Racial Disparities in Elective Total Knee and Hip Replacement Surgeries during the Covid-19 Pandemic: A Retrospective Study of a Diverse Population in Washington State

Purpose of Study: Total knee (TKA) and hip (THA) arthroplasty procedures are recognized as effective treatments for osteoarthritis of the knee and hip joints which are the leading causes of lower extremity disability among older adults. Previous studies have demonstrated a variance in patients electing to undergo these interventions with non-White patients having significantly lower utilization rates. Our study examined if these disparities continued to exist during the COVID-19 pandemic period. Methods Used: This retrospective cohort study included 580 patients who underwent TKA or THA in 2020 and 2021 in a racially diverse region in Washington State. Demographic data, comorbidities, and post-surgical outcomes were recorded. Patients were stratified as those identifying as White (n=490, 84.5%) or Hispanic/ Latino (n=65, 11.2%). Patients identifying with other races (n=25, 4.3%) were excluded from the study due to small sample sizes. Differences between our two groups were examined using a chi-square test for categorical variables and an independent t-test for continuous variables. The level of significance was set at P < 0.05. Summary of Results: Compared to the White patients, Hispanic/ Latino identifying patients were younger (61.9+/-12.79 years versus 68.58+/-9.00 years;P <0.001), had lower Charlson Comorbidity Index scores (P=0.019), and were more likely to use non-Medicare or Medicaid insurance (P <0.001). No differences were observed in postoperative complication (P=0.632) and COVID-19 infection (P=0.465) rates between the groups. Conclusion(s): Although Hispanic/ Latino identifying patients in this region constitute 45.8% of our study population according to the most recent census tabulation, they accounted for only 11.2% of the patients in our study. These patients were also younger, had fewer comorbidities, and tended to use non-Medicare or Medicaid insurance suggesting an exclusive Hispanic/ Latino patient population electing to undergo TKA or THA procedures during the COVID-19 pandemic. Future studies controlling for osteoarthritis risk factors and patients' election of treatment options may explain these disparities we have observed.

A CASE OF LONG-TERM TOLERANCE AFTER KIDNEY TRANSPLANTATION.

We present a case of long-term organ functioning (ca.10 years) after allografting of a cadaveric kidney without usage of immunosuppressing drugs. In 2005, a patient suffering from a hypertensive form of chronic glomerulonephritis, have received an allogeneic graft of cadaveric kidney compatible for AB0 system, HLA antigens (A19, B07, DR04), and negative results of cross-match test. The graft function was immediately restored, with normalization of creatinine levels achieved 4-5 days after surgery. Immunosuppression with cyclosporine, solumedrol, cellcept, metypred and simulect was performed in the hospital. Pulse therapy with solumedrol was performed on the day +20 due to the development of initial rejection signs. The postoperative period proceeded without infectious complications. The patient was discharged being recommended to take cyclosporine, Cell-Sept and Metypred. Within a year after transplantation, the patient claimed for pain in the hip joint, and, therefore, metypred was completely canceled. Subsequently, the Cellcept was replaced with a Mayfortic. In 2007, the signs of coxarthrosis were revealed at computed tomography, followed by aseptic necrosis of the the right femur head. Deforming osteoarthritis of the right hip joint was detected, and the hip replacement surgery was suggested. In 2010, due to risk of side effects from ongoing immunosuppressive therapy, e.g., joint damage, the Mayfortic was canceled. In 2012, being in fear of original Sandimmun Neoral replacement by a generic drug, the patient completely refused cyclosporine therapy. In 2021, the endoprosthetics of the right hip joint was performed, and the surgical wound healed initially. Since 2012, the patient has not completely taken immunosuppressive therapy. Over this time period, the patient has never been admitted to the hospital for impaired functioning of the organ graft. Meanwhile, he monitored his graft function on regular basis undergoing biochemical analyses, clinical examination, ultrasound studies of the graft and made regular visits to the outpatient department. In 2021, a week after hip replacement, there was a slight increase in serum creatinine, followed by further increase to 230 mmol/L in 2021, and to 310 mmol/L in March 2022. In February 2022, the patient suffered mild respiratory infection (confirmed COVID-19). In March 2022, the first clinical signs of increasing nephropathy appeared, i.e., swelling of both lower extremities, with leukocytes in urine upon routine analysis, increased blood flow resistance in the main artery of the transplant shown by ultrasound study. Due to worsening of the patient's condition, he resumed taking the prescribed immunosuppressants. Copyright © 2022, SPb RAACI.

Physiotherapy Rehabilitation Post Total Hip Replacement in the Case of Avascular Necrosis of the Femur: A Case Report.

Avascular necrosis of the femur is an irreversible and painful disorder in which the epiphyseal bone suffers from ischemia necrosis owing to an interruption in blood flow to the femoral head, resulting in bone destruction. Later, it leads to osteoarthritis of the hip joint. Here, we present the case of a 35-year-old male who came with a complaint of pain on the left side of the hip region for the past 15 days. Since the patient tested positive for COVID-19, he was quarantined. An X-ray was carried out once the quarantine period was completed, which revealed avascular necrosis of the left femoral head. He was advised to have a total hip replacement and underwent the surgery. After one month, the patient started experiencing pain on the right side of the hip region. He visited the rural hospital, where an X-ray was carried out, which revealed avascular necrosis of the right femoral head. For reducing pain and improving functional independence and quality of life postoperatively, a well-planned physiotherapy protocol was incorporated, which included lower limb and pelvic floor strengthening exercises and a balance training program. The Numerical Pain Rating Scale and Harris Hip Score have been used as outcome measures to demonstrate the efficacy of the treatment.

Meeting the demands for bone allografts: Challenges during COVID-19 pandemic

Background: Bone allografts have been an integral part of orthopedic procedures such as revision hip surgery or reconstruction of large bone defects. Femoral heads and necks were harvested from living donors undergoing total hip arthroplasty (THA). They were stored fresh frozen or processed into bone chips by the Innsbruck Bone Bank. The challenge was to meet the demand for bone grafts through in-house manufacturing even during Covid-19 pandemic restrictions. Method(s): Key data from the bone bank's registry and the hospital administration between January 2019 and March 2022 were analysed with regard to collection of fresh frozen allogenic femoral heads /necks and the manufacture of bone chips and their discard. Donor suitability and release criteria were assessed in accordance with EU and national legislation. Result(s): In 1,249 primary THA surgeries 640 femoral heads and necks were harvested. In the mean 51.4% of these yielded the bulk material for bone chips manufacture. Due to Covid-19 pandemic restrictions the number of grafts retrieved was lowest in Q1 2020 and Q4 2021. The proportion of unreleased transplants remained fairly consistent at 14%, but the reasons for discard varied: technical issues were eliminated, but the increase for discard to >30% due to reasons in donor history required the revision of the questionnaire and the collaboration with the team responsible for listing diagnoses in the medical records. By 2020, the bone chip discard rate had increased to 8%. Hence modification of cleaning and gowning brought it back down to 2% . Conclusion(s): Providing high quality bone allografts is a complex task. In this context, it is important to regularly evaluate the registry data and to modify the process accordingly, thus ensuring adequate supply of allografts even in times of significant restrictions.

Comparison of an In-Person versus Virtual Interprofessional Escape Room and Simulation Experience for Pharmacy, Nursing and Physical Therapy Students

Introduction: The COVID-19 pandemic has forced health professions programs to deliver educational content virtually, including interprofessional education (IPE). Data are lacking comparing educational outcomes and students' attitudes toward virtual versus in-person IPE. Research Question or Hypothesis: Will virtual interprofessional (IP) escape room/simulation experiences impact students' IP socialization and knowledge similar to equivalent in-person experiences? Study Design: Pre-posttest quasi-experimental design. Method(s): IP student teams (pharmacy, nursing, physical therapy) completed an in-person or virtual escape room/simulated case conference experience. Escape room themes were sepsis and joint precautions following hip replacement surgery. In the case conference, students collaboratively developed an IP discharge care plan for a patient after hip replacement complicated by post-operative sepsis. Before and after the learning experience, students completed a knowledge test and a validated pre-post survey assessing IP socialization (Interprofessional Socialization and Valuing Scale-21;ISVS-21). At post, students completed a program evaluation. Data were compared using two-way repeated measures ANOVA using SPSS v26 with alpha=0.05. Result(s): ISVS-21 scores increased for both in-person (n=262) and virtual (n=210) experiences. Pre-experience scores were statistically but not meaningfully different between groups [5.1(0.9) in-person;5.5 (0.9) virtual;p<0.05]. ISVS-21 mean change scores differed slightly between groups [0.9(1.3) in-person;0.5(0.8) virtual;p<0.05;Cohen's d=0.40]. Pre-test knowledge scores were not different [6.7(1.8) inperson;6.6(1.6) virtual;p=0.4], however mean change scores differed modestly between groups [0.7(1.4) in-person;0.1(1.8) virtual;p<0.05;Cohen's d=0.39]. Both in-person and virtual experiences were rated highly per the program evaluation. Conclusion(s): Differences between in-person versus virtual IPE escape room/simulated case conference experiences for pharmacy, nursing and physical therapy students were present but minor. Virtual IPE may offer a comparable alternative to in-person IPE and could be an acceptable option for programs encountering financial or logistical barriers to implementing effective in-person IPE..

Overnight joint replacement surgery: a pilot Australian study.

BACKGROUND: With a stretched healthcare system and elective surgery backlog, measures to improve efficiency and decrease costs associated with surgical procedures need to be prioritized. This study compares the benefits of multi-disciplinary involvement in an enhanced recovery after surgery (ERAS) protocol-led overnight model following total hip replacement (THR) and total knee replacement (TKR). METHODS: Patients in each of two private hospitals undergoing THR or TKR were prospectively enrolled. One hospital (Overnight) was fully committed to the ERAS protocol implementation on all levels and formed the treatment group while in the other hospital (control), patients only had the anaesthetic and operative procedure as part of the ERAS protocol but did not follow the perioperative measures of the protocol. Outcomes on hospital length of stay (LOS), inpatient rehabilitation, functional outcomes, satisfaction, adverse events and readmission rates were investigated. RESULTS: Median LOS in the Overnight group was significantly smaller than in the control group (1 vs. 3 days, P < 0.0001). The Overnight group had lower rates of inpatient rehabilitation utilization (4% vs. 41.2%, P < 0.0001), similar improvements in functional hip and knee scores and no increased rate of adverse events or readmission. All patients in both groups were satisfied with their treatment. CONCLUSION: Overnight THR and TKR can safely be performed in the majority of patients, with a multi-disciplinary approach protocol and involvement of all perioperative stakeholders.

Primary hip and knee arthroplasty at district level is safe and may reduce the burden on tertiary care in a low-income setting.

BACKGROUND: Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level. METHODS: Retrospective review of consecutive hip and knee primary arthroplasty cases performed at a District Hospital (DH), and a Tertiary Academic Hospital (TH) in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts. RESULTS: Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2 ± 2.0 days at DH level and 7.6 ± 7.1 days for TH (p < 0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p < 0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p < 0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p > 0.05). Periprosthetic joint infection (PJI) rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level. During the study period, 228 patients received their arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list. CONCLUSIONS: Hip and Knee Arthroplasty at District health care level is safe and; for the reason that the DH feeds into the TH; providing arthroplasty at district level may help ease the pressure on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures. LEVEL OF EVIDENCE: Level III Retrospective cohort study.

Abstracts of Roma Pain Days 2022

The proceedings contain 42 papers. The topics discussed include: new frontiers of intra-articular infiltration;art therapy, negative emotion and pain: preliminary data;epidural steroid injection versus interferential therapy in managing chronic low back pain;results of treatment of the post-COVID-19 infection femur head aseptic necrosis;day-case surgery: pain-related readmission or delayed discharge. a preliminary data mining and literature review;acute pain alleviation in the emergency department: outcomes of a Greek nation-wide survey;results of using transversus abdominis plane (TAP) block as a component of multimodal analgesia in patients undergoing solid organ transplantation;patients who associate pain with red color report less intense pain after hip replacement surgery: prospective, consecutive pilot study;neuropathic pain in Moroccan rheumatology practice: about 1528 patients;and assessment of neuropathic pain in Moroccan rheumatology university hospital.

ATYPICAL PRESENTATION OF FAT EMBOLISM SYNDROME IN AN IMMUNOCOMPROMISED PATIENT

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Fat embolism is a syndrome that can occur during orthopedic procedures or fractures of the long bones, especially the femur and tibia. It can affect multiple organs, including the brain, skin, and lungs, causing the triad of altered mentation, petechiae, and hypoxemia. Here, we present a case of a 54-year-old woman at risk for graft versus host disease (GVHD) who presented with dyspnea a few weeks after an orthopedic procedure. Initial chest radiograph was notable for parenchymal infiltrates, and she was initially treated with antibiotics without improvement. CASE PRESENTATION: A 54-year-old woman with a history of leukemia, stem cell transplantation years ago, GVHD (skin liver, ocular, oral, joints (not lung), with clinical and cytogenetic remission underwent total hip arthroplasty. Two weeks later, she developed lethargy and dyspnea and presented to the emergency department. She was found to have an elevated WBC of x19.5 k/ul (normal 4.1-9.3k/uL) with a left upper lobe consolidation on the chest radiograph (Figure 1). She was treated empirically for pneumonia and discharged with a 7-day course of levofloxacin. Despite completing the course of antibiotics, her dyspnea worsened, and she presented to the emergency department two weeks later with worsening hypoxemia. Computed tomography (CT) of the chest showed bilateral diffuse ground-glass opacities (GGOs) with patchy consolidations in a broncho-vascular distribution (Figure 2). She was negative for COVID-19, Influenza A, B and Legionella urinary antigen. The differential diagnosis included infection and GVHD among others. She underwent bronchoalveolar lavage (BAL). The Gram stain and the culture did not suggest an infection. Pathology from BAL returned significant for reactive bronchial and squamous cells with lipid-laden macrophages. She was started on steroids. Her clinical status improved dramatically, and she was eventually discharged. At a 3-month follow-up her symptoms had improved. Her CT scan also showed significant improvement (Figure 3). DISCUSSION: Our case highlights the successful diagnosis of fat embolism in the lungs in a patient with complicated medical history. Fat embolism usually presents as ground glass opacities. However, the diagnosis was more challenging in this case due to a significant time lapse between her surgery and her presentation to the hospital. She also lacked the other common signs of fat embolism including altered mentation and skin changes. Therefore, other etiologies, such as GVHD, bacterial or viral infection were initially strongly considered. CONCLUSIONS: The diagnosis of fat embolism syndrome condition should still be suspected despite a delay from the initial surgery. Diagnosis in immunocompromised patients requires a detailed workup to rule out other etiologies. Reference #1: Johnson, M. J., & Lucas, G. L. (1996). Fat embolism syndrome. Orthopedics, 19(1), 41-49. Reference #2: Newbigin, K., Souza, C. A., Torres, C., Marchiori, E., Gupta, A., Inacio, J., … & Peña, E. (2016). Fat embolism syndrome: state-of-the-art review focused on pulmonary imaging findings. Respiratory medicine, 113, 93-100. Reference #3: Swiatek, K., Kordic, G., & Jordan, K. (2018). An Unlikely Presentation of Fat Embolism Syndrome. Chest, 154(4), 686A. DISCLOSURES: No relevant relationships by Raheel Anwar No relevant relationships by Boris Medarov

First Polish mobile application for patients undergoing total hip arthroplasty.

Total hip arthroplasty (THA) is one of the most frequent orthopedic procedures worldwide and its surgical volume is constantly growing. To address the patients' restricted access to healthcare resources and limited one-on-one contact with the surgeon during the COVID-19 pandemic, we created a reliable source of information for patients undergoing THA. The use of mHealth is increasing with access to modern technology in Poland. Information related to health issues is the second most common web search performed by older adults. Our project aimed to create the first Polish mobile application for THA patients: Endopedia. Endopedia was developed for the Android platform based on a survey performed among patients and a collection of frequently asked questions on patients' internet forums. The content was adapted to the elderly and visually impaired requirements. mHealth solutions should not replace one-on-one conversation, but they can provide substantial support for patients in conditions of limited information.

Abstracts SECCA 2021

The proceedings contain 24 papers. The topics discussed include: applications of 3d models in pelvis and hip surgery;intraoperative fractures of the acetabulum in total hip arthroplasty;does depression influence postoperative total hip atroplasty?;are we meeting patient's expectations after hip preserving surgery?;hip fractures during the COVID-19 pandemic: characteristics, management and outcomes;digital preoperative planning in total hip arthroplasty: our experience;emphysematous osteomyelitis of the hip: a case report;how a tripolar system helps us in revision surgery hip;clinical and radiological risk factors for revision surgery in primary total hip replacement: a study on 4,013 total hip replacements from 2000 to 2020;and peri-prosthetic Vancouver B2 post operative femoral fractures. clinical, functional and radiographic outcomes in a case series.

RAPT Scores Predict Inpatient Versus Outpatient Status and Readmission Rates After IPO Changes for Total Joint Arthroplasty: An Analysis of 12,348 Cases.

BACKGROUND: Changes to Medicare's Inpatient Only List (IPO) and factors associated with the COVID pandemic have led to more total joint arthroplasty (TJA) patients to be designated as outpatient (OP). This potentially complicates postoperative care for patients with lower functional status and poor social support. These factors make the decision between OP versus inpatient (IP) designation particularly challenging for healthcare teams. The Risk Assessment and Prediction Tool (RAPT) was designed to indicate patient risk for needing posthospital discharge to facility and considers social and functional factors. The purpose of this study is to 1) evaluate the correlation of RAPT as a clinical tool to aid decision-making regarding OP versus IP for Total Hip and Knee Arthroplasty (THA and TKA), 2) assess the impact of recent changes to the IPO and the COVID pandemic on OP TJA readmission rates, and 3) determine whether 90-day readmissions are correlated with RAPT scores after OP TJA. METHODS: We identified all elective TKA and THA patients from 2015 through 2021 in our electronic health record at our large, urban, academic health system. Fracture patients were excluded. For those patients with available RAPT scores, we determined OP and IP designations, with IP defined as those with length-of-stay 2 midnights or more. We performed subanalysis of OP between same-day and next-day discharge. RAPT scores and readmission rates were compared at time points related to changes in the IPO: before TKA removal in 2018 (period A), from 2018 until THA removal in 2020 (Period B), and after January 1, 2020, inclusive of impact from the COVID pandemic (Period C). RESULTS: Reviewed were 11,819 elective TKAs and 10,212 elective THAs. RAPT scores were available for 6,759 TKA patients and 5,589 THA patients. For both TKA and THA, RAPT scores between IP, same-day, and next-day discharged OP were significantly different across all time periods (P < .001). The percentage of OP designation increased across all time periods for TKA and THA. Over these same time periods, mean RAPT scores decreased significantly for both OP TKA and OP THA (P < .01). Concurrent with these changes were significant increases in OP THA 90-day readmission rates across Periods A and B (P = .010) as well as A and C (P = .006). Readmitted OP TKA had significantly lower RAPT scores than OP TKA without readmission during Period B (P < .001). Readmitted OP THA had significantly lower RAPT scores than those without readmission for all periods (P < .05). To facilitate clinical utility, median RAPT scores were also analyzed, and showed that RAPT scores for OP THA patients with readmission were 1 to 2 points lower for all time periods. CONCLUSION: RAPT scores correlate with IP versus OP status for both TKA and THA and vary significantly with same-day versus next-day discharge. OP TJA RAPT scores may also help predict readmission, and counsel some patients away from OP surgery. Average RAPT scores of 10, 9, and 8 appeared to be separators for same day, next day, and inpatient stay. Changes to the IPO and COVID pandemic correlate with decrease in RAPT scores for both TKA and THA patients within all designations. In addition, a shift toward lower RAPT for OP TJA correlates with increased 90-day readmission rates for OP TJA. Taken together, these results suggest that patients with poorer function and worse social support systems are increasingly being driven toward OP surgery by these changes, which may play a role in increasing readmission rates. Social support and functional factors should be considered for OP elective TKA and THA. Further, any OP TJA value-based payment system must account for these variables.

A Retrospective Analysis of Effect of COVID-19 on Revision Total Knee and Hip Arthroplasty

Background: The SARS-CoV-2 (Covid-19) has significantly impacted the health of the people around the globe. Primary Total Hip arthroplasty (THA) and Total Knee arthroplasty (TKA) were significantly affected in the pandemic time. The canceled surgeries of THA and TKA were rescheduled as majority of the beds in the hospitals were occupied by COVID patients. Due to this, patients for such surgery accumulated and many patients faced serious health issues. In addition to THA and TKA, Covid-19 pandemic also significantly impacted Total Joint arthroplasty (TJA) volume. According to analysis, the annual volume of the TKA and THA for 2020 was around 128,000 and 66,000 respectively. Aim: To analyze the effect of COVID-19 on revision total knee and hip arthroplasty. Methods: For the study, the data was collected from the institutional registry for TJA and pending revisions for the TKA and THA patients. Approximately 465 inpatient beds between April 2019 and March 2020 considered for the study. Procedures were conducted for 12 months prior to the initial shutdown of elective surgery (April 19 – March 20). The percentage changes for urgent revisions for TJA were compared focusing on pre and post-Covid TKA and THA. Results: Two groups were defined as pre-Covid patients (n = 190) and post-Covid patients (n= 160). The mean age of the patient in pre-Covid group was 75.3 years (SD = 1.01) and post-Covid group was 68.9 years (SD = 11.52). For TKA revision, in pre-covid group, 33.3% of the patients had Aseptic loosening and 22.2% had Periprosthetic joint infection, and 16.6% required Urgent revision. On the other hand, in post-Covid group, 33.3% of the patients had Aseptic loosening and 21.2% had Periprosthetic joint infection, and 18.1% required Urgent revision. Post-Covid cases of THA were also increased as out of 94 patients, 15.9% required Urgent revision. There was no significant difference between the groups for TKA revision (p>0.05). Similarly, apart from Aseptic loosening (p<0.05), there was no significant difference between the groups for THA revision (p>0.05). Conclusion: It has been carried out that revision of TKA and THA decreased in health care system during Covid-19 pandemic compared to pre-Covid. The numbers of urgent cases were increased in both groups such as the numbers of urgent cases for THA were 15.9% and TKA was 18.1% post-Covid and these are creating the backlog for the care professionals to provide the better treatment and recovery of the patients.

Did hand washing and use of personal protective equipment (PPE) reduce transmission of surgical site infections during the SARS-CoV-2 pandemic?

Aim: A retrospective case-control study comparing Surgical Site Infections (SSIs) following primary hip and knee arthroplasty before and during the SARS-CoV-2 pandemic across East Sussex NHS Trust (ESHT). The aim of this study was to evaluate whether the government advice relating to increased vigilance surrounding hand hygiene and use of personal protective equipment (PPE) reduced SSIs following elective arthroplasty. Method: Data was obtained from Public Health England website relating to SSIs following primary hip and knee arthroplasty between April 2019 and March 2020 (pre-pandemic) performed at ESHT and compared to April 2020 to March 2021 (pandemic). Results: A total of 454 patients underwent a total hip replacement (THR) during the pre-pandemic period with 12 patients developing an SSI (2.6%). Comparatively, during the pandemic period, 146 patients underwent a THR with 4 reporting an SSI (2.7%). A total of 449 patients underwent a total knee replacement (TKR) during the pre-pandemic period with 11 reporting an SSI (2.5%). In contrast, 9 of the 138 patients undergoing a TKR during the pandemic group developed an SSI (6.5%). Conclusions: As the data shows, there was no significant difference observed between SSIs following THR performed at ESHT prior to and during the pandemic. Surprisingly, there was a 2.6-fold increase in SSI following TKR during the pandemic period compared with prepandemic. Both of these findings seemingly reject the null hypothesis that increased vigilance to hand hygiene and use of PPE mandated by the government and echoed by healthcare trusts during this time would reduce transmission of infections.

Pooled waiting lists for primary hip and knee arthroplasty: Are the outcomes inferior to a named consultant list?

Aim: A pooled waiting list model is where patients are treated in turn by the first available surgeon and works to use existing resources more efficiently to better match demand. Aim is to compare quantitative data of patients on the pooled list and named-consultant' list and to determine the superiority of either list based on favourable outcomes. Method: This single centre, retrospective study compared outcomes of primary elective hip and knee arthroplasty for osteoarthritis in patients from pooled and 'named-consultant' waiting lists over a 1-year period. The study period was before the corona virus pandemic. 371 total knee replacements (TKR) and 373 total hip replacements (THR) were included. Baseline characteristics were compared between patients from pooled and named-consultant lists. Results: In the pooled TKR group, a significantly higher proportion of patients were older with higher BMI and ASA grade (p=0.027, p= 0.479, p<0.001 respectively). There was no difference in baseline characteristics in the THR cohort. Waiting time to surgery was less in the pooled TKR group (mean=4.17months) with no significant difference in mortality, revision and infection rates, length of stay, operative blood loss, DVT/PE rate, proportion requiring pain team referral and the number with unsatisfactory range of motion at follow-up. There was no significant difference in any outcomes between two groups in the THR cohort. Conclusions: Pooled lists can therefore be an excellent tool in primary THR/TKR to efficiently utilize all available resources (surgeons and theatre time) without compromising on patient outcomes and prompting use in all UK arthroplasty centres.

Zolendronic acid after teriparatide: Pandemic observations

Objective: Teriparatide for sever osteoporosis is followed by antiresorptive drugs, and one option in patients with gastric intolerance is zolendronic acid or denosumab (1-5). During pandemic lockdown, the access to bone assessment was limited (1-5). Type 1 diabetic patients are particularly at risk for bone loss, but also for COVID-19 infection, thus the importance of respecting the pandemic rules (1-5). We aim to introduce a female case diagnosed with severe menopausal osteoporosis that was followed during post-teriparatide sequence of medication, including during pandemic days. Case report: This is a type 1 diabetic female of 77 y who was first diagnosed with menopausal osteoporosis 8 y ago (lumbar T-score of-3.1 SD) and started medication with weekly alendronate in addition to vitamin D supplements. After 3 y, she suffered a single spontaneous vertebral fracture thus teriparatide was initiated for 2 y (with good tolerance): lumbar T-score went from -3.1 to -1.9 SD. In the meantime, due to bilateral coxarthrosis she needed bilateral hip replacement. Further on, she continued with biannually denosumab for 8 injections, reaching a lumbar BMD-DXA 0.942 g/cm2, T-score of -2 SD, Z-score of -0.8 SD so an intravenous perfusion with zolendronic acid 5 mg was administered plus vitamin D supplements. While she had no additional fracture and glycated haemoglobin A1c remained around 6.2-6.4%, one year later, the pandemic started, so only bone turnover markers (BTM) were assessed, not DXA: suppressed CrossLaps=0.22 ng/mL (normal: 0.33-0.782 ng/ mL), osteocalcin=11 ng/mL (normal: 15-46 ng/mL), P1NP=27 pg/mL (normal: 15-45 pg/mL). She continued with vitamin D, and 20 months after injection CrossLaps remained low (=22 ng/mL) with normal osteocalcin (=15 ng/mL), P1NP (=28 pg/mL) and stationary BMD. Conclusion: Zolendronic acid effect in osteoporotic patients is easy to access by blood assays if DXA is not available, while lack of BTM increase is suggestive for a good outcome.

UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): what does analysis of linked, routinely collected national data sets tell us about mid-late term revision risk after hip replacement? Retrospective cohort study.

OBJECTIVE: To identify patients at risk of mid-late term revision of hip replacement to inform targeted follow-up. DESIGN: Analysis of linked national data sets from primary and secondary care (Clinical Practice Research Datalink (CPRD-GOLD); National Joint Registry (NJR); English Hospital Episode Statistics (HES); Patient-Reported Outcome Measures (PROMs)). PARTICIPANTS: Primary elective total hip replacement (THR) aged≥18. EVENT OF INTEREST: Revision surgery≥5 years (mid-late term) after primary THR. STATISTICAL METHODS: Cox regression modelling to ascertain risk factors of mid-late term revision. HR and 95% CI assessed association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision. RESULTS: NJR-HES-PROMs data were available from 2008 to 2011 on 142 275 THR; mean age 70.0 years and 61.9% female. CPRD GOLD-HES data covered 1995-2011 on 17 047 THR; mean age 68.4 years, 61.8% female. Patients had minimum 5 years postprimary surgery to end 2016. In NJR-HES-PROMS data, there were 3582 (2.5%) revisions, median time-to-revision after primary surgery 1.9 years (range 0.01-8.7), with 598 (0.4%) mid-late term revisions; in CPRD GOLD, 982 (5.8%) revisions, median time-to-revision 5.3 years (range 0-20), with 520 (3.1%) mid-late term revisions.Reduced risk of mid-late term revision was associated with older age at primary surgery (HR: 0.96; 95% CI: 0.95 to 0.96); better 6-month postoperative pain/function scores (HR: 0.35; 95% CI: 0.27 to 0.46); use of ceramic-on-ceramic (HR: 0.73; 95% CI: 0.56 to 0.95) or ceramic-on-polyethylene (HR: 0.76; 95% CI: 0.58 to 1.00) bearing surfaces.Increased risk of mid-late term revision was associated with the use of antidepressants (HR: 1.32; 95% CI: 1.09 to 1.59), glucocorticoid injections (HR: 1.33; 95% CI: 1.06 to 1.67) and femoral head size≥44 mm (HR: 2.56; 95% CI: 1.09 to 6.02)No association of gender, obesity or Index of Multiple Deprivation was observed. CONCLUSION: The risk of mid-late term THR is associated with age at primary surgery, 6-month postoperative pain and function and implant factors. Further work is needed to explore the associations with prescription medications observed in our data.

A Safety Evaluation of the Resumption of Elective Orthopaedic Services in Higher Risk Patients During the COVID-19 Pandemic.

Introduction The COVID-19 pandemic has caused mass disruption to all aspects of society, with elective orthopaedics not spared. The pandemic has the potential to cause a tsunami of health burden in the community if elective services are not resumed to pre-pandemic levels of activity. Studies have shown that elective orthopaedics can be safely carried out in a COVID-19 free hospital. This study reviewed the transition in operating at an independent COVID-19 free hospital to an NHS hospital concurrently treating patients with COVID-19. Methods A strategy of phased relaxation of clinical comorbidity criteria was followed. Patients from the orthopaedic waiting list were selected according to these criteria and observed recommended preoperative isolation protocols. Operations were undertaken in the independent sector under the COVID-19 contract and the NHS site. Patients were assessed from all phases in the resumption of services. In-hospital and post-operative complications with specific enquiries regarding the development of COVID-19 symptoms or the need and outcome for COVID-19 testing at 14 days and six weeks was recorded. Results This study included 263 patients, of which 155 were female. The mean age of patients was 52.45. The mean BMI of all patients was 29.1 kg/m2. Additionally, 124 patients were American Society of Anesthesiologists (ASA) grade 1, 117 ASA grade 2 and 22 ASA grade 3 and 167 patients underwent a major operation, with total hip replacement being the most common operation. There were no in-hospital complications. No patients had a positive test result or symptoms of COVID-19 in the six-week post-operative period. Conclusion In summary, we demonstrated that elective orthopaedic surgery can be safely undertaken via a green pathway in a higher risk patient cohort when COVID-19 is prevalent in the community.