Socioeconomic deprivation is associated with worse health-related quality of life and greater opioid analgesia use while waiting for hip and knee arthroplasty.

Aims: The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: Postal surveys were sent to 1,001 patients on the waiting list for THA or TKA in a single Northern Ireland NHS Trust, which consisted of the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee Scores. Electronic records determined prescriptions since addition to the waiting list and out-of-hour GP and emergency department attendances. Deprivation quintiles were determined by the Northern Ireland Multiple Deprivation Measure 2017 using postcodes of home addresses. Results: Overall, 707 postal surveys were returned, of which 277 (39.2%) reported negative "worse than death" EQ-5D scores and 219 (21.9%) reported the consumption of strong opioids. Those from the least deprived quintile 5 had a significantly better EQ-5D index (median 0.223 (interquartile range (IQR) -0.080 to 0.503) compared to those in the most deprived quintiles 1 (median 0.049 (IQR -0.199 to 0.242), p = 0.004), 2 (median 0.076 (IQR -0.160 to 0.277; p = 0.010), and 3 (median 0.076 (IQR-0.153 to 0.301; p = 0.010). Opioid use was significantly greater in the most deprived quintile 1 compared to all other quintiles (45/146 (30.8%) vs 174/809 (21.5%); odds ratio 1.74 (95% confidence interval 1.18 to 2.57; p = 0.005). Conclusion: More deprived patients have worse health-related quality of life and greater opioid use while waiting for THA and TKA than more affluent patients. For patients awaiting surgery, more information and alternative treatment options should be available.

The painful truth of waiting for hip and knee arthroplasty in Northern Ireland.

Aims: The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting. Methods: This was a cohort study of 991 patients on the waiting list for arthroplasty in a single Northern Ireland NHS trust: 497 on the waiting list for ≤ three months; and 494 waiting ≥ three years. Postal surveys included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee scores to assess HRQoL and joint-specific function. Electronic records determined prescriptions since addition to the waiting list and patient attendances at OOH GP/EDs. Results: Overall, 712/991 (71.8%) responded at ≤ three months for THA (n = 164) and TKA (n = 199), and ≥ three years for THA (n = 88) and TKA (n = 261). The median EQ-5D-5L score in those waiting ≤ three months was 0.155 (interquartile range (IQR) -0.118 to 0.375) and 0.189 (IQR -0.130 to 0.377) for ≥ three years. Matched controls had a median EQ-5D-5L 0.837 (IQR 0.728 to 1.000). Compared to matched controls, EQ-5D-5L scores were significantly lower in both waiting cohorts (p < 0.001) with significant differences found in every domain. Negative scores, indicating a state "worse than death", were present in 40% at ≤ three months and 38% at ≥ three years. Patients waiting ≥ three years had significantly more opioid (28.4% vs 15.2%; p < 0.001) and antidepressant prescriptions (15.2% vs 9.9%; p = 0.034) and significantly more joint-related attendances at unscheduled care (11.7% vs 0% with ≥ one ED attendance (p < 0.001) and (25.5% vs 2.5% ≥ one OOH GP attendance (p < 0.001)). Conclusion: Patients on waiting lists in Northern Ireland are severely disabled with the worst HRQoL and functional scores studied. The lack of deterioration in EQ-5D-5L and joint-specific scores between patients waiting ≤ three months and ≥ three years likely reflects floor effects of these scores. Prolonged waits were associated with increased dependence on strong opiates, depression, and attendances at unscheduled care.

Using tranexamic acid for an additional 24 hours postoperatively in hip and knee arthroplasty saves money: a cost analysis from the TRAC-24 randomized control trial.

AIMS: Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. METHODS: TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. RESULTS: Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. CONCLUSION: This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536-542.

Mechanical and Anatomical Alignment Guide Techniques Are Superior to Freehand in Achieving Target Orientation of an Acetabular Component.

BACKGROUND: Achieving accurate and consistent acetabular component orientation remains a major challenge in total hip arthroplasty. METHODS: We used a pelvic model to compare freehand techniques vs mechanical and anatomical alignment guides in achieving a target operative inclination (OI) and operative anteversion (OA). Thirty subjects comprising consultant orthopedic surgeons, orthopedic trainees, and nonsurgical staff positioned an acetabular component in a pelvic model using 3 different methods for guiding inclination and another 3 for guiding version. RESULTS: Using either a standard mechanical alignment guide (MAG) or a spirit level MAG technique eliminated outliers from target OI, while the freehand method resulted in 46.7% of measurements outside the OI target range. The spirit level MAG technique significantly outperformed the standard MAG technique in median unsigned deviation from target OI (0.8° vs 2.1°, P < .001). Either method of referencing the transverse acetabular ligament for version yielded lower deviations from target OA than the freehand method and fewer outliers from the ±5° target range. Surgical experience was not a significant factor for accurately achieving target OI and OA. CONCLUSIONS: Even in an idealized in vitro model, a wide range of OI and OA is seen with the freehand technique of cup placement by subjects of all levels of surgical experience. Using either a standard MAG or a spirit level MAG reduces deviations in target OI, with the spirit level MAG method yielding the best accuracy. Using the transverse acetabular ligament to guide cup anteversion yields more accurate OA.

Risk Factors for Significant Radiolucent Line Development in a Fully Coated Hydroxyapatite Stem.

BACKGROUND: The risk factors for and clinical impact of radiolucent lines (RLLs) in cementless total hip arthroplasty remain contentious. The aim of this work was to describe a method of classification that has clinical significance and to identify risk factors. METHODS: A cohort of 288 subjects with unrevised Corail stems (DePuy Synthes, Warsaw, IN) were reviewed with radiographs and Oxford Hip Scores at 10 years. Based on clinical experience, three groups were defined; those with no RLLs (NoRLLs), those considered to have benign RLLs (BenRLLs), and those considered to have significant RLLs (SigRLLs). SigRLLs were then compared to BenRLLs and NoRLLs to determine the validity of this classification. RESULTS: One hundred and nine (37.8%) had NoRLLs, 111 (38.5%) had BenRLLs, and 68 (23.6%) had SigRLLs. No significant difference apart from gender was noted between the occurrence of BenRLLs and NoRLLs after multinomial regression analysis, consequently the NoRLLs and BenRLLs groups were combined (NoSigRLLs) and compared to SigRLLs. Non-cross-linked polyethylene (odds ratio = 4.6, P < .001), collarless stem design (odds ratio = 9.4, P < .001), undersizing (odds ratio = 1.2, P = .028), and male sex (odds ratio = 2.1, P = .008) were risk factors for SigRLLs. Regression analysis also revealed that increasing age at operation decreased the likelihood of SigRLLs (P < .001). Patients with SigRLLs had significantly higher pain scores (P = .005) although overall Oxford Hip Scores were not significantly different (P = .364). CONCLUSION: The definition of SigRLLs proposed in this study was significantly associated with that of non-cross-linked polyethylene, absence of a collar, undersizing, and higher pain scores.

30-day mortality following trauma and orthopaedic surgery during the peak of the COVID-19 pandemic: a multicentre regional analysis of 484 patients.

AIMS: Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. METHODS: This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019. RESULTS: Overall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade > 3 and/or age > 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period. CONCLUSION: Overall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus.Cite this article: Bone Joint Open 2020;1-7:392-397.

Rapidly Progressive Osteoarthritis and Acetabular Bone Loss Outcomes for Patients Undergoing Primary Total Hip Replacement.

Rapidly progressive osteoarthritis (RPO) is a rare condition which is poorly understood. Limited published literature is available. Reported here is a cohort of patients with RPO and acetabular bone loss who underwent primary THA. Risk factors, degree of acetabular bone loss and outcomes are presented. A typical case of RPO is described and investigations discussed. A retrospective audit was undertaken. 49 patients over an 18-year period were included. RPO patients were significantly older (P < 0.01) and had a lower BMI (P = 0.03). The mean acetabular bone loss in this cohort was 10.0 mm. Pathogenesis and risk factors for developing RPO remain unclear and future research is necessary. Repeat imaging in patients with deteriorating symptoms is important and urgent surgery is required maintain bone stock.

Are There Gender-Specific Errors in Restoration of Hip Biomechanics That Affect Outcome Following Total Hip Arthroplasty?

BACKGROUND: There are morphologic differences between males and females, which are currently underappreciated during total hip arthroplasty. We sought to assess whether these differences affected surgical process and subsequent outcome. METHODS: A total of 123 patients (75 females, 48 males) had preoperative and 1-year Oxford Hip Score (OHS) and pain scores recorded. Acetabular height and offset, femoral height and offset, and acetabular floor depth were measured on preoperative and postoperative X-rays and then compared to their normal opposite hip. Discrepancies between the replaced and normal hip X-ray measurements were then correlated with changes (the delta gain) in preoperative and 1-year postoperative OHS and pain scores. RESULTS: Postoperatively, females had significantly greater femoral height discrepancy (P = .023) which meant they were lengthened. This led to a reduced delta gain in OHS and pain score at 1 year. Males lost more acetabular offset than females (P = .002), leading to a medialized acetabular center and subsequently reduced delta gain in pain score at 1 year (P = .017). CONCLUSION: Females have a smaller femur leading to a bias toward a conservative (higher) neck cut compared with males and potential for femoral lengthening. Males have a greater acetabular floor depth compared with females and thus reaming to the true floor results in greater loss of acetabular offset. In this series, both scenarios led to reduced improvement in OHS and/or pain scores at 1 year.

The impact of cerclage cabling on unstable intertrochanteric and subtrochanteric femoral fractures: a retrospective review of 465 patients.

PURPOSE: To assess the potential impact of using cerclage cables or wires when undertaking fixation of unstable intertrochanteric and subtrochanteric fractures. METHODS: Patients were identified from a validated hospital database which included patients from all trauma units within Northern Ireland from 2008 to 2015. The primary outcome measure was return to theatre for any reason. Secondary outcome measures included quality of reduction, tip-apex distance, length of stay, mortality at 3 and 12 months and functional outcomes assessed by Barthel Index and mobility. RESULTS: 465 patients were included (157 in the cerclage/wire group and 308 without). Mean age of 79.6 years, with 330 females and 135 males. There was no statistical difference between the groups in relation to baseline demographics and risk factors for complications. 24 patients required further surgery, 13 (8.3%) in the cerclage group and 11 (3.6%) in those without (p < 0.03). Cabling of intertrochanteric fractures resulted in further surgery in 9.1% versus 3.4% without. Quality of reduction was improved in the cerclage group (p < 0.01), however improvements were less noticeable in intertrochanteric fractures (32.3% classified as good) compared to subtrochanteric fractures (52.4% good). Length of stay was longer in the cerclage group (p < 0.01). No differences were noted in mortality, Barthel score or mobility at 3 and 12 months. CONCLUSIONS: Cerclage cables/wires can augment fixation in subtrochanteric fractures with potential benefits including improving quality of reduction. Evidence for their use in intertrochanteric fractures is much more contentious and we would advise they only be used where a definite improvement in reduction can be obtained with the minimum number possible.

Resilience in medical doctors: a systematic review.

INTRODUCTION: Resilience can be difficult to conceptualise and little is known about resilience in medical doctors. AIMS: This systematic review discusses the existing literature on influences on resilience levels of medical doctors. METHODS: The bibliographic databases PubMed, MEDLINE, EMBASE and PsycINFO were searched from 2008 to November 2018 using keyword search terms resilience* AND ("medical physician*" OR doctor* OR surgeon* OR medical trainee* or clinician*). RESULTS: Twenty-four studies were deemed eligible for inclusion. A narrative synthesis was performed. The following influences on resilience in doctors were identified: demographics, personality factors, organisational or environmental factors, social support, leisure activities, overcoming previous adversity and interventions to improve resilience. CONCLUSIONS: Resilience is not limited to a doctor's own personal resource. Published studies also highlight the influence of other modifiable factors.

Improving handover of acute orthopaedic admissions.

Handover is a crucial part of patient care and is a well recognized cause of patient harm if not performed well. The introduction of full shift working for doctors has placed even more emphasis on this area of patient care. We identified handover of orthopaedic admissions in our unit was substandard. A prospective audit over a one week period including the weekend was undertaken. The Royal College of Surgeons of England guidance on handovers was used as minimum criteria and we also included criteria essential for handover of orthopaedic patients. This initial audit revealed a poor standard of handover. 21 patients were included and in particular patient location (57%), responsible consultant (14%), and pending investigations (29%) were poorly performed. In addition two patient safety incidents were noted, including one admission that was not handed over. To improve the handover we created a trauma specific handover proforma. We then conducted a re-audit again over a one week period including the weekend with the proforma in use. There was a notable improvement, 17 patients were included and only 3 criteria fell below 80%. We presented our findings at the local audit meeting where the results were discussed with all members of the trauma team. We suggested that an electronic proforma, accessible from multiple computers within the hospital may improve handover further. This was created in conjunction with the IT department. Once again we reaudited handover over a one week period including the weekend with the electronic proforma in use. 23 patients were included and a further improvement was noted; only one criterion fell below 95%. In conclusion handover of acute fracture admissions within the unit has undoubtedly improved. The electronic proforma tool was a simple, cost effective, and accurate method of improving handover.