Predicting Factors for Requiring Routine Postoperative Blood Analysis in Primary Hip and Knee Arthroplasty: A Prospective Study.

Background Minimising unnecessary expenditure is essential to cope with high demands on the health sector. A set of full blood count, electrolyte, creatinine and urea tests cost £12 in the National Health Service (NHS). Identifying selected patients requiring postoperative blood tests following primary knee and hip arthroplasty will avoid unnecessary tests and help to reduce expenditure.  The aim of our study is to propose criteria for requesting postoperative blood tests that are safe and do not miss patients. Materials and methods We prospectively evaluated 126 patients (72 in the total knee replacement (TKR) group and 54 in the total hip replacement (THR) group) who underwent either an elective primary THR or a TKR. The mean patient age was 71 years. Patient demographics as well as in-patient events throughout each patient's hospital stay were recorded. Hospital readmissions were also monitored for up to 90 days postoperatively.  Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY) with paired t-tests / Wilcox and mixed measures analysis of variance. Binary logistic regression was used to identify predictors of patients requiring a postoperative blood test. Results Analysis of our data identified the following as risk factors for requiring postoperative full blood count tests, including pre-operative Hb of ≤ 110 g/L, cardiac disease, clinical features of anaemia postoperatively and intraoperative blood loss of > 500 mL. The additional risk factors identified for requiring postoperative electrolyte and urea tests are deranged pre-operative electrolytes and clinical signs or symptoms of electrolyte/renal disturbance such as anuria. No patient was readmitted within 90 days of discharge. Conclusion Overall, applying the criteria we have devised would have saved 74 blood tests in the cohort of 126 patients. This provides an odds ratio of 14.0 (95% confidence interval: 1.77-110, p=0.012) of an abnormal result in the patients that would have been tested, compared to those that would not have been tested.

Maintaining Postgraduate Healthcare Education During COVID-19: Does a Virtual Format Allow Effective Engagement and Personal Development?

Introduction The COVID-19 pandemic has brought unprecedented challenges in health care, leading to a dramatic change in service provision and impacting surgical training. The availability of a virtual meeting platform allowed our team to develop a new educational programme aiming to maintain an ethos of education safely, focusing on providing an opportunity to develop non-technical skills and maintain reflective practice. Materials and Methods Microsoft Teams was used to conduct two streams of weekly education: a journal club focussing on developing critical evaluation skills, and case-based in-depth discussion forum to develop presentation skills and evidence-based management. A questionnaire after 10 weeks was used to evaluate the effectiveness and engagement of the two streams. Results Fifty-three responses were received. Seventy-two percent felt that their engagement in teaching was increased on a virtual platform. There was 88% satisfaction with the platform. Reflective practice increased and 40% of respondents felt their non-technical skills improved. Sixty-eight percent stated that they would like to continue the virtual format going forward and 88% would recommend this to their peers. Ninety-two percent felt that the platform played a pivotal role in helping maintain team morale during this period. Conclusion Our experience of using a virtual tool to maintain education within our department is very positive. There has been good engagement with positive reflection and learning at a time of great change in the NHS. Both trainees and non-trainees have benefited. With ongoing COVID still influencing clinical practice, we recommend utilising virtual platforms to maintain education in surgical departments.

Informed consent for surgery on neck of femur fractures: A multi-loop clinical audit.

BACKGROUND: The Montgomery case in 2015 resulted in a pivotal change in practice, leading to a patient-centric approach for informed consent. Neck of femur (NOF) fractures are associated with a high rates perioperative morbidity and mortality. Using guidelines highlighted by the British Orthopaedic Association we performed a multi-loop audit within our department to assess the adequacy of informed consent for NOF fractures. METHODS: Two prior cycles had been performed utilising a similar framework. Prior interventions included ward posters, verbal dissemination of information at Junior Doctor's (JD) induction and amendments to the JD handbook. For the latest audit loop, a retrospective analysis of 100 patients was performed. Risk were classified as common, less common, rare and 'other' non-classifiable risks. The adequacy of informed consent was evaluated by assessing the quality and accuracy of documentation in the signed Consent Form-1s for compos mentis patients. RESULTS: Infection, bleeding risks, clots and anaesthetic risks were documented in all patients (100%). Areas of improvement included documentation of neurovascular injuries (98%), pain (75%) and altered wound healing (69%). There was no significant change in the documentation of failure of surgery (83%) and neurovascular injuries (98%). Poorly documented risk factors included mortality (21%), prosthetic dislocation (14%) and limb length discrepancy (6%). CONCLUSION: Following the latest cycle, the trust has now approved the use of 2 consent-specific stickers (for arthroplasty or fixation), amendable on a patient-to-patient basis. As part of the multi-loop process, the cycle will be repeated every year, in line with Junior Doctor rotations. Medical professionals have an ethical, moral and legal obligation to ensure they provide all information regarding surgical interventions to aid patients in making an informed decision.

Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation.

Varus malalignment in total hip arthroplasty has been associated with poor long-term outcomes and complications including abnormal load distribution, endosteal osteolysis, frank loosening, and periprosthetic fractures. Postoperative radiographic assessment was performed on 224 patients from our case series who underwent cemented Exeter total hip arthroplasty using the direct lateral approach alone. No patient had a true varus-aligned stem (ie, ≤-5° on the coronal assessment). We describe our surgical technique, with 4 easily reproducible technical tips to achieve positional consistency of the femoral stem: commencing stem insertion from the piriform fossa entry point, using a femoral stem distal centralizer, aiming the tip of the component to the center of the patella, and placing the thumb between the calcar and inferior neck of the femoral component to prevent the stem from tipping into varus.