of orthopaedic surgeons routinely review their patients after six weeks, following surgery. During the first six weeks, orthopaedic surgeons are blissfully unaware of how frequently their patients seek medical attention related to problems with their arthroplasty. During this period of time, General Practitioners play a vital role in the care of the post-operative arthroplasty patient.

The aim of this study was to determine how frequently patients seek medical attention following primary joint replacement in this interim six-week period.

102 patients from a single practice who had undergone a primary hip or knee replacement from 2003 to 2011 were included and the notes of all these patients were analysed retrospectively. Within this group there were 33 men and 69 women. 45 (44.1%) patients sought medical attention during the 6-week period, which accounted for 69 GP led interventions. The maximum number of interventions was four and a minimum of zero. Of these, 45 patients (29.4%) were seen once, 9 (8.8%) were seen twice, 3 (2.9%) were seen three times and 3 (2.9%) were seen four times. The interventions were for the following reasons: 1(0.9%) for post operative anaemia, 5 (4.9%) for constipation, (1.9%) for post operative nausea, 8 (7.8%) for leg pain (1 scanned for DVT), 5 (4.9%) for leg swelling (2 scanned for DVT), 12 (11.7%) were administered antibiotics, of which 1 was for a chest infection (1 scanned for DVT), 7(6.8%) for a wound review (1 scanned for DVT) (2 patients were started on antibiotic) and 19.6% (20) patients were seen for post operative analgesia. In total, there were 5 (4.9%) patients scanned for DVT and all scans were negative.

GPs play a vital, often underestimated role in the post operative care of primary arthroplasty patients. The majority of interventions were required simply because of inadequate post-operative analgesia being given to patients upon discharge. This is an issue that the orthopaedic department can address, which will improve patient care and ease the burden on primary care. Patients still continue to see their GPs for suspected wound infections despite being instructed to contact the hospital. This issue needs to be addressed with further education, as any infection, even superficial, can have devastating consequences if it spreads to the prosthesis.

The primary objective is to compare revision rates for lumbar disc replacement (LDR) and fusion at the same or adjacent levels in Ontario, Canada. The secondary objectives include acute complications during hospitalization and in 30 days, and length of hospital stay. A population-based cohort study was conducted using health administrative databases including patients undergoing LDR or single level fusion between October 2005 to March 2018. Patients receiving LDR or fusion were identified using physician claims recorded in the Ontario Health Insurance Program database. Additional details of surgical procedure were obtained from the Canadian Institute for Health Information hospital discharge abstract. Primary outcome measured was presence of revision surgery in the lumbar spine defined as operation greater than 30 days from index procedure. Secondary outcomes were immediate/ acute complications within the first 30 days of index operation. A total of 42,024 patients were included. Mean follow up in the LDR and fusion groups were 2943 and 2301 days, respectively. The rates of revision surgery at the same or adjacent levels were 4.7% in the LDR group and 11.1% in the fusion group (P=.003). Multivariate analysis identified risk factors for revision surgery as being female, hypertension, and lower surgeon volume. More patients in the fusion group had dural tears (p<.001), while the LDR group had more “other” complications (p=.037). The LDR group had a longer mean hospital stay (p=.018). In this study population, the LDR group had lower rates of revision compared to the fusion group. Caution is needed in concluding its significance due to lack of clinical variables and possible differences in indications between LDR and posterior decompression and fusion

We recently performed a clinical trial comparing motor sparing blocks (MSB) to periarticular infiltration (PAI) following total knee arthroplasty (TKA). We found that MSBs provided longer analgesia (8.8 hours) than PAI with retention of quadriceps strength, and with similar function, satisfaction, and length of hospital stay. However, its potential increased cost could serve as a barrier to its adoption. Therefore, our aim was to compare the costs of MSBs to PAI following TKA. We conducted a retrospective review of data from our previous RCT. There were 82 patients included in the RCT (n=41 MSB group, n=41 PAI group). We compared the mean total costs associated with each group until hospital discharge including intervention costs, healthcare professional service fees, intraoperative medications, length of stay, and postoperative opioid use. Seventy patients were included (n=35 MSB group, n=35 PAI group). The mean total costs for the MSB group was significantly higher ($1959.46 ± 755.4) compared to the PAI group ($1616.25 ± 488.33), with a mean difference of $343.21 (95% CI = $73.28 to $664.11, p = 0.03). The total perioperative intervention costs for performing the MSB was also significantly higher however postoperative inpatient costs including length of stay and total opioid use did not differ significatnly. Motor sparing blocks had significantly higher mean total and perioperative costs compared to PAI with no significant difference in postoperative inpatient costs. However, its quadricep sparing nature and previously demonstrated prolonged postoperative analgesia can be used to facilitate an outpatient TKA pathway thereby offsetting its increased costs

Aim. Bone and joint infection requires antimicrobial treatment for 6 to 12 weeks. When patients are well prepared and instructed regarding their therapy, they are more likely to have less side effects and improved compliance. Although side effects are common, this coaching is often not routinely performed when oral treatment is given. We developed a monitoring and guidance program for our outpatients who are on long term antimicrobial therapy, in which we can early signal side effects and treatment failure and coach the patients in their journey of infection treatment. Method. In our tertiary referral centre for orthopaedic infections, we started the outpatient monitoring of antimicrobial treatment (OMAT)- team for patients who will receive antimicrobial therapy for >2 weeks. Before discharge, our trained nurse gives instruction to the patient. Within 3 days after hospital discharge the patient is contacted by phone to, if necessary, clarify ambiguities in monitoring set up. During this contact, the nurse checks for side effects, addresses logistic problems regarding laboratory monitoring or future appointments and coaches patients for other questions. The patient is instructed how to recognize and who to contact in case of red flags and problems possibly related to the treatment. This is repeated after every laboratory check-up. Supervision is performed by an infectious disease specialist in close collaboration with the patient's surgeon. Results. The OMAT-team started in October 2020 and consists of 3 trained nurses and 3 ID specialist. In one year, 453 patients were proactively monitored for a mean of 11 weeks. Routinely, laboratory measurements were performed 1 week after the start of therapy and every 3–4 weeks thereafter, which resulted in 2711 contacts per year. In total, 64% of the patients reported side effects and 13% needed one or more extra laboratory measurement. This led to 40 additional outpatient consultations by the ID specialist because of complications of treatment and a switch of the antimicrobial agent in 31% of the patients. Conclusions. OMAT seems to improve the early signalling of complications regarding treatment, which is likely to improve compliance. The OMAT-team serves as a easy to access team to discuss any problem regarding antimicrobial therapy. Being proactive, the OMAT-team intervenes in an early stage of problems regarding side effects, logistics of the treatment and possible treatment failure. Future analysis of our data will show to what extend this will lead to prevention of re-hospitalization and improvement of success rate

Objective. As the aging society progresses rapidly in Japan, the number of elderly patients underwent TKA is increasing. These elderly patients do not expect to do sports, but regain independency in the activity of daily living. Therefore, we measured basic ambulatory function quantitatively using 3m timed up and go (TUG) test. We clinically experienced patient with medially unstable knee after TKA was more likely to result in the unsatisfactory outcome. We hypothesized that post-operative knee stability influenced ambulatory function recovery after TKA. In this study, we evaluated ambulatory function and knee stability quantitatively, and analyzed the effect of knee stability on the ambulatory function recovery after TKA. Materials & Methods. Seventy nine patients with varus type osteoarthritic knees underwent TKA were subjected to this study. The mean age of surgery was 72.4 years old. Preoperative standing coronal deformity was 9.6 degrees in varus. TUG test results in less duration with faster ambulatory function. TUG (seconds) was measured at 3 time periods; pre-operatively, at hospital discharge and 1year after surgery. To standardize TUG recovery time during 1 year after TKA, we defined TUG recovery rate as the percentage of recovery time to the pre-operative TUG as shown in the following equation. TUG recovery rate (%) = (TUG pre-op –TUG 1y po) / TUG pre-op ×100. We also evaluated the knee stability at hospital discharge and 1year after surgery. The knee stability at extension and flexion were assessed by varus and valgus stress radiography using Telos (10kg) and stress epicondylar view with 1.5kg weight at the ankle respectively. Image analyzing software was used to measure joint separation distance (mm) at medial as medial joint opening (MJO) and at lateral as lateral joint opening (LJO) at both knee extension and flexion. (Fig.1). The sequential change of TUG was analyzed using repeated measures ANOVA (p<0.05). The influence of joint opening distances (MJO and LJO at extension and flexion) on TUG 1y po and TUG recovery rate were analyzed using simple linear regression analysis (p<0.05). Results. The mean TUGs were 13.4, 13.7 and 10.8 seconds pre-operatively, at hospital discharge and 1 year after TKA respectively. Significant decrease was found at 1 year after surgery. TUG pre-op did not show significant correlation to any joint openings. TUG 1y po was positively correlated with both flexion and extension MJO at hospital discharge. (Fig.2) TUG recovery rate negatively correlated to flexion-MJO at hospital discharge. (Fig.3). Discussions. The most interesting findings in the present study were that both flexion and extension MJO at hospital discharge were positively correlated with TUG 1y po and negatively correlated with TUG recovery rate. This indicated that early post-operative medial stability played an important role in the recovery of ambulatory function. The early post-operative medial instability would cause pain and deteriorate functional recovery after surgery. There is some disagreement regarding the importance of pursuing the perfect ligament balance, which would be more likely to result in medial instability. Consequently, surgeons should prioritize medial stability for better ambulatory functional recovery after TKA

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

The coronavirus pandemic has reduced the capability of Canadian hospitals to offer elective orthopaedic surgery requiring admission, despite ongoing and increasing demands for elective total hip and total knee arthroplasty surgery (THA and TKA). We sought to determine if the coronavirus pandemic resulted in more outpatient THA and TKA in Nova Scotia, and if so, what effect increased outpatient surgery had on 90 day post-operative readmission or Emergency Department/Family Doctor (FD) visits. The study cohort was constructed from hospital Discharge Abstract Data (DAD), inpatient admissions, and National Ambulatory Care Reporting System (NACRS) data, day surgery observations, using Canadian Classification of Health Intervention codes to select all primary hip and knee procedures from 2005-2020 in Nova Scotia. Emergency Department and General Practitioner visits were identified from the Physician Billings data and re-admissions from the DAD and NACRS. Rates were calculated by dividing the number of cases with any visit within 90 days after discharge. Chi-squared statistics at 95% confidence level used to test for statistical significance. Knee and hip procedures were modelled separately. There was a reduction in THA and TKA surgery in Nova Scotia during the coronavirus pandemic in 2020. Outpatient arthroplasty surgery in Nova Scotia in the years prior to 2020 were relatively stable. However, in 2020 there was a significant increase in the proportion and absolute number of outpatient THA and TKA. The proportion of THA increased from 1% in 2019 to 14% in 2020, while the proportion of TKA increased from 1% in 2019 to 11% in 2020. The absolute number of outpatient THA increased from 16 cases in 2019, to 163 cases in 2020. Outpatient TKA cases increased from 21 in 2019, to 173 in 2020. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED following TKA but not THA which was not statistically significant. For outpatient THA and TKA, there was a decrease in 90 day readmissions, and a statistically significant decrease in FD presentations. Outpatient THA and TKA increased significantly in 2020, likely due to the restrictions imposed during the coronavirus pandemic on elective Orthopaedic surgery requiring admission to hospital. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED for TKA, and a decrease in 90 day readmissions and FD presentations for THA and TKA. Reducing the inpatient surgical burden may result in a post-operative burden on ED, but does not appear to have caused an increase in hospital readmission rates

C-reactive protein (CRP) level is used at our tertiary paediatric hospital in the diagnosis, management, and discharge evaluation of paediatric septic arthritis patients. The purpose of this study was to evaluate the efficacy of a discharge criterion of CRP less than 2 mg/dL for patients with septic arthritis in preventing reoperation and readmission. We also aimed to identify other risk factors of treatment failure. Patients diagnosed with septic arthritis between January 1, 2007 and December 31, 2017 were reviewed retrospectively. The diagnosis of septic arthritis was made based on clinical presentation, laboratory results and the finding of purulent material on joint aspiration or the isolation of a bacterial pathogen from joint fluid or tissue. Bivariate tests of associations between patient or infection factors and readmission and reoperation were performed. Quantitative variables were analyzed using Mann-Whitney tests and categorical variables were analyzed using Chi-square tests. One hundred eighty-three children were included in the study. Seven (3.8%) were readmitted after hospital discharge for further management, including additional advanced imaging, and IV antibiotics. Six (85.7%) of the readmitted patients underwent reoperation. Mean CRP values on presentation were similar between the two groups: 8.26 mg/dL (± 7.87) in the single-admission group and 7.94 mg/dL (± 11.26) in the readmission group (p = 0.430). Mean CRP on discharge for single-admission patients was 1.71 mg/dL (± 1.07), while it was 1.96 mg/dL (± 1.19) for the readmission group (p = 0.664), with a range of < 0 .8 to 6.5 mg/dL and a median of 1.5 mg/dL for the two groups combined. A total of 48 children (25.9%) had CRP values greater than the recommended 2 mg/dL at discharge, though only three of these patients (6.2%) were later readmitted. The only common variable in the readmitted children was either a negative culture result at time of discharge or atypical causative bacteria. CRP values are useful in monitoring treatment efficacy but not as reliable as a discharge criterion to prevent readmission or reoperation in children with septic arthritis. We recommend determining discharge readiness on the basis of clinical improvement and downtrending CRP values. There was a higher risk of readmission in children with an atypical causative bacteria and when culture results were negative at discharge. Close monitoring of these patients after discharge is suggested to identify signs of persistent infection

Currently 180 days is the target maximum wait time set by all Canadian provinces for elective joint replacement surgery. In Nova Scotia however, only 34% of Total Knee Arthroplasties (TKA) and 51% of Total Hip Arthroplasties (THA) met this benchmark in 2017. Surgery performed later in the natural history of disease is shown to have significant impact on pain, function and Health related Quality of Life at the time of surgery and potentially affect post-operative outcomes. The aim of this study is to describe the association between wait time and acute hospital Length of Stay (LOS) during elective hip and knee arthroplasty in province of Nova Scotia. Secondarily we aim to describe risk factors associated with variations in LOS. Data from Patient Access Registry Nova Scotia (PAR-NS) was linked to the hospital Discharge Access Database (DAD) for primary hip and knee arthroplasty spanning 2009 to 2017. There were 23,727 DAD observations and 21,329 PARNS observations identified. Observations were excluded based on missing variables, missing linkages, revision status and emergency cases. Percentage difference in LOS, risk factors and outcomes were analyzed using Poisson regression for those waiting more than 180 days compared to those waiting equal or less than 180 days. For primary TKA, 11,833 observations were identified with mean age of 66 years, mean wait time of 348 days and mean LOS of 3.6 days. After adjusting for controls, patients waiting more than 180 days for elective TKA have a 2.5% longer acute care LOS (p < 0.028). Risk factors identified for prolonged LOS are advanced age, female gender, higher surgical priority indicator, required blood transfusion, dementia, peptic ulcer disease, cerebrovascular disease, heart failure, chronic kidney disease, malignancy, ischemic heart disease and diabetes. Factors associated with decreased LOS are surgical year, use of local anesthetic, peripheral location of hospital and admission to hospital from home. For primary THA, 6626 observations were identified with mean age of 66 years, mean wait time of 267 days and mean LOS of 4 days. Patients waiting more than 180 days for THA did not show a statistically significant association with LOS. Risk factors and protective factors are the same with exception of CVD and use of local anesthetic. Our findings suggest a positive and statistically significant association for patients waiting more than 180 days for TKA and longer acute care LOS. Longer LOS may be due to deteriorating health status while placed on a surgical waitlist and may represent a delayed and indirect cost to the patient and the healthcare system. Ultimately with projected increase in demand for elective joint replacement surgeries, our findings are aimed to inform physicians and policy makers in management of surgical waitlist efficiency and cost effectiveness. For any reader inquiries, please contact . shahriar-s@hotmail.com

This session will be practically oriented, focusing on important surgical decisions and on technical tips to avoid complications. The panel will be polled concerning individual preferences as regards the following issues in primary total hip arthroplasty: 1. Perioperative antibiotics; 2. Blood management and tranexamic acid protocols; 3. Surgical indications: high BMI patients; 4. Surgical approach for primary total hip arthroplasty: indications or preferences for direct anterior, anterolateral, posterior; 5. Acetabular fixation; 6. Tips for optimizing acetabular component orientation; 7. Femoral fixation: (a) Indications for cemented and uncemented implants. Case examples will be used.; (b) Is there still a role for hip resurfacing?; 8. Femoral material and size: (a) Preferred head sizes and materials in different situations.; (b) Is there a role for dual mobility implants in primary THA?; 9. Bearing surface: present role of different bearings. Case examples will be used. 10. Tips for optimizing intraoperative hip stability; 11. Tips for optimizing leg length; 12. Postoperative venous thromboembolism prophylaxis; 13. Heterotopic bone prophylaxis; 14. Postoperative pain management; 15. Hospital discharge: is there a role for outpatient surgery?; 16. Postoperative rehabilitation protocol: weight bearing, role of physical therapy; 17. Postoperative activity restrictions; hip dislocation precautions; 18. Is there value to physical therapy as outpatient after THA?; 19. Long-term antibiotic prophylaxis for procedures

This session will be practically oriented, focusing on important surgical decisions and on technical tips to avoid complications. The panel will be polled concerning individual preferences as regards the following issues in primary total hip arthroplasty: 1.) Peri-operative antibiotics; 2.) Blood management and tranexamic acid protocols; 3.) Surgical indications: High BMI patients; 4.) Surgical approach for primary total hip arthroplasty: indications or preferences for direct anterior, anterolateral, posterior; 5.) Acetabular fixation; 6.) Tips for optimizing acetabular component orientation; 7.) Femoral fixation: Indications for cemented and uncemented implants. Is there still a role for hip resurfacing?; 8.) Femoral material and size: Preferred head sizes and materials in different situations. Is there a role for dual mobility implants in primary THA?; 9.) Bearing surface: Present role of different bearings; 10.) Tips for optimizing intra-operative hip stability; 11.) Tips for optimizing leg length; 12.) Post-operative venous thromboembolism prophylaxis; 13.) Heterotopic bone prophylaxis; 14.) Post-operative pain management; 15.) Hospital discharge: Is there a role for outpatient surgery?; 16.) Post-operative rehabilitation protocol: weight bearing, role of physical therapy; 17.) Post-operative activity restrictions; hip dislocation precautions; 18.) Is there value to physical therapy as outpatient after THA?; 19.) Long-term antibiotic prophylaxis for procedures

Introduction. Rapid increase of aged population has been one of major issue affecting national health care plan in Japan. In 2006, Japanese Orthopaedic Association proposed the clinical entity of musculoskeletal ambulation disorder symptom complex (MADS) to define the elderly population with high risk of fall and ambulatory disability caused by musculoskeletal disorders. Osteoarthritis of the knee is one of major cause of MADS. The number of patients with MADS underwent total knee arthroplasty (TKA) had been increased in Japan, and also expected to increase worldwide in the near future. The effectiveness of TKA for the patient with MADS has not been well evaluated. In the present study, we analyzed the early post-operative functional recovery after TKA using 2 simple performance tests to diagnose MADS. Material & Method. Fifty patients with varus type osteoarthritic knees implanted with posterior-stabilized (PS) TKAs were subjected to this study. There were 44 female and 6 male patients. The mean age of the patients was 71.6 years (range, 59 to 84 years). Patients were subjected to 2 functional performance tests which were essential tests for MADS diagnosis. Firstly, 3 meter timed up and go test (TUG) was used to evaluate ambulation. Secondary one leg standing time with open eyes was measured to assess balancing ability. 2 tests were performed pre-operatively, 2 weeks after surgery and at discharge (23.8 days po). MADS was defined to be diagnosed if TUG and one leg standing time was not less than 11 seconds and/or less than 15 seconds respectively. Each parameter was compared among at above mentioned three time points -using a repeated measured analysis of variance (p<0.05). Results. The number of the patients with MADS were 37, 44 and 38 in 50 patient pre-operatively, 2 weeks after surgery and at hospital discharge respectively. Mean TUG was 12.9, 16.9 and 14.0 sec. respectively [fig 1]. TUG significantly increased during 2 weeks after TKA, followed by significant decrease at discharge. There were no significant improvements in ambulation during hospital stay. Mean one leg standing time with operated and non-operated side leg at three time points were 11.0, 12.4, 17.9 sec, and 18.4, 17.9, 24.2 sec. each respectively [fig 2]. There were no significant improvements during initial 2 weeks after surgery. Significant increase of one leg standing time was found after 2 weeks, and balancing ability was found to be improved during hospital stay. Discussion & Conclusion. Although both parameters assessing ambulatory and balancing function were found to be improved post-operative 2 weeks, still as much as 76% of patients were suffered from MADS at hospital discharge in our patient population. These results indicate that the patient after TKA has still exposed to high risk of fall and ambulatory dysfunction at discharge. We should reconsider the appropriate rehabilitation protocol especially for the elderly patient with MADS to meet with patient expectation and enhance early post-operative care

The position of this surgeon is that there is no approach that provides superior outcomes for total hip replacement (THR). The direct anterior approach (DAA) has become popular with patients because of marketing by companies, misinformation given to journalists for public consumption, and yes, some surgeons. Because of patient pressure generated by this marketing there has been pressure on surgeons to convert their surgical approach for perceived protection of their practice. Unfortunately, the leaders of orthopaedic organizations have not countered this marketing with education of the public that there is NO scientific evidence to support DAA superiority. These orthopaedic organizations exist to be advocates for their members but have abdicated that responsibility. Whatever happened to the time honored belief of choosing a surgeon to do your operation? Instead we now choose an approach? Do anterior surgeons think that they are immune to the Bell Curve of talent? The fact is that there is NO outcome data of DAA with the longest follow up study being one year, and recent data from both coasts of the USA raise concerns with more failures from loosening of the femoral component. How in the world can we bamboozle patients about better results when there are no published results with the DAA except for recovery? The mini-posterior approach has data for all aspects of its use. Short term data shows rapid recovery and hospital discharge can be the same day; gait studies show A quality at six weeks (so does this mean that cut muscles recover quickly?). Dislocation rates are equal in most comparative studies, but I believe this favors the DAA, however, fractures are 3X greater with DAA. Data from the Mayo Clinic comparative studies showed posterior patients return to work faster! There are two 10 year studies of mini-posterior patients which show some of the best 10 year results in the literature. And there are superior technical surgeons who perform this operation to the benefit of their patients, and they should not need to suffer the implicit bias from DAA marketing that their care of patients is inferior

This session will be practically oriented, focusing on important surgical decisions and on technical tips to avoid complications. The panel will be polled concerning individual preferences as regards the following issues in primary total hip arthroplasty: 1.) Peri-operative antibiotics; 2.) Blood management and tranexamic acid protocols; 3.) Surgical indications: High BMI patients; 4.) Surgical approach for primary total hip arthroplasty: indications or preferences for direct anterior, anterolateral, posterior; 5.) Acetabular fixation; 6.) Tips for optimizing acetabular component orientation; 7.) Femoral fixation: (a) Indications for cemented and uncemented implants. (b) Is there still a role for hip resurfacing?; 8.) Femoral material and size: (a) Preferred head sizes and materials in different situations. (b) Is there a role for dual mobility implants in primary THA?; 9.) Bearing surface: Present role of different bearings. 10.) Tips for optimizing intra-operative hip stability; 11.) Tips for optimizing leg length; 12.) Post-operative venous thromboembolism prophylaxis; 13.) Heterotopic bone prophylaxis; 14.) Post-operative pain management; 15.) Hospital discharge: Is there a role for outpatient surgery?; 16.) Post-operative rehabilitation protocol: weight bearing, role of physical therapy; 17.) Post-operative activity restrictions; hip dislocation precautions; 18.) Is there value to physical therapy as outpatient after THA?; and 19.) Long-term antibiotic prophylaxis for procedures

Adverse events (AEs) following spine surgery are very common. It is important to monitor the incidence of AEs to ensure that appropriate practices are implemented to minimise AEs and improve patient outcomes. The Spine Adverse Events Severity System (SAVES) is a validated AE recording tool specifically designed for spine surgery and the Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) is a similar tool intended for general orthopaedic surgery. The main objective was to prospectively collect AE data from spine surgery patients using SAVES and OrthoSAVES and compare their viability and applicability for use. The longterm objective is to enhance patient safety by tracking AEs with a view towards potentially changing future healthcare practices to eliminate the risk factors for AEs. For a 10-week period in June-September 2015, three spine surgeons used SAVES to record AEs experienced by any elective spine surgery patients. In addition, a trained independent clinical reviewer with access to electronic records, medical charts, and allied health professionals (e.g. nurses, physioterhapists) used SAVES and OrthoSAVES to record AEs for the same patients. At discharge, the SAVES forms from the surgeons and SAVES and OrthoSAVES forms from the independent reviewer were collected and all AEs were recorded in a database. In 48 patients, the independent reviewer recorded a total of 45 AEs (4 intra-operative, 41 post-operative), compared to the surgeons who recorded a total of 8 AEs (2 intra-operative, 6 post-operative) (P2) were recorded by both the independent reviewer and surgeons. OrthoSAVES had the capacity to directly record 3 additional AEs that had to be included in the “Other” section on SAVES. SAVES and OrthoSAVES are valuable tools for recording AEs. Use of SAVES and OrthoSAVES has the potential to enhance patient care and safety by ensuring AEs are followed by the surgeon during their in-hospital stay and prior to discharge. Independent reviewers are more effective at capturing AEs following spine surgery, and thus, could be recruited in order to capture more AEs and maximise different complication diagnoses in alignment with proposed diagnosis-based funding models. The next step is to analyse AE data identified by the hospital discharge abstract to determine whether retrospective administrative coding can adequately record AEs compared to prospectively-collected AE data with SAVES/OrthoSAVES

The inmate population is a unique cohort with several healthcare-related challenges. International studies have demonstrated higher rates of infectious diseases, chronic diseases and psychiatric disorders in inmates when compared to general population. However, little is known about the outcomes following total joint arthroplasty in this population. This retrospective chart review aims to outline the differences in clinical outcomes after hip and knee total joint arthroplasty in the Kingston inmate population compared to the national population standard. A list of all inmate inpatient hospital visits with diagnostic/procedure codes pertaining to total joint arthroplasty within the last ten years was obtained through a computer-based search of the Kingston General Hospital Discharge Abstract Database(DAD). The patient charts were reviewed and demographic and outcome data pertinent to our study was collected. Data was compiled using Excel and imported into IBM SPSS for descriptive analysis. Twenty male inmate patients underwent 24 primary Total Hip Arthroplasties(THA) or Total Knee Arthroplasties(TKA) and one medial unicompartmental knee arthroplasty from May 2003 to January 2013. The average age was 58 with mean Body Mass Index(BMI) of 34. Median American Society of Anesthesiologist(ASA) score was 3 and mean Charlston Comorbidity Index was 3.92. The rates of HCV and HIV were 35%(n=5) and 0%, respectively. Average length of stay from time of initial procedure was 4.2 days. The overall revision rate was 24% (n=6). Reasons for revision included deep prosthetic infection (50%, n=3), aseptic loosening (17%, n=1), arthrofibrosis (17%, n=1) and late periprosthetic fracture (17%, n=1). Infection rates were reported at 16% (n=4); 75% of which were deep prosthetic infections requiring revision surgery. Other complications included ST-elevation myocardial infarction(STEMI) (n=1), and postoperative knee stiffness requiring manipulation under anesthesia(MUA) (n=1). Compared to Correctional Services Canada(CSC) data on male inmate health in 2012, our study population demonstrated a higher rate of HCV (35% vs. 9.4%), diabetes (30% vs. 4.2%) and overall cardiovascular and respiratory comorbidities. This may reflect the higher rate of comorbidities associated with osteoarthritis, such as BMI>25, which was evident in 95% of our study population vs. 64.5% in Canadian inmates. Total joint revision rates in our inmate study population was 24%, which is higher than the 2014 Canadian Joint Replacement Registry's yearly revision rate of 8.7% in THA and 5.2% in TKA. Our study population also demonstrated infection as the leading cause for revision at 50%, compared to 14.5% for THA and 19.6% for TKA in the general Canadian population. Further study of the complex biopsychosocial risk factors in the inmate population is warranted to better define pre-surgical risk assessment criteria

Introduction. Knee osteoarthritis is a leading cause of disability around the world. Traditionally, total knee arthroplasty (TKA) is the gold standard treatment; however, unicompartmental knee arthroplasty (UKA) has emerged as a less-invasive alternative to TKA. Patients with UKAs participate earlier with physical therapy (PT), have decreased complications, and faster discharges (1, 2). As UKA has evolved, so has computer navigation and robotic technology. The Robotic Assisted UKA combines the less invasive approach of the UKA with accurate and reproducible alignment offered by a robotic interface (3)(Figure1). A key part of a patient's satisfaction is perioperative pain control. Femoral nerve blocks (FNB) are commonly performed to provide analgesia, though they cause quadriceps weakness which limits PT (4). An alternative is the adductor canal block (ACB) which provides analgesia while limiting quadriceps weakness (4). The adductor canal is an aponeurotic structure in the middle third of the thigh containing the femoral artery and vein, and several nerves innervating the knee joint including the saphenous nerve, nerve to the vastus medialis, medial femoral cutaneous nerve, posterior branch and occasionally the anterior branch of the obturator nerve (5). In a multi-modal approach with Orthopedic Surgery, Regional Anesthesia, and PT departments, an early goal directed plan of care was developed to study ACB in UKA with a focus on analgesia effectiveness and PT compliance rates. Methods. Following IRB approval, we performed a case series including 29 patients who received a single shot ACB. Primary outcomes were distance walked with PT on postoperative day (POD) 0 and 1 and discharge day. Our secondary outcomes included Visual Analog Scale (VAS) scores in the post-anesthesia care unit (PACU), 8 and 24 hours postoperatively and oral morphine equivalents required for breakthrough pain. Results. All patients received PT prior to discharge. With respect to distance walked, the median distance on POD 0 was 26 feet (IQR 9–66), and on POD 1 was 128 feet (IQR of 80–200), and the median day of discharge was POD 1 (IQR 0–2). In this study, the patients’ median age was 64 (IQR 59–69) and the median BMI was 31 kg/m2 (IQR 22–41). The median VAS score in the PACU was 1 (IQR 0–7). The VAS scores for 8 and 24 hours were 5 (IQR 2–7) and 5 (IQR 2.7–7). Median oral morphine equivalents required for breakthrough pain were 99.5 mg (IQR 67.5–150.5 mg) (Figure 3). Conclusion. This case series supports that a single shot ACB facilitates early PT and hospital discharge in patients post UKA

Aim:. To audit pertrochanteric fractures treated with a cephalomedullary device in a public health institution. Method:. A retrospective 3 year analysis from January 2007 to December 2010 using theatre records and patient files. Analysis was done in terms of age, time to surgery, duration of surgery, elective or emergency, type of device used, perioperative complications and other factors. Results:. A total of 96 cases were confirmed. The average age was 67.4 years (13 to 99 years). The average time to theatre was 6.9 days. The average duration of surgery was 2 hours 59 minutes. A Trigen reconstruction nail was used in 59.4 % of the cases followed by a PFNA (26%) and others (13.6%). In 30% of cases surgery time was >3 hours and most were done electively (85.4%) during normal working hours. Revision surgery due to poor surgical technique was reported in 8 of 96 (8.3%) cases. Conclusion:. Our audit confirms that pertrochanteric fractures are common in elderly and young patients involved in high velocity trauma especially motor vehicle accidents. Pertrochanteric fractures lead to prolonged morbidity in hospital stay and theatre time. Cephalomedullary devices have reduced these complications and resulted in early rehabilitation and hospital discharge with only 8% of revisions in 3 years

Aims. To establish if the principles of Enhanced Recovery, an evidence-based, integrated, multi-modal approach to improving recovery following colonic resection are transferable to elective orthopaedic primary arthroplasty surgery. The principles are to reduce the stress response provoked by surgery and eliminate the peri-operative catabolic state by optimally managing patients' metabolism, expectations, postoperative pain and mobility. This combination of interventions has not been tested in Orthopaedics before. Methods. We conducted a single surgeon, consecutive patient, interventional, cohort study of primary total hip and knee arthroplasties. Our intervention was Enhanced Orthopaedic Recovery (EOR). Results. We retrospectively reviewed 138 primary joint replacements. We performed a power calculation before prospectively assessing the next 50 hip and 32 knee arthroplasties. A two-tailed t-test showed a highly statistically significant fall in mean time to discharge (Hips 8.1-5.4 total nights stay, p=0.003, knees 8.5-5.3 total nights stay, p<0.001) and a fall in expected date of discharge from 5 to 3 postoperative days. We studied the complication and readmission rate and found no apparent difference. Conclusions. We have shown that by implementing EOR, reduced time to functional recovery and subsequent hospital discharge can be safely achieved with consequent quality of life and health economic benefits

Introduction. As the aging society progresses rapidly, the number of patients underwent total knee arthroplasty (TKA) is increasing especially for the elderly population. In Japan, the average age for TKA is around 75 years old. Japanese Orthopaedic Association indicated a new clinical entity of musculoskeletal ambulation disability symptom complex (MADS) to define the higher risk of fall and ambulatory disability in the elderly population in 2006. The diagnosing criteria for MADS consists of 2 simple performance tests. 3m timed up and go test (TUG) evaluates ambulatory function, and one leg standing time (ST) assesses balancing ability. Objective. In this study, we analyzed the effect of TKA on the ambulatory function by quantitative measurement using 2 simple performances test: TUG and ST. Materials & Methods. Forty four patients (6 males and 38 females) with varus type osteoarthritic knees underwent TKA were involved. The mean age of surgery was 72.7 years old. TUG and ST were performed at 4 time periods; pre-operatively, 2 weeks after surgery, at hospital discharge (average 24.1 days) and 1year after surgery. Ambulatory disability (MADS) was diagnosed if TUG was not less than 11 seconds and/or ST was less than 15 seconds. 36 patients (82%) were diagnosed to MADS preoperatively. We divided these 36 patients into two groups depending on the performance tests one year after TKA. 24 patients (67%) still suffered from MADS (Group1), and remaining 12 patients (33%) recovered from MADS (Group2). We compared preoperative factors (age, femoro-tibial angle, ROM, etc.) and the results of ST and TUG between Group 1 and Group 2 using the Mann-Whitney test (p<0.05). Results. The complication rates of MADS in all 44 patients were 82.0, 88.9, 83.3, and 55.6% at 4 time periods respectively. Significant functional recoveries were observed with decrease of TUG and increase of ST at 1 year after surgery (Fig. 1). Average age at surgery was significantly higher in Group 1 (74.7yo) comparing to Group 2 (69.3yo). The sequential change of mean TUG and ST at 4 time periods were shown for each group in Fig. 2 and Fig. 3. We found no significant difference in TUG but significant difference in ST between two groups. Patient in Group 2 could stand on one leg longer than Group 1 preoperatively even with no significant difference in TUG. Discussions. We evaluated the ambulatory function using 2 simple performance tests, and found significant improvements in both balancing ability (ST) and ambulatory function (TUG) one year after TKA. However, more than 50% of our patient population still suffered from ambulatory disability (MADS) at 1 year after surgery. As much as 70% of preoperatively MADS complicated patients were found to meet MADS criteria even one year after TKA. Only 30% of preoperatively MADS complicated patient could recover from MADS. This group was relatively younger and showed better balancing ability preoperatively. Our results suggested that standing time measurement would be simple and useful predictor for the functional recovery after TKA