Impact of the Harm Review Service for Patients Awaiting Elective Hip and Knee Surgeries for More Than 52 Weeks.

Background The coronavirus disease 2019 (COVID-19) pandemic has affected medical practice worldwide. In the UK, elective operative lists had to be postponed to accommodate the increase in hospital admissions. Within our local trauma and orthopaedic department, a harm review clinic was developed for these postponed elective cases. The purpose of this clinic was to evaluate the impact and outcomes of the delay in elective hip and knee procedures. Methodology The elective list database of William Harvey Hospital, Kent, from April to December 2020 was retrospectively analysed. Inclusion criteria included all lower limb primary arthroplasty, elective lower limb revision surgery, and other hip and knee procedure patients waiting more than 52 weeks for surgery. All patients had telephone consultations averaging 10 minutes. Data included patients' symptoms, fresh investigations, changes in treatment plans, mental health status, and value of consultation were assessed and recorded. Results A total of 242 patients from eight lower limb consultants were analysed. Patients with hip pathology accounted for 39.2% (95 patients) versus knee pathology accounting for 60.7% (147 patients). In total, 13 (5.37%) patients reported improvement in their physical symptoms, whereas 46 (19%) felt their symptoms worsen. Overall, 26 (10.7%) patients had a change in their treatment plan following the consultation. In total, 18 (7.4%) patients required further face-to-face follow-up following the telephone consultation There were no patients who had significant physical or mental harm. Conclusions The COVID-19 pandemic has brought changes in how we practice medicine. The harm review service has been a valuable service to both patients and the orthopaedic department. This harms review clinic was able to identify changes in treatment plans for patients. A small percentage of patients required face-to-face appointments. We suggest telephone assessment should be the first mode of communication with patients. Further studies should be conducted in other specialities to determine if there are similar outcomes.

Intra-articular steroid injections in large joint arthritis: A survey of current practice.

INTRODUCTION: Intra-articular corticosteroid injections are widely used as a management modality for mild large joint osteoarthritis (OA). In contrast, there is little guidance or consensus on the use of steroids in moderate to severe disease. The aim of this study is to explore the current practice of surgeons in relation to the use of therapeutic intra-articular steroid injections in patients awaiting large joint arthroplasty for OA. METHODS: An anonymous questionnaire was distributed to consultants performing large joint arthroplasty in four National Health Service Trusts. Participants were questioned on their use of intra-articular therapeutic steroid injections in patients listed for elbow, shoulder, hip or knee arthroplasty. Data was collected over 6 months and analysed using Microsoft Excel. RESULTS: A total of 42 surgeons were included in the study with the majority performing lower limb arthroplasty (73%). About 21 (50%) surgeons indicated they would perform injections in the patient group of interest. Two would perform an unlimited number of injections, whilst the remainder would perform between one and three injections. Respondents most commonly indicated they would tell patients that an injection would provide between 6 and 12 weeks of benefit (14 of 39 surgeons, 36%). Most injecting surgeons (88%) leave 4 months between an injection and subsequent arthroplasty due to increased risk of infection if surgery is performed sooner. CONCLUSION: This study demonstrates variation in practice in the use of intra-articular steroids in the analysed patient group, and the way surgeons council their patients. National or specialist society guidelines may help to reduce this variation in practice.

Analysis of Risk Factors and Consequences of Consecutive Proximal Femur Fractures in Elderly Patients.

Background Proximal femur fracture (PFF) carries significant morbidity, mortality, and cost implications to the health system. Subsequent contralateral fracture further decreases patient performance and increases the healthcare burden. This study aimed to identify and evaluate potential risk factors for consecutive PFF. Methodology Pilgrim Hospital PFF database from 2012 to 2019 was retrospectively analyzed. Patients over 60 years with low-energy fractures were included. Pathological and atypical fractures and polytrauma were excluded. Results There were 114 patients (4.18%) with contralateral hip fractures out of a total of 2727 PFF patients; 80% were females. The mean age was 82 years for the first hip fracture and 85 years for the second. The average time interval between fractures was 36 months. The fracture pattern was the same on both sides in 74.3% of patients (P<0.0001). Out of 53 patients with cemented hip hemiarthroplasty (CHH) on one side, 31 patients (59%) had a second CHH for the contralateral side. Likewise, out of 48 patients who had dynamic hip screw fixation during the first admission, 33 patients (69%) had the same procedure on the contralateral side too. During the two consecutive admissions, the length of hospital stay was not significantly different (P=0.30), median American Society of Anesthesiologists (ASA) grades were 3, hyponatremia increased from 25% to 29% (P=0.5), mean decline in abbreviated mental test score (AMTS) was 0.4, deterioration of Clinical Frailty Score and Charlson morbidity index were from 4.5 to 5.9 (P<0.0001), and from 5.4 to 6.1, respectively, and institutional residency was increased from 23 to 46 (P>0.0014). Conclusion The similarity of fracture pattern bilaterally requiring similar surgical procedures is comparable with other literature. Even though there is minimal or no change in the ASA, AMTS, and hospital stay between the two admissions, there is a significant decline in clinical frailty, mobility status, and an increase in residential dependency following a subsequent fracture. Our findings demonstrate the importance of emphasizing secondary preventive measures to prevent a consecutive fracture.