Day case unicompartmental knee replacement: An update of the Torbay experience.

BACKGROUND: Hospitals throughout the United Kingdom face significant challenges in regards to inpatient bed capacity, leading to growing interest in day case arthroplasty. Day case Unicompartmental Knee Replacement (UKR) has been offered within our unit since 2010, with successive evaluations of pathway outcomes performed in 2011 and 2015. Since then, our day case UKR pathway has expanded. This study aims to evaluate the safety, efficiency and patient satisfaction with this expanded pathway. METHODS: Data was prospectively collected for all patients undergoing a UKR between January 2017 and August 2019. Data collected included the pathway planned, date of admission, date of discharge and re-admissions to hospital within 30 days of surgery. Patient satisfaction was evaluated via a follow-up questionnaire. RESULTS: 109 patients underwent a UKR between January 2017 and August 2019. 83 patients (76%) were planned through the day case pathway. 63 patients were successfully discharged on the day of surgery. One day case pathway and two inpatient pathway patients were re-admitted within 30 days of surgery with medical conditions. A high level of patient satisfaction with our day case pathway was identified. CONCLUSION: UKR with planned discharge on the day of surgery is possible for a large proportion of patients provided that robust pathway and protocol design is undertaken. Following 10 years' experience, our day case UKR pathway has increasingly become the default for the majority of our patients. We report high patient satisfaction and low 30-day re-admission rates. However, 100% success rate for day of surgery discharge remains challenging.

Should we use dabigatran or aspirin thromboprophylaxis in total hip and knee arthroplasty? A natural experiment.

BACKGROUND: Despite long clinical experience some authorities recommend against the use of aspirin for perioperative VTE prophylaxis and favour alternatives such as dabigatran. A change from Dabigatran to an Aspirin based protocol in a British district general hospital created the conditions of a natural experiment. METHODS: We conducted a single centre, retrospective study of 6-months using a dabigatran based protocol (THA n = 191, TKA n = 155) and 6-months using and aspirin based protocol (THA n = 165, TKA n = 136). Outcomes addressed include: VTE used, VTE events within 90-days, 30-day return to theatre (RTT) rates, and 90-day mortality. RESULTS: Pre-intervention, the dabigatran prescription rate was 73% (n = 139) and 78% (n = 123) with aspirin prescription post-intervention in 67% (n = 110) and 70% (n = 90) for THA and TKA respectively. We found a similar VTE rate when comparing dabigatran and aspirin groups for THA (2.2% vs. 0%, p = 0.17) and TKA (0.64% vs. 0%, p = 0.32). Similarly, no difference in the RTT rate was seen for THA (0.7% vs.2.7%, p = 0.23) or TKA (1.6% vs. 3.2%, p = 0.38). CONCLUSION: No significant differences in safety were found comparing aspirin to dabigatran for VTE prophylaxis for lower limb arthroplasty which, has not been previously reported and represents significant cost saving implications.

The effect of obesity and increasing age on operative time and length of stay in primary hip and knee arthroplasty.

We retrospectively reviewed 589 patients undergoing lower-limb arthroplasty, recording age, body mass index (BMI) and co-morbidities. The effect of these on operative duration and length of stay (LOS) was analysed. For a 1 point increase in BMI we expect LOS to increase by a factor of 2.9% and mean theatre time to increase by 1.46minutes. For a 1-year increase in age, we expect LOS to increase by a factor of 1.2%. We have calculated the extra financial costs associated. The current reimbursement system underestimates the financial impact of BMI and age. The results have been used to produce a chart that allows prediction of LOS following lower limb arthroplasty based on BMI and age. These data are of use in planning operating lists.

National Joint Registry data inaccuracy: a threat to proper reporting.

INTRODUCTION: The authors set out to investigate the accuracy of the information their unit was inputting onto the National Joint Registry. This is important both in relation to implant surveillance and also to the use of these data to monitor the performance of surgeons. METHOD: A single consultant's arthroplasty patients were audited over 12 months. Data taken from the National Joint Registry were compared to the operation notes and the hospital's computer system. RESULTS: Of 78 cases inputted, 27 (35%) were incorrect. Sixteen cases (21%) had the incorrect 'consultant in charge' recorded, eight cases (10%) had the incorrect 'operating surgeon' recorded and three cases (4%) had both errors. The most frequent inaccuracies resulted from listing by another consultant and incorrectly recorded trainee supervision. These errors were highlighted to the unit and a corrected process was designed. The intervention was to implement this process by presenting to the involved groups and displaying posters to prevent the error-producing process. The audit was repeated (after 6 months) showing eradication of the problem. DISCUSSION: It is the surgeon's duty to ensure data recorded under his/her name are accurate and justify any discrepancies when compared to other surgeons. Pooling of patients and supervision of trainees are sources of potential error.

Endovascular coil embolization of pseudoaneurysm of a branch of the anterior tibial artery following total knee replacement.

Arterial complications after total knee arthroplasty are rare. We report a unique case of traumatic pseudoaneurysm of a branch of the anterior tibial artery following total knee arthroplasty. The patient was successfully treated using endovascular methods.

Dislocated Thompson hemiarthroplasty--the management of the recurrent dislocator.

Dislocation of a Thompson hemiarthroplasty of the hip is a serious complication with a high mortality rate. Previous papers have focused on surgical techniques to try and prevent dislocation. There is little in the literature on how to manage a patient after a dislocation. Patients with a dislocated Thompson hemiarthroplasty over a 5-year period from 1997 to March 2002 were analysed. Attempts were made to identify factors which may contribute to redislocation. Our strategies for preventing redislocation were evaluated. Of the 612 patients who received a Thompson hemiarthroplasty 23 patients (4%) dislocated. The average number of dislocations per patient was 2.4. Thirteen patients (57%) redislocated their prosthesis. Ten patients (43%) dislocated at least twice. Seven patients (30%) had either a total hip replacement, Girdlestone's procedure or the hip was left dislocated. Out of 15 patients fitted with an abduction brace 8 (60%) redislocated. Out of 8 patients treated with traction 6 (75%) redislocated. The 6-month mortality for patients suffering a dislocation was 7/23 (30%). If the prosthesis dislocates twice, the hip should be deemed unstable and consideration should be given to a revision procedure. Abduction braces and traction are ineffective in this condition and should be abandoned.

Patella baja following chronic quadriceps tendon rupture.

Patella baja is a complication of chronic quadriceps tendon rupture. In this case we present the treatment of this problem by the proximal transfer of the tibial tubercle allowing an environment in which the quadriceps tendon can heal.

Least possible fixation of fractures of the proximal humerus.

The purpose of this study was to assess the clinical outcome of an unreported technique of the least possible fixation for valgus-impacted fractures. Using an open technique without any sharp deep soft tissue dissection, the split between the tuberosities is opened to allow elevation of the impacted humeral head fragment. The tuberosities are reduced and repaired with absorbable sutures between the rotator cuff insertions. No bone grafting, Kirschner wire or other fixation device was used. For 11 patients, with an average age of 55 years, who were operated between 1989 and 1998, the mean follow-up period was 69 months. The patients were assessed radiologically and clinically using the Constant-Murley score. As a percentage of the normal side, the Constant-Murley scores ranged from 55 to 100% (mean 86%); there were eight patients with scores >80%, two patients with scores between 70 and 79% and one patient with score <70%. One patient (9%) showed avascular necrosis (AVN). This fixation allows preservation of the soft tissues in an open approach and avoids the dangers of other fixation methods. There is a low risk of AVN and it allows a good functional result.