Do joint-preserving hip procedures compromise subsequent total hip arthroplasty? A meta-analysis of complications, functional outcome and survivorship.

BACKGROUND: Joint-preserving hip operations can help relieve pain and delay the need for long-term joint arthroplasty. Previous research has not identified procedures that can compromise outcomes following total hip arthroplasty (THA). This meta-analysis aims to evaluate the effect of joint-preserving hip operations on outcomes following subsequent THA. METHODS: MEDLINE, EMBASE and Scopus databases were searched from the date of inception until February 2024. All studies comparing outcomes following THA in individuals with (PS) and without prior surgery (NPS) of the femur or pelvis were included. Data on operative time, blood loss, intra- and post-operative complications, functional outcomes, and implant survivorship were extracted. RESULTS: 16 studies, comprising 2576 patients were included (PS = 939, NPS = 1637). The PS group was associated with significantly longer operative time [MD: 8.1, 95% CI: 4.6-11.6], significantly greater blood loss [MD: 167.8, 95% CI: 135.6-200.0], and a higher risk of intra-operative peri-prosthetic fracture [RR: 1.9, 95% CI: 1.2-3.0], specifically, with prior femoral osteotomy. There were no differences in terms of risks of dislocation [RR: 1.8, 95% CI: 1.0-3.2], implant loosening [RR: 1.0, 95% CI: 0.7-1.5], or revision surgery [RR: 1.3, 95% CI: 1.0-1.7] between the two groups. The PS group was associated with significantly poorer improvements in functional outcome [MD: -5.6, 95% CI: -7.6-(-3.5)], specifically, with prior acetabular osteotomy. Implant survivorship in the two groups was comparable after one year [HR: 1.9, 95% CI: 0.6-6.2] but significantly inferior in the PS group after five years [HR: 2.5, 95% CI: 1.4-4.7], specifically, with prior femoral osteotomy. CONCLUSION: Joint-preserving hip operations are associated with greater intra-operative challenges and complications. In subsequent joint arthroplasty, prior acetabular procedures affect functional outcomes while prior femoral procedures influence implant survivorship. Hip pain due to the morphological sequelae of pediatric hip pathology can be debilitating at a young age. Surgical decision-making at that time needs to consider the survivorship of a THA implanted at that young age against the consequences of hip preservation surgery on further THA.

The utility of cemented femoral stems in modern THA: a 10-year comparative analysis of the Charnley and Exeter stems.

BACKGROUND: Total hip replacement (THR) is one of the most common surgical procedures performed worldwide. The controversy surrounding the relative merits of a cemented composite beam or cemented taper-slip stem in total hip replacement continues. Our aims primarily were to assess the 10-year outcomes of cemented stems using Charnley and Exeter prostheses with regional registry data and secondarily to assess the main predictors of revision. METHODS: We prospectively collected registry data for procedures performed between January 2005 and June 2008. Only cemented Charnley and Exeter stems were included. Patients were prospectively reviewed at 6 months, 2, 5 and 10 years. The primary outcome measure was a 10-year all-cause revision. Secondary outcomes included 're-revision', 'mortality' and functional 'Western Ontario and McMaster Universities Osteoarthritis Index' (WOMAC) scores. RESULTS: We recorded a total of 1351 cases in the cohort, 395 Exeter and 956 Charnley stems. The overall all-cause revision rate at 10 years was 1.6%. The revision rate for Charnley stem was 1.4% and 2.3% revision rate for all Exeter stems with no significant difference noted between the two cohorts (p = 0.24). The overall time to revision was 38.3 months. WOMAC scores at 10 years were found to be insignificantly higher for Charnley stems (mean 23.8, σ = 20.11) compared to Exeter stems (mean 19.78, σ = 20.72) (p = 0.1). CONCLUSION: There is no significant difference between cemented Charnley and Exeter stems; they both perform well above the international average. The decline in the use of cemented THA is not fully supported by this regional registry data.

Implementation of Ireland's first state-funded day-case total hip arthroplasty programme.

BACKGROUND: Over the last two decades, many elective procedures have transitioned to day-case surgery thanks to the introduction of 'enhanced recovery' protocols. Only recently has total hip arthroplasty been considered a candidate for day-case surgery, as it was once associated with significant pain, mobility impairment and prolonged postoperative recovery. The National Orthopaedic Hospital Cappagh became the first public hospital in Ireland to set up a day-case total hip arthroplasty service in June 2018, and since then has performed over 109 such cases. AIMS: We outline our day-case total hip arthroplasty pathway, with specific focus on anaesthetic considerations. We report rates of failed discharge and readmission. RESULTS: We achieved successful same-day discharge in 90.8% of our first 109 cases. Readmission rate was 4.6%. CONCLUSION: Our experience of implementing a day-case total hip arthroplasty pathway was highly positive and congruent with expectations from the literature. With appropriate patient selection and education, day-case total hip arthroplasty is not just safe, but of benefit to both patients and healthcare systems.

Developmental dysplasia of the hip is common in patients undergoing total hip arthroplasty under 50 years of age.

INTRODUCTION: Developmental dysplasia of the hip (DDH) refers to congenital and/or developmental hip instability that can result in hip joint subluxation or dislocation. When detected neonatally, conservative treatment with hip bracing can restore normal hip anatomy. Missed detection of DDH in the neonatal period or late development of DDH often requires surgical intervention to correct the abnormal anatomy. Furthermore, despite surgical intervention, residual sequelae may persist leading to early osteoarthritis of the hip joint requiring joint replacement surgery. AIM: This study investigates the prevalence of hip dysplasia in patients undergoing total hip arthroplasty (THA) under 50 years of age. METHODS: The hip arthroplasty database at a national referral centre was investigated from January 2014 to December 2020. In patients under 50 years of age, those with an adequate pre-operative anteroposterior pelvic radiograph without previous hip arthroplasty were included, while those with inadequate radiographs were excluded. The following measurements were made on the contralateral non-operated hip: (1) lateral centre-edge angle (LCEA), (2) Tönnis angle, (3) acetabular version, (4) acetabular depth, (5) femoral head lateralisation, (6) femoral head extrusion index, and (7) acetabular depth-to-width ratio. RESULTS: In total, 451 patients were included in this study. Twenty two percent of the patients had hip dysplasia, based on a LCEA of <25° and 42.6% of patients had hip dysplasia, based on a Tönnis angle of > 10°. The mean LCEA and Tönnis angle were 31.47 ± 9.64 and 9.82 ± 6.79°, respectively. CONCLUSION: Hip dysplasia is common in patients undergoing THA under the age of 50 years with over 40% having dysplasia according to the Tönnis angle. Classification of primary and secondary osteoarthritis in the joint registries will benefit our knowledge on the prevalence of DDH in the adult population.

The Irish National Orthopaedic Register Under Cyberattack: What Happened, and What Were the Consequences?

BACKGROUND: On May 14, 2021, a criminal cyberattack was launched against the Irish public healthcare system, the Health Service Executive, resulting in a complete shutdown of all national healthcare computer systems, including the Irish National Orthopaedic Register (INOR). Cyberattacks of this kind occur sporadically, and postevent analyses can inform future preparedness efforts, but few such analyses have been published. QUESTION/PURPOSE: What was the impact of the cyberattack in terms of (1) registry downtime, (2) harms to patients, and (3) costs to the INOR for data contingency and reconciliation? METHODS: All nine hospitals using the INOR were included for data collection. Since establishment in 2014, the INOR has been rolled out to all eight public elective hospitals, capturing all hip and knee arthroplasty procedures. One private hospital was also captured, with plans to expand the private sector coverage. Individual institutional records and central INOR records were queried with respect to downtime, potential harms to patients (including intraoperative complications because of a lack of data on existing implanted components and complications directly attributed to delayed or canceled procedures), and costs related to additional person-hours addressing data reconciliation. Objective data directly related to the uncontrolled INOR downtime were collected, including duration of downtime, contingency methods employed, quality of contingency data collected, adverse patient events, methods of data salvage and reconciliation, and the cost of data contingency and reconciliation measures. Costs were estimated by the additional person-hours of work completed, multiplied by the hourly rate of that employee. Employees at each of the nine hospitals were asked to provide their additional person-hours of work performed because of the attack. These hours were corroborated by observing the time taken at each unit to reconcile data for single cases multiplied by the number of cases at that unit. Employees included nurses, clinical nurse specialists, and doctors of various grades. Person-hour rates were calculated using the Health Service Executive's published salary scales. RESULTS: The INOR suffered a median downtime of 134 days (range 119 to 272 days) across nine sites. No serious adverse patient events were identified. The immediate implementation of a paperwork fallback method for the INOR successfully resulted in 100% case capture during the downtime. However, 2850 additional person-hours were required for data reconciliation at an estimated cost of USD 181,000 to USD 216,000. More subjectively, as reported by interviews with INOR leads at each hospital, the cyberattack negatively impacted operating room efficiency with delays between procedures because of additional paperwork data collection, disrupted patient flow for paperwork data collection on the ward level and in the outpatient clinics, and disrupted resource allocations and staff capabilities because of additional paperwork requirements during the contingency period. CONCLUSION: Disruptions to data collection and data accessibility after this cyberattack were successfully countered by a contingency plan; however, substantial financial costs and additional resources were required for data conservation and reconciliation. CLINICAL RELEVANCE: In addition to robust preventative security measures, national registers and other healthcare systems should have secondary data backup facilities and reliable fallback procedures prepared for such events.

The Role of a Seven-Day Physiotherapy Service in Reducing Length of Stay and Improving Cost-Effectiveness in Arthroplasty Surgery.

Background Length of hospital stay post hip and knee arthroplasty is influenced by several factors, including gender, home circumstances and underlying diagnosis. Due to increasing demand for hip and knee arthroplasty, elective units, operating within already stressed healthcare systems, must identify methods of increasing efficiency and capacity. We sought to establish whether the lack of a seven-day inpatient physiotherapy service resulted in an increased hospital length of stay post primary hip and knee arthroplasty. Methods One hundred consecutive joint replacements (50 total hip replacements and 50 total knee replacements (TKRs)), performed in our institution from January to February 2020, were assessed. The length of stay for the cohort was analysed, and delays to discharge were identified. T-test was used to analyse the difference in length of stay based on the day of the week the surgery was performed. Results The mean length of stay for all primary hip and knee arthroplasties was 3.42 (standard deviation (SD): 1.62) days. Hip and knee arthroplasties performed on a Thursday or Friday had a significantly higher average length of stay than those performed on Monday, Tuesday or Wednesday (3.89 versus 3.02, p=0.006). We calculated that operating a six-day versus seven-day physiotherapy service in our unit cost 318 bed days per year equating to €986,535. Conclusion Length of stay post total hip and knee arthroplasty in our unit is significantly affected by the day of the week that surgery is performed. Elective orthopaedic units should consider all means of maximising efficiency and lowering costs given the future challenges in service provision.

Does MRI Knee in Those over 50 Years with Knee Pain in Osteoarthritis Alter Management? A Retrospective Review.

Knee osteoarthritis (OA) is a significant cause of pain and disability worldwide. Imaging provides diagnosis, prognostication, and follow-up. Radiographs are first line, useful, and inexpensive. Magnetic resonance imaging (MRI) can detect additional features not seen on radiograph, but it is of questionable usefulness in the management of knee OA. Our aim was to investigate the usefulness of MRI in the workup of knee OA and whether MRI alters management in knee OA. A retrospective review was performed of consecutive MRI knees performed for knee pain in those over 50 years. Clinical information and documentation of management plan pre- and post-MRI were collected. Assessment was made whether the MRI results influenced the final management plan. Of the 222 MRI knees included for study, the majority (62.2%) had not had a recent radiograph. OA was reported in 86.9% of radiographs and 89.6% of MRI. On MRI, the most prevalent finding was tearing/abnormality of the medial meniscus, seen in 47% of MRIs overall, increasing to all in severe OA. MRI assisted with management in 9.5% of all (21/222) patients, and changed management plans in 23% of those that had documented management plans prior to the MRI (6/26 patients). MRIs can guide tailored management in knee OA and are useful for surgical planning; however, they should only be ordered in certain cases, and a radiograph should always be performed first. MRI should be considered if symptoms are not explained by OA alone or the appropriate treatment option requires MRI.

Obesity trends over 10 years in primary hip and knee arthroplasty-a study of 12,000 patients.

OBJECTIVES/AIMS: Obesity and its increasing prevalence are global public health concerns. Following joint replacement, there is evidence to support that obese patients are more likely to suffer complications. We examined 10-year trends in BMI of the primary total hip and total knee replacement cohorts in our institution to discern whether the BMI of these patients has changed over time. METHODS: We examined BMI data of patients who underwent primary hip and knee arthroplasty from our institutional database from January 1, 2010 to December 31, 2019 (n = 12,169). We analysed trends in BMI over this period with respect to (i) surgical procedure, (ii) gender, and (iii) age categories. RESULTS: The overall number of surgical procedures increased over the study period which meant more obese patients underwent surgery over time. Average BMI did not change significantly over time; however, there was a statistically significant increase in BMI in females aged < 45 in both arthroplasty groups. CONCLUSION: The average BMI of patients undergoing primary hip and knee arthroplasty in our high-volume tertiary orthopaedic centre has remained relatively unchanged over the past 10 years; however, our local service is caring for a greater number of overweight/obese patients due to the increase in overall volume. This will have significant implications on health care expenditure and infrastructure going forward which further emphasises the importance of ongoing national obesity prevention strategies. The increase in BMI seen in females aged < 45 may mark an impending era of obese younger patients with end-stage osteoarthritis.

Can teleconsent improve patient recall of surgical risks in knee arthroplasty? A randomised controlled trial.

OBJECTIVES: Informed consent plays a vital role in managing patients undergoing knee arthroplasty (KA). Unfortunately, patient recall of informed consent remains poor. Evidence has suggested that telemedicine and teleconsent can be safe, cost-effective, and well-received by patients. The primary aim of this study was to evaluate the effect of an additional preoperative teleconsent session on patient recall of surgical risks 1 month after knee arthroplasty. The secondary aim was to assess its impact on patient satisfaction. METHODS: Sixty adult patients awaiting knee arthroplasty were randomly allocated to receive an additional preoperative teleconsent consultation (intervention group) or not (control group), along with the standard informed consent on the day of surgery. Participants were contacted 1 month after surgery to assess recall of surgical risks and satisfaction with the process. Demographics and education levels were recorded for each patient. RESULTS: The mean recall rates were 16% and 12% in the study and control groups, respectively, with no significant difference (p = 0.42). There was a significant difference between the mean satisfaction scores in the intervention group and the control group (9.8/10 vs 9/10, p = 0.0004). Lastly, there was a significant positive correlation between the education level and the number of risks recalled in the study (p = 0.05) and control groups (p = 0.04). CONCLUSION: The additional preoperative teleconsent session had no significant effect on the risk recall rate but improved patient satisfaction. Our findings suggest education level may play a role in information recall. We can advocate for the increased use of teleconsent and telemedicine in patients undergoing KA or any elective orthopaedic procedure due to its perceived positive effects on patient satisfaction rates.

Can Bar Code Scanning Improve Data Capture in a National Register? Findings from the Irish National Orthopaedic Register.

BACKGROUND: The Irish National Orthopaedic Register (INOR) provides a national mechanism for managing data on THA and TKA in Ireland, including a detailed implant record populated by intraoperative implant bar code scanning. It is critically important that implant details are recorded accurately for longitudinal outcome studies, implant recalls, and revision surgery planning. Before INOR's 2014 launch, Irish hospitals maintained separate, local institutional arthroplasty databases. These individual databases typically took the form of hardcopy operating room (OR) logbooks with handwritten patient details alongside the descriptive stickers from the implant packaging and/or individual institution electronic records using manual electronic implant data input. With the introduction of the INOR, a single, unifying national database was established with the ability to instead collect implant data using bar code scanning at time of implant unpackaging in the OR. We observed that bar code data entry represented a novel and potentially substantial change to implant recording methods at our institution and so sought to examine the potential effect on implant data quality. QUESTIONS/PURPOSES: We compared the new bar code scanning method of implant data collection used by the INOR to the previously employed recording methods at our institution (in our case, the previous methods included both an electronic operation note database [Bluespier software] and a duplicate hardcopy OR logbook) and asked (1) Does bar code scanning improve the completeness of implant records? (2) Does bar code scanning improve the accuracy of implant records? METHODS: Although the INOR was launched in 2014, our institution went live with it in 2019. To avoid any potential recording issues that may have occurred during the 2019 introduction of the novel system, a clear period before the introduction of INOR was selected at our institution to represent an era of manual data input to Bluespier software: July 2018. Although we initially aimed for 2 months of data from July 1, 2018, to August 31, 2018 (n = 247), we decided to proceed to 250 consecutive, primary THAs or TKAs for clarity of results. No procedure meeting these criteria was excluded. A second recent period, January 2021, was identified to represent an era of bar code data input; 250 consecutive, primary THAs or TKAs were also included from this date (to February 15, 2021). No case meeting these criteria was excluded. A total of 4244 implant parameters from these 500 primary THAs or TKAs were manually cross-referenced for missing or incorrect data. Eleven THA and six TKA parameters were chosen for comparison, including implant names and component sizes. For each case, either the 2018 Bluespier electronic record or the 2021 INOR electronic record was manually interrogated, and implant details were recorded by two authors before they were compared against the duplicate record for every case (the reference-standard OR logbook containing the corresponding implant product stickers) for both completeness and accuracy. Completeness was defined binarily as the implant parameter being either present or absent; we did likewise for accuracy, either that parameter was correct or incorrect. The OR logbooks were chosen as the reference standard because we felt the risk of product stickers containing errors (inaccuracies) was negligible, and in our collective experience, missing stickers (incompleteness) has not been encountered. Logbook case completeness was also confirmed by comparison to our inpatient management system. RESULTS: With the introduction of the automated bar code data entry in the INOR, the proportion of missing data declined from 7% (135 of 2051) to 0% (0 of 2193), and the proportion of incorrectly recorded implant parameters declined from 2% (45 of 2051) to 0% (0 of 2193). The proportion of procedures with entirely accurate implant records rose from 53% (133 of 250) to 100% (250 of 250). CONCLUSION: The completeness and accuracy of implant data capture was improved after the introduction of a contemporary electronic national arthroplasty registry that utilizes bar code data entry. CLINICAL RELEVANCE: Based on the results of this study, other local and national registers may consider bar code data entry in the OR to achieve excellent implant data quality. Future studies may examine implant data quality at a national level to validate the bar code-populated data of the INOR.

Influence of a Preadmission Procedure-Specific Consent Document on Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement: A Randomized Controlled Trial.

OBJECTIVES: Consent is a legal and ethical requirement for undertaking surgical procedures; however, the literature suggests that there continues to be poor recall among patients of the surgical risks discussed during the consent process. The aim of this study was to evaluate whether the addition of a preadmission procedure-specific consent document would improve patient recall of surgical risks at 4 weeks after total hip replacement in patients consented with a procedure-specific consent form. METHODS: A prospective randomized controlled trial allocated seventy adult patients who were undergoing a primary total hip replacement to either receive (intervention group) or not receive (control group) a preadmission procedure-specific consent document. All patients were also consented with a procedure-specific consent form on the morning of surgery and were contacted 4 weeks later to assess recall of surgical risks. RESULTS: There was a very poor recall rate seen in both the intervention group (16%) and the control group (13%), with no statistically significant difference between them (P = 0.49). A large number (30%) of patients could not recall a single risk. A subgroup analysis excluding these "consent nonresponders" did show a significantly increased recall rate in the intervention group (24.5% versus 18.25%, P = 0.02). CONCLUSIONS: Patient recall of potential complications of total hip replacement was poor despite the intervention. Although not effective overall, the use of a preadmission procedure-specific consent document did improve recall of potential complications of surgery in a subset of patients. The phenomenon of consent nonresponders is worth exploring in future research.

Instant messaging apps and data protection: combining to improve hip fracture care?

INTRODUCTION: The General Data Protection Regulation (GDPR) continues to have implications for how healthcare information is managed and shared. This presents challenges as telemedicine plays a more central role in service healthcare service provision, particularly since the beginning of 2020. We aim to measure how improved communication through a GDPR-compliant messaging app can influence time-dependent key performance indicators for hip fracture management in a tertiary-referral trauma hospital. METHODS: Using an instant messaging service, a hip fracture group was created and access was provided to all stakeholders in hip fracture care-trainee and consultant emergency physicians and orthopaedic surgeons, as well as advanced nurse practitioners, bed managers, ward managers and theatre managers. Irish Hip Fracture Database (IHFD) standard compliance was compared from April to December 2017 and April to December 2018. RESULTS: Two periods in 2017 and 2018 saw 121 and 122 hip fracture patients admitted, respectively. Mean time to admission to an orthopaedic ward in 2017 was 47 ± 42.9 h and 33.3 ± 42 h in 2018 (P = 0.5). Mean time to surgery in 2017 was 83.66 ± 53.46 h and 39.11 ± 10.84 h in 2018 (p = 0.026). CONCLUSIONS: Irish Hip Fracture Database Standards present a challenge to orthopaedic departments competing with other hospital specialties for access to beds and theatre space. The introduction of a GDPR-compliant social media messaging service has contributed to significantly reducing the time to surgery for these patients. Streamlining communication through messaging services has and continues to be vital to improving care for hip fracture patients, both in the healthcare environment and beyond.

A multi-site review of second hip fractures across 6 Dublin teaching hospitals.

INTRODUCTION: Fragility hip fractures are common and costly. Secondary fracture prevention is a treatment goal following hip fracture; however, the number of those that proceed to fracture their contralateral hip in Ireland is unknown. There are plans to introduce a Fracture Liaison Service Database in Ireland which will aim to prevent secondary fractures. To establish a baseline figure for secondary hip fractures, the injury radiographs of 1284 patients from 6 teaching hospitals over a 1-year period were reviewed. METHODS: Irish Hip Fracture Datasheets and corresponding injury radiographs were reviewed locally for all hip fractures within each respective teaching hospital for a 1-year period (2019). RESULTS: A total of 8.7% of all fragility hip fractures across the 6 hospitals were secondary hip fractures (range 4.9-11.5%). 46% occurred within years 1 to 3 following index hip fracture. Forty-eight per cent of patients were started on bone protection medications following their second hip fracture. DISCUSSION/CONCLUSION: Approximately 1 in 11 hip fractures treated across the 6 teaching hospitals assessed in 2019 was a patient's second hip fracture. We advocate for the widespread availability of Fracture Liaison Services to patients throughout Ireland to assist secondary fracture prevention.

Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement With Standardized Versus Procedure-Specific Consent Forms.

OBJECTIVES: Informed consent plays a pivotal role in the operative process, and surgeons have an ethical and legal obligation to provide patients with information to allow for shared decision-making. Unfortunately, patient recall after the consent process is frequently poor. This study aims to evaluate the effect of procedure-specific consent forms on patient's recall four weeks after total hip replacement (THR). METHODS: This is a prospective study using a posttest-only control group design. Sixty adult patients undergoing total hip replacement were allocated to be consented using either the generic or the surgery-specific consent form. Four weeks after surgery, a phone interview was conducted to assess patient's recall of risk of surgical complications. RESULTS: Patient demographic characteristics and educational attainment were similar in both groups. There was a statistically significant increase in the mean number of risks recalled in the study group at 1.43 compared with 0.67 in the control group (P = 0.0131). CONCLUSIONS: Consent is a complex process, and obtaining informed consent is far from straightforward. A statistically significant improvement in patient's recall with the use of procedure-specific consent forms was identified, and based on this, we would advocate their use. However, overall patient recall in both groups was poor. We believe that improving the quality of informed consent may require the sum of small gains, and the use of procedure-specific consent forms may aid in this regard.

Regional trauma patterns during the COVID-19 pandemic.

BACKGROUND: The current pandemic has impacted heavily on health systems, making unprecedented demands on resources, and forcing reconfiguration of services. Trauma and orthopaedic units have cancelled elective surgery, moved to virtual based clinics and have been forced to reconsider the provision of trauma. Our national elective orthopaedic centre has been re-designated as a trauma centre to allow tertiary centres re-direct triaged trauma. Many governments, as part of their COVID-19 management, have significantly restricted activity of the general population. We proposed that trauma patterns would change alongside these changes and maintaining existing standards of treatment would require dedicated planning and structures. METHODS: Referrals over a six-week period (March 15th to April 30th) were retrospectively reviewed. Data was collected directly from our referral database and a database populated. Analysis was performed to assess trauma volume, aetiology, and changes in trends. RESULTS: There were one hundred and fifty-nine referrals from three individual hospitals within the timeframe. Mean age of patient's referred was 55 (range17-92). Males accounted for 45% of cases. F&A injuries were the most common (32%), followed by H&W (28%), UL (17%), H&F (16%) and K&T (7%). In comparison to the corresponding time-period in 2019, trauma theatre activity reduced by almost one half (45.3%) CONCLUSION: The majority of trauma referred to our Dublin based centre during COVID-19 related population restrictions appears to be home based and trauma volumes have decreased. Significant reductions are apparent in work and sport related injuries suggestive of compliance with COVID-19 activity guidelines. Maintaining existing standards of treatment requires dedicated planning.

Crisis change management during COVID-19 in the elective orthopaedic hospital: Easing the trauma burden of acute hospitals.

INTRODUCTION: With the emergence of the 2019 novel coronavirus and its resulting pandemic status in March 2020 all routine elective orthopaedic surgery was cancelled in our institution. The developing picture in Italy, of acute hospitals becoming overwhelmed with treating patients suffering with severe and life-threatening symptoms from the disease, prompted the orthopaedic surgeons to formulate a plan to transfer trauma patients requiring surgery to the elective hospital to unburden the acute hospital system. METHODS: Under the threat of this pandemic; protocols and algorithms were established for referral, acceptance and care of trauma patients from acute hospitals in the region. Each day, as new guidance on COVID-19 emerged, our process and algorithms were adjusted to reflect pertinent change. RESULTS: The screening of all patients referred, worked well in keeping our hospital "COVID-free" with respect to patients undergoing operations. An upward trend in cases referred reflected the decreased capacity in the acute hospitals due to rising cases of COVID-19 within the hospital network. During the first 7 weeks of the pandemic 308 operations were performed, (31.1% upper limb, 33.4% lower limb, 4.1% spine, 14.1% urgent elective, 17.4% plastic surgery cases). Regular review and audit of the activity in the hospital as well as communication with the referring teams enabled appropriate planning to accommodate the increase in case-mix as the need arose. DISCUSSION: This paper details the steps that were taken in planning for such a change in management specific to the orthopaedic surgery setting and the lessons learnt during this process. The success of the development of this pathway was facilitated by clear communication channels, flexibility to adapt to changing process and feedback from all stakeholders. The implementation of this pathway allowed the unburdening of acute hospitals dealing with the pandemic that was steadily reducing access to operating theatres and anaesthetic resources.

Outcomes of the Exeter V40 cemented femoral stem at a minimum of ten years in a non-designer centre.

AIMS: The Exeter V40 cemented femoral stem was first introduced in 2000. The largest single-centre analysis of this implant to date was published in 2018 by Westerman et al. Excellent results were reported at a minimum of ten years for the first 540 cases performed at the designer centre in the Exeter NHS Trust, with stem survivorship of 96.8%. The aim of this current study is to report long-term outcomes and survivorship for the Exeter V40 stem in a non-designer centre. METHODS: All patients undergoing primary total hip arthroplasty using the Exeter V40 femoral stem between 1 January 2005 and 31 January 2010 were eligible for inclusion. Data were collected prospectively, with routine follow-up at six to 12 months, two years, five years, and ten years. Functional outcomes were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Outcome measures included data on all components in situ beyond ten years, death occurring within ten years with components in situ, and all-cause revision surgery. RESULTS: A total of 829 stems in 745 patients were included in the dataset; 155 patients (20.8%) died within ten years, and of the remaining 664 stems, 648 stems (97.6%) remained in situ beyond ten years. For the 21 patients (2.5%) undergoing revision surgery, 16 femoral stems (1.9%) were revised and 18 acetabular components (2.2%) were revised. Indications for revision in order of decreasing frequency were infection (n = 6), pain (n = 6), aseptic component loosening (n = 3), periprosthetic fracture (n = 3), recurrent dislocation (n = 2), and noise production (ceramic-on-ceramic squeak) (n = 1). One patient was revised for aseptic stem loosening. The mean preoperative WOMAC score was 61 (SD 15.9) with a mean postoperative score of 20.4 (SD 19.3) (n = 732; 88.3%). CONCLUSION: The Exeter V40 cemented femoral stem demonstrates excellent functional outcomes and survival when used in a high volume non-designer centre. Outcomes are comparable to those of its serially validated predecessor, the Exeter Universal stem.Cite this article: Bone Jt Open 2020;1-12:743-748.