Patients offered fluid two-hours preoperatively have improved satisfaction, fewer complications and no increased intra-operative risk. Our hospital has prolonged pre-operative starvation times for trauma patients. Failure-Modes-and-Effects-Analysis (FMEA) was used to identify points of inefficiency in the preoperative starvation system.

Data was collected from patients, ward-staff and computer-systems, on pre-operative starvation times and food provision following cancellation. A process map of the system was created. Failure-modes-and-effects were identified at interview and stakeholders were asked to risk-evaluate each failure-mode by providing consequence scores, probability of failure and of detection.

Over 7-days, 27 patients were reviewed. Average fasting times were 6.84 (2–22.25) hours for fluid, and 12.03 (3–28.75) hours for food. Five patients were cancelled with a mean NMB time of 17.25 (3–28.75) hours. The highest risk scores identified were regarding the decision to place a patient on the list (10), keeping patients NBM (10.16) and being cancelled and fed (10.11).

Process-mapping and FMEA can be applied to the pre-operative starvation of trauma patients to identify parts of the system that will have the biggest impact if improved. Engaging the multidisciplinary-team allowed all members to feel involved in risk assessment and quality improvement. Using FMEA should facilitate change and improve the system of pre-operative starvation.

The International Commission on Radiological Protection has established standards for radiation protection. This study aims to determine actual and perceived radiation dose and audit safe practice when using image-intensifiers in theatre.

Between September 2012 and March 2013, 50 surgeons were surveyed during 39 procedures. Information collected by radiographers included the number of images the surgeons thought they used, actual number used, dose, screening time, number of people scrubbed, wearing thyroid collars and standing within 1m of the image-intensifier when in use.

The primary surgeon was more likely to estimate the number of images used correctly compared to the assistant. Supervising consultants were most accurate, followed by registrars as primary surgeons, consultants as primary surgeons then assisting registrars, and lastly SHOs. Most surgeons underestimated the number of images used. 87.5% of scrubbed staff were standing within 1m of the image-intensifier during screening and 36.5% were wearing thyroid protection. Three surgeons stated they were not wearing collars as they were unavailable.

We conclude that surgeons have a reasonable estimation of the x-rays used but are not undertaking simple steps to protect themselves from radiation. We plan to initiate an education program within the department and have ordered new, lightweight thyroid collars.

Tibiofemoral joint dislocations are uncommon. Four cases of paediatric knee dislocation are described, none in British journals.

We report two paediatric patients who presented with a 3-ligament knee injury following in-field or spontaneous reduction. One case was initially diagnosed as patella dislocation.

One patient, age 12 years, had associated nerve and vessel injury so underwent fixation, vascular grafting and fasciotomy emergently. The second, age 15 years, underwent acute reconstruction following MRI evidence of both cruciates and medial-collateral ligament ruptures, with tears to both menisci.

History is essential to diagnosis as the knee is often relocated at the scene. Tibiofemoral dislocation can be confused with patellofemoral dislocation. There are important differences on examination, which should be performed carefully, and must include neurovascular status. Knee AP and lateral radiographs can exhibit subtle signs, posterior subluxation of the tibia is pathognomonic of PCL rupture and should raise suspicion of dislocation.

These cases show that traumatic dislocation is an important differential diagnosis in a child that presents with a painful knee. Although an uncommon injury, particularly in the skeletally immature, it is essential to recognise the possibility of knee dislocation in children so that prompt diagnosis and treatment of this limb threatening injury can occur.

Recent reports observe that orthopaedic surgeons lack essential knowledge about ionising radiation. We aim to demonstrate perceived use of image-intensifiers by surgeons and awareness of radiation doses used during fractured neck of femur surgery.

Surgeons at a regional trauma centre were sent an online questionnaire. They were shown two neck of femur fracture radiographs and asked the total number of images they would use to reduce and fix the fracture with a dynamic-hip-screw / inter-medullary nail respectively. They were asked the maximum safe radiation dose, and that of ‘hip pining’ compared to CXR as outlined by the Ionising Radiation Regulations 1999.

For a DHS, consultants and registrars estimate their image use similarly. For IM nailing, consultants estimated higher image use than registrars, and double the number of X-rays taken for IM nailing compared to DHS. Knowledge levels regarding radiation doses during orthopaedic hip procedures are very low.

There is an expectation that more images will be used in IM nailing procedures. We plan to educate orthopaedic surgeons about radiation dose and safety. Correlating our findings with actual use of image in theatre when performing hip fracture surgery would extend the use of this study.

Introduction

The management of young patients with painful medial compartment osteoarthritis remains controversial. Opening wedge medial high-tibial osteotomy using a locking plate has shown good results in selected patients. This cohort of patients has high physical demands and previous studies have warned against operating on patients with increased body mass index (BMI).

The cement in cement technique for revision total hip arthroplasty (THA) has shown good results in selected cases. However, results of its use in the revision of hemiarthroplasty to THA has not been previously reported.

Between May 1994 and May 2007 28 (20 Thompson's and 8 Exeter bipolar) hip hemiarthroplasties were revised to THA in 28 patients using the cement in cement technique. All had an Exeter stem inserted at the time of revision. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford. Hip scores and radiographs were analysed post-operatively and at latest follow up.

The mean age at time of hemiarthroplasty revision was 80 (35 to 93) years. The reason for revision was acetabular erosion in 12 (43%), recurrent dislocation in eight (29%), aseptic stem loosening in four (14%), periprosthetic fracture in two (7%) and infection in a further two (7%) patients. No patient has been lost to follow up. Three patients died within three months of surgery. The mean follow up of the remainder was 50 (16 to 119) months. Survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Three cases (11%) have since undergone further revision, one for recurrent dislocation, one for infection, and one for periprosthetic fracture.

The cement in cement technique can be successfully applied to revision of hip hemiarthroplasty to THA. It has a number of advantages in this elderly population including minimising bone loss, blood loss and operative time.

It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice.

During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for.

Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list.

Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually.