Aims

Arthroplasty has been shown to generate the most waste among all orthopaedic subspecialties, and it is estimated that hip and knee arthroplasty generate in excess of three million kg of waste annually in the UK. Infectious waste generates up to ten times more CO2 compared with recycled waste, and previous studies have shown that over 90% of waste in the infectious stream is misallocated. We assessed the effect of real-time waste segregation by an unscrubbed team member on waste generation in knee and hip arthroplasty cases, and compared this with a simple educational intervention during the ‘team brief’ at the start of the operating list across two sites.

Abstract

Abstract

The National Health Service produces over 500,000 tonnes of waste and 25 mega tonnes of CO2 annually. Operating room waste is segregated into different streams which are recycled, disposed of in landfill sites, or undergo costly and energy-intensive incineration processes.

By assessing the quantity and recyclability of waste from primary hip and knee arthroplasty cases, we aim to identify strategies to reduce the carbon footprint of arthroplasty surgery.

Data was collected prospectively at a tertiary orthopaedic hospital, in the theatres of six arthroplasty surgeons between April – July 2022. Fifteen primary total hip arthroplasty (THA) and 16 primary total knee arthroplasty (TKA) cases were included; revision and complex primary cases were excluded.

Waste was categorised into non-hazardous waste, hazardous waste, recycling, sharps, and linens. Each waste category was weighed. Items disposed as non-hazardous waste were catalogued for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined from packaging.

Average total waste generated for THA and TKA were 14.46kg and 17.16kg respectively, with TKA generating significantly greater waste (p < 0.05).

On average only 5.4% of waste was recycled in TKA and just 2.9% in THA cases. The mean recycled waste was significantly greater in TKA cases compared to THA, 0.93kg and 0.42kg respectively (p < 0.05).

Hazardous waste represented the largest proportion of the waste streams for both TKA (69.2%) and THA (73.4%). On average TKA generated a significantly greater amount (11.87kg) compared to THA (10.61kg), p < 0.05.

Non-hazardous waste made up 15.1% and 11.3% of total waste for TKA and THA respectively.

In the non-hazardous waste, only two items (scrub brush packaging and sterile towel packaging) were identified as recyclable based on packaging.

We estimate that annually total hip and knee arthroplasty generates over 2.7 million kg of waste in the UK. Through increased use of recyclable plastics for packaging, combined with clear labelling of items as recyclable, medical suppliers can significantly reduce the carbon footprint of arthroplasty. Our data highlight only a very small percentage of waste is recycled in total hip and knee arthroplasty cases.

Aims

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

Aims

The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic.

Aims

Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization and surgical site infection (SSI). This paper reports the impact of routine MRSA screening and the “cleanyourhands” campaign on rates of MRSA SSI and patient outcome.

Introduction

Data on the outcome of THA in patients under the age of 30 years is sparse. There is a perceived reluctance to offer surgery to young patients on the basis of potential early failure of the implant. We aim to review our experience with THA in this group of patients to establish outcomes in a high volume specialist arthroplasty unit.

Wrist block has been used to provide pain relief for many procedures on the hand and wrist but its role in arthroscopy of the wrist remains unexplored. Chondrotoxicity has been a concern with the intra-articular infiltration of local anaesthetic. We aimed to evaluate and compare the analgesic effect of portal and wrist joint infiltration with a wrist block on the pain experienced by patients after arthroscopy of the wrist.

A prospective, randomised, double-blind trial was designed and patients undergoing arthroscopy of the wrist under general anaesthesia as a day case were recruited for the study. Levo-bupivacaine was used for both techniques. The effects were evaluated using a ten-point visual analogue scale, and the use of analgesic agents was also compared. The primary outcomes for statistical analyses were the mean pain scores and the use of analgesia post-operatively.

A total of 34 patients (63% females) were recruited to the portal and joint infiltration group and 32 patients (59% males) to the wrist block group. Mean age was 40.8 years in the first group and 39.7 years in the second group (p > 0.05). Both techniques provided effective pain relief in the first hour and 24 hours post-operatively but wrist block gave better pain scores at bedtime on the day of surgery (p = 0.007) and at 24 hours post-operatively (p = 0.006).

Wrist block provides better and more reliable analgesia in patients undergoing arthroscopy of the wrist without exposing patients to the risk of chondrotoxicity.

Cite this article: Bone Joint J 2015;97-B:1250–6.

Introduction

Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device.

Introduction: The conventional radiological assessment of hallux valgus (HV) involves measuring the intermetatarsal angle, HV angle, congruity of the metatarsophalangeal joint and the overall clinical deformity of the forefoot. However, in the current practice, these angles are seldom measured. We observed consistent displacement of the lateral sesamoid (LS) along with HV deformity. The position of the LS in relation to the head of the first metatarsal has never been studied before. We aim to study this pattern of the LS and to quantify the severity of the deformity which could help make clinical decisions.

Methods: 112 radiographs of 60 consecutive patients who underwent a weight bearing radiographs of their feet were studied. Statistical analysis was performed to identify the correlation of displacement with conventional angle measurements.

Results: A definite pattern in displacement of the lateral sesamoid was noted. This displacement also showed a statistical correlation with the conventional measurement of inter-metatarsal angle.

Discussion: Previous research which studied the displacement of medial sesamoid in these deformities was not received with great enthusiasm due to the difficulty in locating the medial sesamoid through the head of the metatarsal. In contrast, the lateral sesamoid lies laterally and any progressive deformity makes it more accessible to assessment. We report a consistent pattern in the displacement of the LS and classified as the position as normal, mild, moderate and severe. As it does not involve any measurements, we believe, this is a quick and reliable technique of assessment of HV deformity and should help to base our operative decisions.

Introduction: There is paucity in guidance on when and what should be said or who should take the consent for patients undergoing lower limb arthroplasty. Never before, the specialists been contacted for current practice and their recommendations on the content and timing of obtaining the consent in these patients.

Materials and Methods: A postal questionnaire was sent to 154 Orthopaedic consultants in the 14 units in NorthWestern region of England. We acquired information on their current practice, awareness of the guidelines and their preferences and recommendations.

Results: A total of 117/154 (76%) consultants responded, of which 84 (55%) fulfilled the inclusion criteria. Currently, 36% patients are consented at preoperative assessment clinic and 40% on admission. 75% of the consultant consent themselves or are consented by their registrars. 70% were aware of local or national policies on who should consent patients and 40% on what should be explained and documented. 75% recommended that operating surgeon should obtain consent. The recommended time for the consent was at preoperative assessment by 57%.

Discussion: If the act of signing the consent form is to be more meaningful it should be signed by the surgeon who is going to perform the operation. This study demonstrates that the consultants agree on the common complications but have a varied threshold for giving the less common risks. With shortening of the waiting time, there is a growing body of surgeons suggesting that the consent should be done at the listing itself.

Purpose of Study: To prospectively evaluate the outcome of single surgeon endoscopic anterior cruciate ligament (ACL) reconstruction with quadrupled hamstring tendons drilling femoral tunnel independent of the tibial tunnel.

Methods and Results: 28 patients underwent endoscopic ACL reconstruction by a single surgeon in a DGH setting. All patients had symptomatic ACL deficiency proven by either MRI or previous arthroscopy. All patients were prospectively scored using the International Knee Documentation Committee (IKDC) score, the Lysholm score, Tegner activity score and the SF36 score. In each patient, an ipsilateral four-strand semi-tendinosus/gracilis tendon graft was used. The femoral tunnel was drilled through the anteromedial portal independent of the tibial tunnel as per the technique described by Leo Pinczewski, Sydney, Australia. This technique was used to place the femoral end of the graft in a more lateral position than obtained by the traditional transtibial technique. The ACL graft was fixed using RCI interference screws. All patients underwent standard accelerated rehabilitation program. All patients were reviewed clinically and radiologically at a mean follow-up 9 months. A significant improvement was noted in all the scores at the time of follow-up. Radiologically all femoral and tibial tunnels were satisfactorily placed with the femoral tunnels being in the 10 o’clock or 2 o’clock position with no evidence of tunnel widening. None of the grafts had failed. We feel that this technique may allow better rotational stability following ACL reconstruction.

We conducted a prospective review of patients treated specifically for phalangeal fractures over a period of 6 months. Data was sourced from patient records, Emergency Dept records and theatre records. X-rays were reviewed by the senior authors using the AGFA IMPAX Web1000 v5.1 System.

A total of 654 patients presented to our hospital during the study. Of these, 257 (39%) patients were referred to the plastics and hand surgical team on-call. Remaining 397 (61%) patients were seen and treated at the local accident and emergency. Our review identified a patient group of 75 out of 654 (11.5%) patients who required operation.

Mechanism of injury: Direct impact: n=60 (80%), Hyperextension n=11 (15%), Hyper-flexion injury n=4 (5%).

The average patient age for a phalangeal fracture was 37.3 years. 47 (63%) patients were in the age group 20–40 years. The mean age for a phalangeal fracture in males was 35.9 (16–75) years and 42.2 (23–70) years in females. The gender distribution of these patients reveals that 58/75 (77%) patients were males. This indicates that males were at an increased relative risk of 3.4 for sustaining a hand fractures than females.

The fractures were studied with respect to their complexity, digit(s) involved, phalanx and the site on the phalanx, pattern of fracture and finally the involvement of the MCP or the IP joints.

Our study revealed that fifty-two (69%) of the fractures were closed while twenty-three (31%) were open. Injuries to the distal phalanges accounted for the most of the open fractures (15/23, 67%). The little finger and the ring finger were the common fingers to be involved.

The fractures were treated with various standard techniques of operative fixation. Postoperatively patients were mobilised as soon as possible and fitted with a removable thermoplastic splint to allow daily active and passive exercises. Hand therapists followed unit protocol including at least one visit per week, with follow up for four to six weeks. Final review was undertaken by a clinician in a dedicated Hand clinic six weeks post fixation.

Our work provides data on incidence and demographic distribution of phalangeal injuries presenting acutely to an NHS Trust covering a population area of 500,000. In our trust it is standard protocol for all such injuries to be reviewed by the Hand team to institute optimal hand therapy for patients. The study enabled us to develop a patient care pathway which will improve both patient and resource management

Introduction: Carpal tunnel syndrome is the most commonly occurring peripheral nerve entrapment syndrome and perhaps also the commonest peripheral nerve to be released. Increasingly there is a suggestion that carpal tunnel syndrome (CTS) is a bilateral disease with the reported incidence of between 16% and 87% and hence the enthusiasts favour bilateral simultaneous carpal tunnel decompression (CTD). Our hypothesis is that there is an increased likelihood of over-treating these patients with this approach of simultaneous carpal tunnel decompression.

Materials and Methods: A retrospective study was conducted to review records of 245 patients who underwent CTD at the Regional Hand Surgery Unit between April 2005 and August 2007. Patients who were referred with symptoms of bilateral CTS and underwent open CTD on at least one wrist were included in the study. The two groups hence formed were Group A comprising patients who underwent consecutive CTD where as Group B comprised patients who underwent only unilateral CTD before discharge. All patients booked for surgery were provided with a resting splint preoperatively. They were reviewed on one or more occasion before listing for decompression on the other side or discharged.

Results: A total of 131 met the inclusion criterion. Group A includes 76 (58%) patients and had symptoms on both sides and signs in 64 (84%) patients. Nerve conduction tests confirmed median nerve compression in 59/60 (98%) patients. Group B includes 55 (42%) patients and had symptoms suggestive of CTS on both sides and signs in 45 (82%) patients. Nerve conduction studies confirmed nerve compression in 38/41 (93%) patients. All patients were followed up for minimum of 6 months before being discharged from further review. At the end of the study, 48/131 (37 %) patients were successfully discharged after a minimum of six months follow up without an operation on the contralateral side.

Discussion: Our study has confirmed the bilateral nature of the disease. Current literature supports simultaneous CTD as it has been shown to be economic to the patient, employers and the healthcare industry. Studies have shown that symptoms are usually severe on one side and sometimes treatment of one hand may lead to the improvement, exacerbation or absence of effect in the other hand regardless of electromyographic findings. 45/131 (37 %) patients in our study were successfully discharged without an operation on the contralateral side after a minimum of six months follow up. Hence, this supports our hypothesis that by following an approach of simultaneous bilateral CTD, there is a increased likelihood of over-treating these patients and exposing them to the potential complications.