Aims

We conducted a randomised controlled trial to assess the accuracy of positioning and alignment of the components in total knee arthroplasty (TKA), comparing those undertaken using standard intramedullary cutting jigs and those with patient-specific instruments (PSI).

Introduction: This observational study assessed the influence of obesity on operating time and duration of hospital admission following Total Knee Arthroplasty (TKA).

Materials and Methods: 263 patients who underwent 276 TKAs between 1st January and December 31st 2005 at the Glenfield General Hospital were identified from the Trent (and Wales) Arthoplasty Audit Group. Patients were grouped into three weight categories based upon BMI. We examined hospital records for 265 of the 276 procedures and compared operating time, length of hospital admission and complication rates between the three BMI groups. Patient perceived outcomes including patient satisfaction, post-operative pain and frequency of walking were compared at 1-year post TKA.

Results: Obesity did not adversely influence operating time and duration of hospital stay. The mean operating time was 82 minutes in patients with a BMI ≤ 25.0, 84 min in those with a BMI 25.1–30.0 and 88 minutes for those with a BMI> 30.0 (p=0.2). The mean hospital stay was 7.7 days in patients with a BMI ≤ 25.0, 7.2 days in the BMI 25.1–30.0 group, and 6.7 days in those with a BMI > 30.0 (p=0.8).

There were no significant differences between the three BMI groups and post-operative complications (p = 0.7), patient satisfaction (p=0.1) or pain levels (p=0.7) at 1-year post-TKA. As has been demonstrated previously, increasing BMI negatively influenced post operative walking frequency (p=0.02)

Conclusion: BMI did not influence operating time, length of stay, complication rates, post operative pain and patient satisfaction post Total Knee Arthroplasty, but was associated with decreased post operative mobility.

We investigated factors associated with postoperative lipiduria and hypoxemia in patients undergoing surgery for orthopedic fractures. We enrolled patients who presented to our emergency department due to traumatic fractures between 2016 and 2017. We collected urine samples within 24 hours after the patients had undergone surgery to determine the presence of lipiduria. Hypoxemia was defined as an SpO2 <95% determined with a pulse oximeter during the hospitalization. Patients’ anthropometric data, medical history, and laboratory test results were collected from the electronic medical record. Logistic regression analyses were used to determine the associations of clinical factors with postoperative lipiduria and hypoxemia with multivariate adjustment. A total of 144 patients were analyzed (mean age 51.3 ± 22.9 years, male 50.7%). Diabetes (odd ratio 3.684, 95% CI 1.256-10.810, p=0.018) and operation time (odd ratio 1.005, 95% CI 1.000-1.009, p=0.029) were independently associated with postoperative lipiduria, while age (odd ratio 1.034, 95% CI 1.003-1.066, p=0.029), body mass index (odd ratio 1.100, 95% CI 1.007-1.203, p=0.035), and operation time (odd ratio 1.005, 95% CI 1.000-1.010, p=0.033) were independently associated with postoperative hypoxemia. We identified several factors independently associated with postoperative lipiduria and hypoxemia in patients with fracture undergoing surgical intervention. Operation time was associated with both postoperative lipiduria and hypoxemia, and we recommend that patients with prolonged operation for fractures should be carefully monitored for clinical signs related to fat embolism syndrome

The use of intraoperative navigation and robotic surgery for minimally invasive lumbar fusion has been increasing over the past decade. The aim of this study is to evaluate postoperative clinical outcomes, intraoperative parameters, and accuracy of pedicle screw insertion guided by intraoperative navigation in patients undergoing lumbar interbody fusion for spondylolisthesis. Patients who underwent posterior lumbar fusion interbody using intraoperative 3D navigation since December 2021 were included. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Short Form Health Survey-36 (SF-36) were assessed preoperatively and postoperatively at 1, 3, and 6 months. Screw placement accuracy, measured by Gertzbein and Robbins classification, and facet joint infringement, measured by Yson classification, were assessed by intraoperative Cone Beam CT scans performed at the end of instrumentation. Finally, operation time, intraoperative blood loss, hospital stay, and screw insertion time were evaluated. This study involved 50 patients with a mean age of 63.7 years. VAS decreased from 65.8±23 to 20±22 (p<.01). ODI decreased from 35.4%±15 to 11.8%±14 (p<.01). An increase of SF-36 from 51.5±14 to 76±13 (p<.01) was demonstrated. The accuracy of “perfect” and “clinically acceptable” pedicle screw fixation was 89.5% and 98.4%, respectively. Regarding facet violation, 96.8% of the screws were at grade 0. Finally, the average screw insertion time was 4.3±2 min, hospital stay was 4.2±0.8 days, operation time was 205±53 min, and blood loss was 169±107 ml. Finally, a statistically significant correlation of operation time with hospital stay, blood loss and placement time per screw was found. We demonstrated excellent results for accuracy of pedicle screw fixation and violation of facet joints. VAS, ODI and SF-36 showed statistically significant improvements from the control at one month after surgery. Navigation with intraoperative 3D images represents an effective system to improve operative performance in the surgical treatment of spondylolisthesis

Introduction. Distal femur fractures have traditionally been stabilized with either lateral locking plate or retrograde intramedullary nail. Dual-plates and nail-plate combination fixation have the theoretical biomechanical advantage, faster union and allows patients to weight bear immediately. The aim of this study is to compare single vs combination fixation, and evaluate outcomes and complications. Method. We retrospectively reviewed all patients over 60, admitted to Christchurch Hospital, between 1st Jan 2016 and 31st Dec 2022, with an AO 33A/33B/33C distal femur fracture. Patient demographics, fracture characteristics, operation details, and follow up data were recorded. Primary outcomes are union rate, ambulatory status at discharge, and surgical complications. Secondary outcomes include quality of reduction, operation time and rate of blood transfusions. Results. 114 patients were included. (92 single fixation, 22 combination fixation). Baseline demographic data and fracture characteristics did not differ between the cohorts. There was no difference in the rate of union or time to union between the two cohorts. Combination fixation patients were allowed to weight-bear as tolerated significantly more than single fixation patients (50% vs 18.9%, p=0.003). There was no difference in length of hospital stay, transfusion, complication and mortality rates. Medial translation of the distal articular block was significantly lower in the combination fixation cohort (1.2% vs 3.4%, p=0.021). Operation time was significantly longer in the combination fixation cohort (183mins vs 134mins, p<0.001). Discussion. The results show no difference in achieving union or time to union, despite better quality of fracture reduction with dual fixation. This differs to previously published literature. The clear benefit of combination fixation is immediate weight-bearing. As expected, operation times were longer with combination fixation, however this did not translate to more complications. Conclusion. Combination fixation allows earlier weight bearing, at the cost of longer operation times

Freehand distal interlocking of intramedullary nails remains a challenging task. If not performed correctly it can be a time consuming and radiation expensive procedure. Recently, the AO Research Institute developed a new training device for Digitally Enhanced Hands-on Surgical Training (DEHST) that features practical skills training augmented with digital technologies, potentially improving surgical skills needed for distal interlocking. Aim of the study: To evaluate weather training with DEHST enhances the performance of novices without surgical experience in free-hand distal nail interlocking compared to a non-trained group of novices. 20 novices were assigned in two groups and performed distal interlocking of a tibia nail in an artificial bone model. Group 1: DEHST trained novices (virtual locking of five nail holes during one hour of training). Group 2: untrained novices without DEHST training. Time, number of x-rays, nail hole roundness, critical events and success rates were compared between the groups. Time to complete the task (sec.) and x-ray exposure (µGcm2) were significantly lower in Group1 414.7 (290–615) and 17.8 (9.8–26.4) compared to Group2 623.4 (339–1215) and 32.6 (16.1–55.3); p=0.041 and 0.003. Perfect circle roundness (%) was 95.0 (91.1–98.0) in Group 1 and 80.8 (70.1–88.9) in Group 2; p<0.001. In Group 1 90% of the participants achieved successful completion of the task (hit the nail with the drill), whereas only 60% of the participants in group 2 achieved this; p=0.121. Training with DEHST significantly enhances the performance of novices without surgical experience in distal interlocking of intramedullary nails. Besides radiation exposure and operation time the com-plication rate during the operation can be significantly reduced

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation

Anterior cervical discectomy and fusion (ACDF) is a well-established spinal operation for cervical disc degeneration disease with neurological compromise. The procedure involves an anterior approach to the cervical spine with discectomy to relieve the pressure on the impinged spinal cord to slow disease progression. The prosthetic cage replaces the disc and can be inserted stand-alone or with an anterior plate that provides additional stability. The literature demonstrates that the cage-alone (CA) is given preference over the cage-plate (CP) technique due to better clinical outcomes, reduced operation time and resultant morbidity. This retrospective case-controlled study compared CA versus CP fixation used in single and multilevel anterior cervical discectomy and fusion for myelopathy in a tertiary centre in Wales. A retrospective clinico-radiological analysis was undertaken, following ACDF procedures over seven years in a single tertiary centre. Inclusion criteria were patients over 18 years of age with cervical myelopathy who had at least six-month follow-up data. SPSS was used to identify any statistically significant difference between both groups. The data were analysed to evaluate the consistency of our findings in comparison to published literature. Eighty-six patients formed the study cohort; 28 [33%] underwent ACDF with CA and 58 [67%] with CP. The patient demographics were similar in both groups, and fusion was observed in all individuals. There was no statistical difference between the two constructs when assessing subsidence, clinical complication (dysphagia, dysphonia, infection), radiological parameters and reoperations. However, a more significant percentage [43% v 61%] of patients improved their cervical lordosis angle with CP treatment. Furthermore, the study yielded that surgery to upper cervical levels results in a higher incidence of dysphagia [65% v 35%]. Finally, bony growth across the cage was observed on X-ray in 12[43%] patients, a unique finding not mentioned in the literature previously. Our study demonstrates no overall difference between the two groups, and we recommend careful consideration of individual patient factors when deciding what construct to choose

Purpose. The aim of this study was to compare the clinical outcomes of the revision TKA in which trabecular metal cones and femoral head allografts were used for large bone defect. Method. Total 53 patients who have undergone revision TKA from July 2013 to March 2017 were enrolled in this study. Among them, 24 patients used trabecular metal cones, and 29 patients used femoral head allografts for large bone defect. There were 3 males and 21 females in the metal cone group, while there were 4 males and 25 females in the allograft group. The mean age was 70.2 years (range, 51–80) in the femoral head allograft group, while it was 79.1 years (range, 73–85) in the metal cone group. Bone defect is classified according to the AORI classification and clinical outcomes were evaluated with Visual Analogue Scale (VAS), Hospital Special Surgery-score (HSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and ROM. Operation time was also evaluated. We used radiographs to check complications such as migration or loosening. We took follow-up x-rays and 3D CT of the patients, to assess the mean bone union period. Shapiro-Wilk test was done to check normality and Student T-test and Mann Whitney U-test were done for comparison between two groups. Result. The mean follow-up period was 3 .75 years (Range; 2.1 ∼ 5.75). The pre-op scores did not show significant difference. The mean VAS in the allograft and trabecular metal cone groups was 2.1 ± 0.87 and 1.8 ± 0.53, respectively (p = 0.16). The mean HSS score were 76.3 ± 5.51 and 79.2 ± 4.12 respectively (p = 0.13) and the mean WOMAC scores were 15.1 ± 3.25 and 14.8 ± 3.31 respectively (p = 0.06), and the mean KOOS scores were 27.8 ± 4.77 and 25.5 ± 4.84, respectively (p = 0.07). The mean ROM ranges were 100.6 ± 17.54 and 101.3 ± 19.22, respectively (p = 0.09). But the mean operation time of the allograft and trabecular metal cone groups was 137 minutes (Range; 111–198) and 102minutes (Range; 93 −133) (p=0.02) respectively, which showed statistical significance. In follow-up x-rays, no migration or loosening of the implants, osteolysis and other complications were found in both groups. In follow-up 3D CT, osteointegration was seen at the trabecular metal cone site, host bone being interpreted to the host bone. The allograft group showed fibrous and stable union in follow-up 3D CT. Conclusion. According to this study, in case of revision TKA with large bone defect, using whether allograft or trabecular metal cones did not affect the clinical outcomes. However, operation time was significantly shorter in trabecular metal cone group, therefore, in patients with poor general condition along with severe underlying diseases, usage of trabecular metal cone would be a better choice to shorten operation time and ease postoperative care. Keywords. Revision TKA, metal cone, allograft, bone defect. For any figures or tables, please contact authors directly

Introduction and Objective. Several factors contribute to the duration of the hospital stay in patients that undergo to total hip arthroplasty (THA), either subjective or perioperative. However, no definite evidence has been provided on the role of any of these factors on the hospitalization length. The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay (LOS) in patients that underwent elective total hip arthroplasty. Materials and Methods. Medical records of patients that underwent THA since the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, renal function, whole blood count. and length of post-operative ward stay were retrieved. The association between clinical, biochemical and surgical factors and the length of hospital stay was explored by means of linear regression models. Results. A total of 743 subjects were included. Retrieved comorbidity included arterial hypertension (47%), dyslipidaemia (20%), chronic kidney disease (CKD) (12%) and diabetes mellitus (9%). The median length of post-operative hospital stay was 4 days (IQR: 2). Variables associated with linear increase of hospitalization length were the estimated Glomerular Filtration Rate (eGFR) (Beta −0.01, 95% CI −0.02, 0), CKD (Beta 0.82, 95% CI 0.29, 1.34), duration of surgery (Beta 0.69, 95% CI 0.44, 0.94). After correction for multiple confounders, the CKD (a-Beta 1.58 95%CI 0.00 – 3.22) and operation time (a-Beta 0.67, 95% CI 0.42, 0.92) were consistently associated with the outcome. Conclusions. Our analysis demonstrated a significant role played by the eGFR (as an index of renal function) in influencing the length of hospital stay

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

Background. Well-fixed cementless stems are sometimes needed to be extracted in patients with complications including periprosthetic infection, stem-neck breakage or trunnionosis. The purpose of this study was to report the clinical outcome in patients undergoing re-implantation surgery following removal of a well-fixed porous-coated cementless stem by the femoral longitudinal split (FLS) procedure(Fig.1, Fig.2). Methods. We conducted a retrospective study and radiographic review of 16 patients who had undergone re-implantation following the FLS procedure to remove a well-fixed stem due to periprosthetic infection, stem-neck breakage or trunnionosis. The study group consisted of 2 men and 14women with an average age of 68.4 years. Mean follow-up was 33.1± 25.0 months. Operation time, intraoperative bleeding, complications, causes of re-operation and clinical score were evaluated and the Kaplan-Meier method was used to evaluate the longevity of the stem. Results. The average operation time was 272±63 minutes and intraoperative bleeding was 420±170 ml. Although postoperative dislocation occurred in 5 hips and sinking of the stem was found in 3 hips after surgery, no progression of the stem sinking was observed and the clinical JOA and JHEQ scores were both improved after re-implantation surgery. Re-implantation surgery with Zweymüller-type stems, which are shorter than those removed, revealed evidence of osseointegration of the stem without femoral fracture. Kaplan-Meier survival analysis of stem revision for any reason as the end point revealed 70.3% survival at 9 years (Fig.3). Conclusion. The FLS procedure is expected to confer successful clinical results without loosening of the stem, following safe extraction of well-fixed porous-coated cementless stems without fracture and will allow re-implantation with shorter cementless stems than those removed. For any figures or tables, please contact the authors directly

Purpose. Various approaches have been reported for the total hip replacement (THR). In recent years, a muscle sparing approach with low postoperative muscle weakness and low dislocation risk has been frequently selected. However, such surgery has a learning curve. Thus, at the time of switching from the conventional approach to such approaches, invasion or infection risk may increase with the operation time extension. The purpose of this study is to clarify the change of invasiveness or latent infection rate with the change in approach in order to select the cases safely at the beginning of introducing a new approach in THR. Methods. In facility A, THR was performed with Dall's approach (Dall), but 1 surgeon changed Dall to anterolateral modified Watson-Jones approach (OCM) and another surgeon changed Dall to direct anterior approach (DAA). In facility B, all 3 surgeons changed posterolateral (PL) approach to OCM. The subjects are 150 cases in total, including the each last 25 cases operated with the conventional approach and the each first 25 cases operated with a new approach (Dall to OCM: 25 + 25, Dall to DAA: 25 + 25, PL to OCM: 25 +25 cases). And, differences in operative time, intraoperative bleeding volume, postoperative hospital stay, and postoperative hemoglobin, white blood cell count, lymphocyte count, creatine kinase (CK), C-reactive protein (CRP) were investigated. Results. The average age of subjects was 64 years (31–87 years old), and there were 27 male subjects and 123 female subjects. In the change from Dall to OCM, only the postoperative hospital stay decreased significantly. In the change from Dall to DAA, the length of hospital stay and postoperative CRP significantly decreased, but the intraoperative bleeding volume increased. In the change from PL to OCM, the operation time, postoperative CRP and CK decreased, but postoperative Hb decreased. Cases with lymphocytes less than 1000/µL or less than 10% after surgery on day 4 are latent infection cases, and in such cases the operation time was significantly longer, the postoperative Hb was significantly lower, and the postoperative CK was significantly higher. However, such cases were not significantly increased by the change of operation approach. Conclusion. Introduction of the muscle sparing approach improved many items on surgical invasion, but some items deteriorated especially at the beginning of a new approach. In the early stages of introduction of the new approach, choosing cases without obesity and without lots of muscle volume may reduce latent infection

A tourniquet is usually used during ankle arthroscopy to allow for improved visibility and reduced operation time. However, clinical studies on knee arthroscopy have not demonstrated this to be true. In addition, Zengerink and van Dijk emphasized a limited tourniquet time in ankle arthroscopy as a possible factor to lower the complication rate even more. The purpose of this prospective randomized controlled trial was to examine the effect of tourniquet use on arthroscopic visualization, operative time, postoperative intra-articular bleeding, postoperative pain scores and outcome of anterior ankle arthroscopy. A consecutive series of 50 patients who were scheduled for anterior ankle arthroscopy were randomized to have the surgery done either without the tourniquet inflated (25 patients) or with the tourniquet inflated (25 patients). The patients were evaluated by the course of the surgery, postoperative intra-articular bleeding, pain during the early postoperative period and by using the subjective and objective functional scores to evaluate the condition of the ankle before and 3 and 6 months after the surgery. The statistical analysis was performed with the normality of distribution tested by both Kolmogorov-Smirnov and Shapiro-Wilk tests. Appropriate parametric or non-parametric methods were then used to test statistical hypotheses, while the statistical significance (alpha, Type I error) was set at .05. Fourty-nine patients were present at the final follow-up, 6 months after the surgery. The results between the groups were comparable regarding the duration of the operative procedure, consumption of sterile saline, visualisation and functional scores. Notable difference between the groups in favour of the non-tourniquet group was present regarding postoperative bleeding, but was not statistically significant. Statistically significant difference in favour of the non-tourniquet group was found regarding postoperative pain during several days in the early postoperative period. Our study has shown that anterior ankle arthroscopy may be performed adequately without the use of a tourniquet and that it has the same operative course as in cases in which the tourniquet is used and functional outcomes which are not worse than in cases in which the tourniquet is used

Abstract. Objective. To compare the clinical and radiological outcome between less invasive stabilization system (LISS, Synthes, Paoli, PA.) and open reduction with internal fixation (ORIF) for the treatment of extraarticular proximal tibia fractures through the lateral approach. Background. Proximal tibial fractures present a difficult treatment challenge with historically high complication rates. ORIF has been in vogue for long time with good outcome. But these are associated with problems especially overlying skin conditions, delayed recovery and rehabilitation with limited functional outcome. LISS is an emerging procedure for the treatment of proximal tibial fractures. It preserves soft tissue and the periosteal circulation, which promotes fracture healing. Patients and methods. Thirty patients with closed proximal tibial fractures were included in this study. They were randomly divided into 2 groups. Group I (n=15) patients were treated by LISS and group II (n=15) by ORIF. Major characteristics of the two groups were similar in terms of age, sex, mode of injury, fracture location, and associated injuries. All patients were followed up at least 6 months. Results. In each group, 12 patients were united, 2 patients were non- united and one patient showed delayed union. The mean operative time in LISS patients was 79.3 min, while in ORIF patients; it was 122 min. All patients of LISS group were exposed to radiation, while only 40% of ORIF group were exposed. The mean time of union of LISS patients was 10.87weeks. While in ORIF patients, the mean time of union was 21.13 weeks. There was no significant difference between both groups regarding the postoperative complications. Functional outcome was satisfactory in both groups. Conclusion. LISS achieves comparable results with ORIF in extraarticular fractures of the proximal tibia. Although LISS potentially has the radiation hazard, it reduces the perioperative complications with a shortened operation time and minimal soft tissue dissection. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Various studies have demonstrated that the necessity for reversal of Warfarin through the use of Vitamin K (Vit K) in neck of femur fracture patients introduces increased duration of stay and poorer outcomes as measured by operative complications and mortality rate. One reason for this delay may be the time latency between admission and the clinicians decision to investigate the INR. In this study we aim to explore the different causes of latency which contribute to a delay to theatre and ascertain whether point of care testing may negate this. We carried out an audit of a cohort of neck of femur fracture patients between 2012 and 2015. Between September 2011 and September 2013, paper notes of 25 patients who were on warfarin at the time of sustaining a Neck of femur fracture (NOF) was obtained within Addenbrookes hospital archives. An additional 80 patients records from the year 2015 were retrieved from EPIC digital records. Time intervals were recorded as follows (from time of A&E assessment by Medical doctor); Interval to orthopaedic specialist assessment, Interval to first INR order, Interval to first INR result seen by specialist, Interval to first Vit K prescribed, Interval to first Vit K given, Interval to Second INR ordered, Interval to second INR seen by specialist, Interval to operation time (as determined by time of team briefing). Analysis of the time intervals as a proportion of total time elapsed between A&E assessment and Time to theatre was performed. Point of care (POC) testing of INR on admission to A&E was introduced and a symmetrical time period was analysed for the same intervals. The latency generated by time taken for a NOF to be assessed by an orthopaedic specialist occupied 8.60% of the total time, the interval between ordering and recording an INR value accounted for 7.96% of time to theatre, the interval between an INR being recorded and subsequently seen by a clinician accounted for 13.4% of time to theatre, the time between orthopaedic specialist assessment and prescription of Vit K took up 7.83% of the total time and the percentage time between Vit K prescription and administration was 12.3%. The time between the first dose of Vit K prescription and arriving at theatre accounted for 76.1% of latency and the time between viewing a second INR and time to theatre occupied 33% of the total time. Following introduction of POC INR testing, there was a statistically significant decrease in time taken for warfarin reversal and consequently a reduction between time of admission to time to theatres. NOF patients who are on warfarin at time of injury introduces complexity to surgical management and planning for theatre. In our audit we demonstrate that causes of delay are distributed throughout the pathway of care and there are several stages. POC INR testing represents an effective method of reducing this latency and improves patient outcome

Introduction. The primary aim of this study was to describe a baseline comparison of early knee-specific functional outcomes following revision total knee arthroplasty (TKA) using metaphyseal sleeves with a matched cohort of patients undergoing primary TKA. The secondary aim was to compare incidence of complications and length of stay (LOS) between the two groups. Methods. Patients undergoing revision TKA for all diagnoses between 2009 and 2016 had patient-reported outcome measures (PROMs) collected prospectively. PROMs consisted of the American Knee Society Score (AKSS) and Short-Form 12 (SF-12). The study cohort was identified retrospectively and demographics were collected. The cohort was matched to a control group of patients undergoing primary TKA. Results. Overall, 72 patients underwent revision TKA and were matched with 72 primary TKAs with a mean follow-up of 57 months (standard deviation (SD) 20 months). The only significant difference in postoperative PROMs was a worse AKSS pain score in the revision group (36 vs 44, p = 0.002); however, these patients still produced an improvement in the pain score. There was no significant difference in improvement of AKSS or SF-12 between the two groups. LOS (9.3 days vs 4.6 days) and operation time (1 hour 56 minutes vs 1 hour 7 minutes) were significantly higher in the revision group (p < 0.001). Patients undergoing revision were significantly more likely to require intraoperative lateral release and postoperative urinary catheterisation (p < 0.001). Conclusion. This matched-cohort study provides results of revision TKA using modern techniques and implants and outlines what results patients can expect to achieve using primary TKA as a control. This should be useful to clinicians counselling patients for revision TKA

The purpose of this study was to compare the outcomes of arthroscopic unilateral surgery and simultaneous bilateral surgery for posterior ankle impingement syndrome (PAIS) in athletes and to evaluate the usefulness of simultaneous bilateral surgery. A total 48 hindfeet of 41 athletes (14 hindfeet of 14 males, 34 hindfeet of 27 females) who underwent arthroscopic surgery for PAIS were studied. Japanese society for surgery of the foot (JSSF) score and visual analogue scale (VAS) were compared before and after surgery, using Wilcoxon signed-rank test. The operation time and the time to return to sports activity were compared in 10 hindfeet of 5 patients who underwent simultaneous bilateral surgery and 38 hindfeet of 36 patients who underwent unilateral surgery, using Wilcoxon rank sum test. Classic ballet was the most common type of sport that caused PAIS (59%, 24/41 athletes). Soccer (10%, 4/41 athletes), baseball (10%, 4/41 athletes), badminton (5%, 2/41 athletes), volleyball (5%, 2/41 athletes), and athletics (5%, 2/41 athletes) followed. The JSSF score improved significantly from 72.7 preoperatively to 98.9 postoperatively in unilateral surgery, and significantly improved from 75.2 preoperatively to 99.0 postoperatively in simultaneous bilateral surgery. VAS significantly decreased from 64.7 preoperatively to 4.8 postoperatively in unilateral surgery, and significantly decreased from 72.7 preoperatively to 1.0 postoperatively in simultaneous bilateral surgery. The operating time was 53.7 minutes on average for unilateral surgery and 101.0 minutes for simultaneous bilateral surgery, significantly longer in bilateral simultaneous surgery. The mean time to return to sports activity was 4.8 weeks for unilateral surgery and 9.6 weeks for simultaneous bilateral surgery, significantly longer in simultaneous bilateral surgery. Both unilateral and simultaneous bilateral surgeries for PAIS in athletes were useful. It should be noted that the operating time and the time to return to sports will be longer. However, considering the 2 times hospitalizations and 2 times surgeries, simultaneous bilateral surgery is one of the treatment options for PAIS

Background. Acromegaly, which stems from high level of serum growth hormone secreted by a benign tumour in the anterior pituitary gland, is likely to cause severe peripheral joint pains due to hypertrophic changes in such joints. Recently, the life expectancy of such patients has been improved and more patients with acromegaly have undergone joint surgeries to mitigate joint pain and malfunctions. However, little is known about to what extent surgical procedures can improve the joint functions of acromegalic patients compared to non-acromegalic cases. Methods. First, we qualitatively analysed prognosis of total hip arthroplasty (THA) of acromegalic patients by investigating 11 cases in which direct anterior approach (DAA) THAs were performed to 8 acromegalic patients in our hospital between 2012 and 2015. Second, we quantitatively compared the functional prognosis of the 11 cases with that of 107 non-acromegalic cases. Technically, to control the difference in age, sex, height, and weight between the two patient groups, we first identified a model that could predict 3month-/6month-/12month-functional prognosis in the control cases. We estimated differences in functional outcomes between the two groups by calculating how accurately the control-case-based model could predict the prognosis of the acromegalic cases. Results. In the qualitative analysis, we found that compared to the control, the most acromegalic cases had atypically advanced degenerative arthritides with osteophytes and enthesophytes proliferations. In addition, some cases showed other signs, such as flattering of femoral head and arthritis with slight osteophytes. Regarding surgical procedures, acromegalic cases were likely to require longer operation time and larger amounts of blood loss compared to the control. In the quantitative analysis, we first identified a model in which age and body height could predict the functional prognosis of DAA THA in the non-acromegalic cases (F[2,104] = 6.7, P = 0.0017). We then found that the actual functional outcomes of the acromegalic cases were not significantly different from those predicted by this control-case-based model (P = 0.18). Conclusions. The qualitative analysis shows the atypical joint structures and resultant prolonged operation time and blood loss in the acromegalic cases. However, the quantitative analysis could not find significant differences in prognosis between the acromegalic and non-acromegalic cases. Although these observations and analyses need to be examined in studies with large sample sizes, this work suggests that functional outcomes of DAA THA to acromegalic patients can be comparable to that to non-acromegalic patients

Summary. Alignment results did not differ between PSG and conventional instrumentation. A small reduction in operation time and blood loss was found with the PSG system, but is unlikely of clinical significance. Length of hospital stay was identical for both groups. Introduction. Several techniques for aligning a TKA exist nowadays. Patient-specific guiding (PSG) has relatively recently been introduced to try to resolve the shortcomings of existing techniques while optimising the operative procedure. Still few reports have been published on the clinical outcome and on the peroperative results of this new technique. This prospective, double-blind, randomised controlled trial was designed to address the following research questions: 1. Is there a significant difference in outliers in alignment in the frontal and sagittal plane between PSG TKA and conventional TKA. 2. Is there a significant difference in operation time, blood loss and length of hospital stay between the 2 techniques. Patients & Methods. 180 patients were randomised for PSG TKA (group 1) or conventional TKA (group 2) in 2 centres. Patients were stratified per hospital. Alignment of the mechanical axis of the leg and flexion/extension and varus/valgus of the individual prosthesis components were measured on digital, standing, long-leg and standard lateral radiographs by 2 independent outcome assessors in both centres. Percentages of outliers, > 3°, were determined. We compared blood loss, operation time and length of hospital stay. Results. There was no statistically significant difference in mean mechanical axis or outliers in mechanical axis between groups. No statistically significant difference was found for the alignment of the individual components in the frontal plane, nor for the percentages of outliers. There was a statistically significant difference in outliers for the femoral component in the sagittal plane, with a higher percentage of outliers in the group 1 (p = 0.017). No such significant result was found for the tibial component in that plane. All interclass correlation coefficients were good. Blood loss was 100 mL less in group 1 (p = 0.000). Operation time was 5 minutes shorter in group 1 (p = 0.000). Length of hospital stay was almost identical with a mean of 3.6 days (p = 0.657). Discussion/Conclusions. The results in terms of obtaining a neutral mechanical axis and a correct position of the prosthesis components did not differ between groups. A small reduction in operation time and blood loss was found with the PSG system, but is unlikely of any clinical significance. Future research should especially focus on cost-effectiveness analysis and functional outcome of PSG TKA