Neuromuscular scoliosis patients face rates of major complications of up to 49%. Along with pre-operative risk reduction strategies (including nutritional and bone health optimization), intra-operative strategies to decrease blood loss and decrease surgical time may help mitigate these risks. A major contributor to blood loss and surgical time is the insertion of instrumentation which is challenging in neuromuscular patient given their abnormal vertebral and pelvic anatomy. Standard pre-operative radiographs provide minimal information regarding pedicle diameter, length, blocks to pedicle entry (e.g. iliac crest overhang), or iliac crest orientation. To minimize blood loss and surgical time, we developed an “ultra-low dose” CT protocol without sedation for neuromuscular patients. Our prospective quality improvement study aimed to determine: if ultra-low dose CT without sedation was feasible given the movement disorders in this population; what the radiation exposure was compared to standard pre-operative imaging; whether the images allowed accurate assessment of the anatomy and intra-operative navigation given the ultra-low dose and potential movement during the scan. Fifteen non-ambulatory surgical patients with neuromuscular scoliosis received the standard spine XR and an ultra-low dose CT scan. Charts were reviewed for etiology of neuromuscular scoliosis and medical co-morbidities. The CT protocol was a high-speed, high-pitch, tube-current modulated acquisition at a fixed tube voltage. Adaptive statistical iterative reconstruction was applied to soft-tissue and bone kernels to mitigate noise. Radiation dose was quantified using reported dose indices (computed tomography dose index (CTDIvol) and dose-length product (DLP)) and effective dose (E), calculated through Monte-Carlo simulation. Statistical analysis was completed using a paired student's T-test (α = 0.05). CT image quality was assessed for its use in preoperative planning and intraoperative navigation using 7D Surgical System Spine Module (7D Surgical, Toronto, Canada). Eight males and seven females were included in the study. Their average age (14±2 years old), preoperative Cobb angle (95±21 degrees), and kyphosis (60±18 degrees) were recorded. One patient was unable to undergo the ultra-low dose CT protocol without sedation due to a co-diagnosis of severe autism. The average XR radiation dose was 0.5±0.3 mSv. Variability in radiographic dose was due to a wide range in patient size, positioning (supine, sitting), number of views, imaging technique and body habitus. Associated CT radiation metrics were CTDIvol = 0.46±0.14 mGy, DLP = 26.2±8.1 mGy.cm and E = 0.6±0.2 mSv. CT radiation variability was due to body habitus and arm orientation. The radiation dose differences between radiographic and CT imaging were not statistically significant. All CT scans had adequate quality for preoperative assessment of pedicle diameter and orientation, obstacles impeding pedicle entry, S2-Alar screw orientation, and intra-operative navigation. “Ultra-low dose” CT scans without sedation were feasible in paediatric patients with neuromuscular scoliosis. The effective dose was similar between the standard preoperative spinal XR and “ultra-low dose” CT scans. The “ultra-low dose” CT scan allowed accurate assessment of the anatomy, aided in pre-operative planning, and allowed intra-operative navigation despite the movement disorders in this patient population

Neuromuscular scoliosis patients face rates of major complications of up to 49%. Along with pre-operative risk reduction strategies (including nutritional and bone health optimization), intra-operative strategies to decrease blood loss and decrease surgical time may help mitigate these risks. A major contributor to blood loss and surgical time is the insertion of instrumentation which is challenging in neuromuscular patient given their abnormal vertebral and pelvic anatomy. Standard pre-operative radiographs provide minimal information regarding pedicle diameter, length, blocks to pedicle entry (e.g. iliac crest overhang), or iliac crest orientation. To minimize blood loss and surgical time, we developed an “ultra-low dose” CT protocol without sedation for neuromuscular patients. Our prospective quality improvement study aimed to determine:. if ultra-low dose CT without sedation was feasible given the movement disorders in this population;. what the radiation exposure was compared to standard pre-operative imaging;. whether the images allowed accurate assessment of the anatomy and intra-operative navigation given the ultra-low dose and potential movement during the scan. Fifteen non-ambulatory surgical patients with neuromuscular scoliosis received the standard spine XR and an ultra-low dose CT scan. Charts were reviewed for etiology of neuromuscular scoliosis and medical co-morbidities. The CT protocol was a high-speed, high-pitch, tube-current modulated acquisition at a fixed tube voltage. Adaptive statistical iterative reconstruction was applied to soft-tissue and bone kernels to mitigate noise. Radiation dose was quantified using reported dose indices (computed tomography dose index (CTDIvol) and dose-length product (DLP)) and effective dose (E), calculated through Monte-Carlo simulation. Statistical analysis was completed using a paired student's T-test (α= 0.05). CT image quality was assessed for its use in preoperative planning and intraoperative navigation using 7D Surgical System Spine Module (7D Surgical, Toronto, Canada). Eight males and seven females were included in the study. Their average age (14±2 years old), preoperative Cobb angle (95±21 degrees), and kyphosis (60±18 degrees) were recorded. One patient was unable to undergo the ultra-low dose CT protocol without sedation due to a co-diagnosis of severe autism. The average XR radiation dose was 0.5±0.3 mSv. Variability in radiographic dose was due to a wide range in patient size, positioning (supine, sitting), number of views, imaging technique and body habitus. Associated CT radiation metrics were CTDIvol = 0.46±0.14 mGy, DLP = 26.2±8.1 mGy.cm and E = 0.6±0.2 mSv. CT radiation variability was due to body habitus and arm orientation. The radiation dose differences between radiographic and CT imaging were not statistically significant. All CT scans had adequate quality for preoperative assessment of pedicle diameter and orientation, obstacles impeding pedicle entry, S2-Alar screw orientation, and intra-operative navigation. “Ultra-low dose” CT scans without sedation were feasible in paediatric patients with neuromuscular scoliosis. The effective dose was similar between the standard preoperative spinal XR and “ultra-low dose” CT scans. The “ultra-low dose” CT scan allowed accurate assessment of the anatomy, aided in pre-operative planning, and allowed intra-operative navigation despite the movement disorders in this patient population

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail. We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy. Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation. This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group

Introduction. External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting. Materials & Methods. This prospective case series evaluated the first 20 consecutive cases of EF removal in the outpatient clinic between 10/06/22 to 16/09/22. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirement, asked to evaluate their experience and perceived pain using the Visual Analogue Scale (VAS). Results. Twenty patients were included in the study. The mean age was 46.6 years (range 21–85 years). Two thirds were male patients (N=13). Post procedure all patients indicated positive satisfaction ratings, each participant responding as either ‘satisfied’ (N=4), ‘very satisfied’ (N=15) or ‘highly satisfied’ (N=1). In addition, 85% of participants reported they would opt for this method of EF removal in future should it be necessary. VAS for pain immediately following completion of the procedure was low, with an average score of 0.45 (range 0–4), where a score of 0= ‘No pain’, and 10 = ‘worst pain possible’. Conclusions. We present the first description of outpatient EF removal using sole regional anaesthesia, with a prospective case series of 20 EF removed in fully awake patients. This novel technique is cost-effective, reproducible, and safe. This not only reduces the burden of these surgical cases on an operating list but also improves patient experience when compared to other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this project demonstrates a method of improving environmental sustainability of surgery, anaesthesia and operating theatres

Aim. In our Bone Infection Unit, epidural anaesthesia and sedation (EA+Sed) is the technique of choice for complex orthoplastic surgery involving lower limb free tissue transfer (LLFTT) (1) as it avoids complications of prolonged general anaesthesia (GA). Following our initial reports of successful use of audio-visual distraction (AVD) as an adjunct to regional anaesthesia we wished to evaluate the AVD effect on the patients’ experience during long duration, complex orthoplastic surgery for chronic osteomyelitis under EA+Sed. Method. Our AVD equipment consists of a WiFi connected tablet and noise reducing head phones, providing access to downloaded music, films and the internet. Patients are also allowed to use their own equipment. All patients were fully informed about AVD and EA+Sed as a choice of anaesthesia. EA was established in the anaesthetic room and continued perioperatively. Sedation with propofol was titrated to the patients’ requirements to ensure comfort during surgery. All patients were followed up postoperatively with a structured questionnaire. Results. Ten patients underwent LLFTT surgery for chronic bone infection under EA+Sed+AVD (picture). Mean duration of surgery was 550 min (480 −600 min). Patients used the AVD to listen to music, watch movies, play internet games and use e-mail and social media. All 10 patients were very satisfied, and 9 reported feeling comfortable or very comfortable intraoperatively. All rated their experience better than previous GAs, with quicker general recovery. All patients would recommend this technique to others. Conclusions. Our case series of patients undergoing prolonged surgery for osteomyelitis under EA+Sed has shown very positive impact of AVD on patients’ experience and confirmed our earlier encouraging observations. This clinical service improvement deserves further evaluation and funding

Dexmedetomidine, an alpha 2 agonist, has been approved for providing sedation in the intensive care unit. Along with sedative properties, it has analgesic activity through its highly selective action on alpha 2 receptors. Recent studies have examined the use of dexmedetomidine as an adjuvant to prolong the duration of peripheral nerve blocks. Studies showing effectiveness of dexmedetomidine for adductor canal block in knee surgery are small. Also, its effectiveness has not been compared to Epinephrine which is a strong alpha and beta receptor agonist. In a previous study, we showed that motor sparing knee blocks significantly increased the duration of analgesia compared with periarticular knee infiltration using local anesthetic mixture containing Epinephrine following total knee arthroplasty (TKA). In this study, we compared two local anesthetic mixtures: one containing Dexmedetomidine and the other Epinephrine for prolongation of motor sparing knee block in primary TKA patients. After local ethics board approval and gaining Notice of Compliance (NOC) from Health Canada for use of Dexmedetomidine perineurally, 70 patients between the ages 18 – 95 of ASA class I to III undergoing unilateral primary total knee arthroplasty were enrolled. Motor sparing knee block − 1) Adductor canal continuous catheter 2) Single shot Lateral Femoral Cutaneous Nerve block 3) Single shot posterior knee infiltration was performed in all patients using 60 ml mixture of 0.5% Ropivacaine, 10 mg Morphine, 30 mg Ketorolac. Patients randomized into the Dexmedetomidine group (D) received, in addition to the mixture, 1mcg/kg Dexmedetomidine and the Epinephrine (E) group received 200mcg in the mixture. The primary outcome was time to first rescue analgesia as a surrogate for duration of analgesia and secondary outcomes were NRS pain scores up to 24 hours and opioid consumption. The time to first rescue analgesia was not significantly different between Epinephrine and dexmedetomidine groups, Mean and SD 18.45 ± 12.98 hours vs 16.63 ± 11.80 hours with a mean difference of 1.82 hours (95% CI −4.54 to 8.18 hours) and p value of 0.57. Pain scores at 4, 6, 12, 18 and 24 hours were comparable between groups. Mean NRS pain scores Epinephrine vs Dexmedetomidine groups were 1.03 vs 0.80 at 4 hours, 1.48 vs 3.03 at 6 hours, 3.97 vs 4.93 at 12 hours, 5.31 vs 6.18 and 6.59 v 6.12 at 24 hours. Opioid consumption was also not statistically significant between both groups at 6, 12 18, 24 hours (p values 0.18, 0.88, 0.09, 0.64 respectively). Dexmedetomidine does not prolong the duration of knee motor sparing blocks when compared to Epinephrine for total knee arthroplasty. Pain scores and opioid consumption was also comparable in both groups. Further studies using higher dose of dexmedetomidine are warranted

London's Air Ambulance (LAA) was first set-up in 1989 as a direct result of a Royal College of Surgeons of England Report highlighting poor trauma care provision. Since its inception, the service's mission is to be an innovative and effective provider of advanced pre-hospital care. The service provides a senior Doctor and senior Paramedic to the scene of any incident within the M25 by helicopter, during the day, and by fast-response car at night. The vast majority of doctors are usually Emergency Medicine Physicians or Anaesthetists. During a 6-month tenure, doctors will usually have completed a number of procedures, which include rapid sequence induction of anaesthesia, pre-hospital blood transfusion, and, procedural sedation. In terms of innovations, the organisation was the first in the UK to provide a 24/7 service. It was also the first to start pre-hospital Rapid Sequence Induction of Anaesthesia for the severely injured; Resuscitative Thoracotomy for the victims of penetrating trauma; and pre-hospital Blood Transfusion for shocked polytrauma patients. The service also has a very thorough induction programme, for new Doctors and Paramedics, and a highly structured Clinical Governance process. The post offers a unique and privileged opportunity to treat the most severely injured at the roadside

Knee dislocation is a rare injury in high energy trauma, but it is even rarer in low energy injuries. We present, to our knowledge, the only case in the world literature of knee dislocation following a cricketing injury. The patient was a 46 year old recreational fast bowler who, whilst bowling, slipped on the pitch on the follow through. He sustained an anteromedial knee dislocation which was reduced under intravenous sedation. He also sustained a neuropraxia of the common peroneal nerve with grade 2 weakness of ankle and toe dorsiflexion. Magnetic Resonance Imaging (MRI) confirmed a complete rupture of anterior cruciate ligament (ACL), lateral collateral ligament (LCL) and postero-lateral corner (PLC). Patient underwent surgical reconstruction and repair of his PLC along with repair of LCL with combination of anchor sutures and metal staple within 72 hours of the injury. He was treated in a cast brace. The ACL insufficiency was treated conservatively. Patient made an uneventful recovery and follow up at 3 months revealed a full range of knee movements with asymptomatic ACL laxity

Total knee arthroplasty is associated with early postoperative pain. Appropriate pain management is important to facilitate postoperative rehabilitation and positive functional outcomes. This study compares outcomes in TKA with three techniques; local infiltration analgesia, single shot femoral nerve block and intrathecal morphine. Methods. Forty-five patients undergoing elective primary Total Knee Arthroplasty (TKA) with were randomized into one of three groups in a double blind proof of concept study. Study arm 1 received local infiltration analgesia ropivacaine intra-operatively, an elastomeric device of ropivacaine for 24 hours post-op. Study arm 2 received a femoral nerve block of ropivacaine with placebo local infiltration analgesia and placebo intrathecal morphine. Study arm 3 received intrathecal morphine, placebo femoral nerve block and placebo local infiltration analgesia. All patients received standardized pre-operative, intraoperative and Post-operative analgesic medication. Participants were mobilized at 4 hrs, 24hrs and 48 hrs post operation. Range of Motion, Visual Analogue Scale (VAS) pain intensity scores and two minute walk test and Timed Up and Go test were performed. Postoperative use of analgesic drugs was recorded. Knee Society Score (KSS), Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were completed at preoperative and 6 weeks post op. Results. Preliminary results of 32 participants convey the positive outcomes after total knee replacement demonstrated by the improvement in Oxford Knee Score and Knee Osteoarthritis Outcome score. There are marked improvements in the 2-minute walk tests at the six week time-point. At day one post-operative only 5 participants were unable to walk. Patient-controlled analgesia was used on 5 occasions on day one, 2 of which continued on day two. Sedation scores were recorded in six participants on day one and 2 on day two. Nausea was reported in 5 cases on day one and 9 on day two. Urinary catheter was needed in 5 cases on day one. Importantly the study remains blinded, therefore an analysis of the three study arms is not available and is therefore currently difficult to report on the statistical significance. There will be further assessment of the efficacy of analgesia using VAS pain scores, analgesia consumption and side effects collected preoperatively, 0–24hrs and 24–48 hours postoperatively between the three randomized groups. The assessment of functional outcomes will be measured between the three groups by comparing the ability to mobilize the first 4 hrs after surgery, maximal flexion and extension, two minute walk test and timed up-and-go preoperatively, on postoperative day 1 and 2 and 6 weeks. Conclusion. Results from the study will provide important information for the management of TKA in the hospital setting. We anticipate completion of all 45 surgeries in the next 2 months. The Blinding codes with be broken thereafter and full data analysis performed. The comparison of the three commonly used analgesic techniques and mobilization outcomes will allow enhanced management of patient's post-operative pain with earlier discharge from hospital an lower complication rates

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Purpose. The authors have used the Edinburgh Visual Gait Score (VGS) in the management of diplegic cerebral palsy patients treated with Botulinum toxoid injections into their hamstrings muscles. Video-filmed gait episodes were recorded before and after Botox injections over a treatment period of 6 years from 2007 to 2012. Method. The video-recordings of 32 patients were available for VGS analysis. Ages ranged from 5 to 22 years, with 17 patients under the age of 12 years, and 15 over 12 years. Gross Motor Function Classification System (GMFSC) levels were accorded to: 8 patients level 1, 10 patients level 2, and 14 patients level 3; 15 were boys and 17 girls. The indication for hamstring injections were a GMFCS level of 1 to 3, age five years or older, no previous hamstring surgery, and a patient keen to have the Botox treatment. Video-recordings were taken with a Sony and a Canon Digital camera in a back-front-back view and a lateral left-right view; walking distance ap was 10 metres, lateral camera distance 5 metres. All injections of Botox were done by the senior author without anaesthetic or sedation. All assessments were done by the junior authors; they did not know the patients, the status before or after injections or repeat injections, or the dates of injections and filming of the episodes. Results. After the Botox injections into the hamstrings bilaterally, no patient changed GMFCS level status, nobody deteriorated; all could be classified in the GMFCS. Conclusion. The Edinburgh VGS is a reliable analysis method for classifying GMF levels in diplegic walking cerebral palsy patients. Video-recordings are permanent and can repeatedly be re-assessed in future; different visual parameters may be chosen for assessment. ONE DISCLOSURE

Regional nerve block for upper limb surgery is an established procedure. Our study was undertaken to look at the patient experience of this. We prospectively studied 59 consecutive patients undergoing shoulder arthroscopic surgery under regional anaesthesia in our department. They completed a questionnaire which they brought back at their first follow up appointment. The questionnaire gathered information of their experience of anaesthesia and surgery, adequate postoperative information. We reviewed if intra-operative pain occurred and if the patients would undergo such a procedure again. All surgeons were upper limb specialists.3 out of 59 patients required conversion to general anaesthetic (5%) due to failure of the block. The introduction of the block was mainly painless;with patients giving a mean scoring of 0.59 on the visual analog pain score (VAS, range 0–5). 26 patients (44%) expressed interest and watched their operation. Of those, 7 patients felt anxious after having the proceedings explained.1 patient discontinued to watch due to this. 10 patients experienced intraoperative pain, 2 requiring local anaesthetic, 8 receiving sedation, giving a mean score of 3.2 on the VAS. 81.4% of patients would have surgery with regional anaesthetic again, 85% would recommend to others. 83% of patients received adequate information. Overall satisfaction of the experience was rated out of 10, with a mean score of 8.7 (median 9). Regional blocks are an established technique. Since patients are awake and can watch their surgery, it is important to consider the patients perception of this experience. The majority of viewing patients were reassured by explanations of their pathology. Most patients would undergo another procedure with regional anaesthesia and would recommend it, suggesting that this is an effective and popular choice. The overall experience is positive. This supports our intention of offering regional blocks for all upper limb surgery, facilitating increasing use of day case facilities, reducing inpatient stays

Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Aims. To discover how the management of traumatic anterior shoulder dislocation in the young patient (17-25) has changed, if at all, over the past six years. Methods. The same postal questionnaire was sent in 2002 and 2009 to 164 shoulder surgeons. Questions were asked about initial reduction, investigation undertaken, timing of surgery, preferred stabilisation procedure, period of immobilisation and rehabilitation programme instigated in first-time and recurrent traumatic dislocators. Summary of Results. Response rate - 92% (2009), 83% (2002). The most likely management of a young traumatic shoulder dislocation:. Reduction under sedation in A&E by A&E doctor (80%). Apart from X-ray, no investigations are performed (80%). Immobilisation for 3 weeks, followed by physiotherapy (82%). 68% would consider stabilisation surgery for first time dislocators (especially professional sportsmen) compared to 35% (2002). Of them, nearly 90% would perform an arthroscopic stabilisation vs. 57.5% (2002). For recurrent dislocators:. 75% would consider stabilisation after a second dislocation. 85% would investigate prior to surgery, choice of investigation being MR arthrogram (52%), compared to 50% (2002). 77% would perform arthroscopic stabilisation vs. 18% (2002), commonest procedure-arthroscopic Bankart repair using biodegradable bone anchors (62% 2009 vs. 27% in 2002). Immobilisation for 3 weeks, full range of motion 1-2 months and return to contact sports 6 - 12 months. Conclusion. There has been a remarkable change in practice compared to the previous survey. A significant proportion of Orthopaedic Surgeons would consider stabilisation in young first-time dislocators instead of conservative management. Arthroscopic stabilisation is now the preferred technique compared to open stabilisation whenever possible. Surgeons are using more investigations prior to listing the patient for surgery, namely the MR arthrogram. There is also an increased use of bio-degradable anchors as compared to metallic bone anchors in 2002

Aims

As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency.

Purpose:. To investigate treatment patterns and efficacy of postoperative strong opioids in patients who underwent total knee arthroplasty (TKA) in Korea. Methods:. A prospective, non-interventional study of 301 patients who underwent TKA and received strong opioids following patient controlled analgesia (PCA) was conducted by reviewing patient charts and diaries from 19 teaching hospitals. Clinical characteristics, strong opioid treatment patterns, efficacy of strong opioid on a scale of 0–10, and opioid-related adverse events (AEs) were investigated during hospitalization and at first outpatient visit. Safety analysis was conducted on 301 patients, and efficacy analysis was conducted on full analysis set (FAS) which consisted of all the patients who had at least 1 efficacy result among 301 patients. Results:. Among the FAS population of 298 patients, 86.9% were female, and mean age was 68.7 ± 7.5 years. Average duration of PCA was 4.3 ± 1.7 days, and average length of hospital stay including surgery was 16.3 ± 7.6 days. The mean duration of strong opioid prescription on a regular basis between PCA discontinuation and discharge was 10.3 ± 6.7 days. At the initial treatment with strong opioid following PCA, mean pain intensity score was 6.1 ± 2.1 upon movement and 4.2 ± 2.4 at rest. At discharge, mean pain intensity score was 4.1 ± 1.9 upon movement and 2.3 ± 1.8 at rest. Meanwhile, pain intensity score at the first outpatient visit was assessed only in 146 patients (49.0%) treated with opioid, and mean pain intensity scores upon movement and at rest were 3.5 ± 2.1 and 1.7 ± 1.8, respectively. Most frequently prescribed opioid was oral oxycodone (47.4%), followed by pethidine injection (17.2%), oral oxycodone/naloxone (12.6%), and transdermal fentanyl (12.0%). Additionally, the most frequently prescribed opioid on a regular basis was oral oxycodone (53.3%), and that on a PRN (pro re nata) basis was pethidine injection (48.4%). Among treatments, mean duration and mean daily dose of oral oxycodone during hospitalization were 6.1 ± 5.6 days and 13.9 ± 8.2 mg, 1.6 ± 1.2 days and 45.5 ± 24.5 mg for pethidine injection, 7.3 ± 5.3 days and 16.2 ± 7.3 mcg/hr for transdermal fentanyl, and 9.4 ± 8.0 days and 23.2 ± 16.8 mg/11.6 ± 8.34 mg for oral oxycodone/naloxone. At discharge, 150 patients (50.3%) were prescribed opioids. The most frequently prescribed strong opioid as discharge medications and their mean daily dose were 17.9 ± 10.5 mg of oxycodone (56.6%), 26.8 ± 17.0 mg/13.4 ± 8.5 mg of oxycodone/naloxone (17.1%), and 15.9 ± 6.1 mcg/hr of fentanyl (11.4%). Of 301 patients, 36 opioid-related AEs were reported in 26 patients (8.6%); the most frequently reported opioid-related AEs were nausea/vomiting in 13 patients (4.3%) experiencing 17 events, constipation in 10 patients (3.3%) experiencing 10 events, and sedation in 3 patients (1.0%) experiencing 3 events. Conclusion:. The first nationwide non-interventional study was conducted to investigate treatment patterns and efficacy of strong opioids in patients who underwent TKA. Among these patients, strong opioids provided favorable pain relief and were well tolerated at relatively low dose following PCA till the first outpatient visit

Aims

COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.

Introduction

Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics.

Aims

The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.