AbstractIntroductionThe rate of day-case total knee replacement (TKR) in the UK is currently ~0.5%. Reducing length of stay improves efficiency, increases operative throughput and tackles the rising demand for joint replacement surgery and the COVID-19 related backlog. We report safe delivery of day-case TKR in an NHS Trust via inpatient wards, with no additional resources.MethodologyDay-case TKRs, defined as patients discharged on the same calendar day as surgery, were retrospectively reviewed with a minimum follow-up of six-months. Analysis of hospital and primary care records was performed to determine readmission and reattendance rates. Telephone interviews were conducted to determine patient satisfaction.ResultsBetween 2016 and 2021, 301/7350 (4.1%) TKRs were discharged on the day of surgery. Mean follow-up was 31.4 (6.2–70.0) months. 28 (9.3%) patients attended Accident and Emergency or other acute care settings within 90-days of surgery; six (2.0%) patients were readmitted. No patients underwent a subsequent revision procedure. There were no prosthetic infections. Two patients underwent secondary patella resurfacing, and one patient underwent arthroscopic arthrolysis after previous manipulation under anaesthetic (MUA). Three patients underwent MUA alone. Primary care consultation records, available for 206 patients, showed 16 (7.8%) patients contacted their General Practitioner within two-weeks post-operatively; two (1.0%) were referred to secondary care. 115/121 (95%) patients telephoned stated they would have day-case TKR again.ConclusionDay-case TKR can be safely delivered in the NHS with no additional resources. We found low incidence of contact with primary and secondary care in the post-operative period, and high patient satisfaction.

AbstractIntroductionNational BOAST guidelines have been developed to coordinate and improve the standard of care for all patients with problems after knee replacement surgery. Since the inception of these guidelines we wanted to assess the impact of these guidelines on patients and their pathways following their discussions at our weekly revision MDT meetings.MethodologyTrust casenotes programs, PACS software and MDT notes were evaluated over the past 12 months (January 2022 to December 2022) to collect data for all patients with problematic knee replacements. Current in-patients discussed at MDT were excluded.ResultsIn total 52 patients with problematic knees were discussed. In terms of the SPECIFIC criteria described in BOAST guidelines, 39% met one or more of these criteria (component loosening, infection, instability, component wear) of which 90% are have had or planned for revision surgery. Of those (61%) not meeting this criteria, 77% have been deemed not to have a surgical cause after further investigations with the rest still pending further investigation.ConclusionThe publication of guidelines has aided in the ongoing management of patients with problematic knee replacements. From our MDT discussions over the last year, its clear that when appropriately investigated and a cause found from the SPECIFIC criteria, patients are offered appropriate revision surgery.Further work with longer-term outcomes from MDT discussions would help to evaluate the impact of these discussions on which problematic knees benefit most from revision surgery and the effect on knee revision networks.

ObjectivesTo assess the efficacy and safety of venous thromboembolism prophylaxis in people undergoing elective total hip replacement.MethodsSystematic review and Bayesian network meta-analyses of randomized controlled trials were conducted for 3 outcomes: deep vein thrombosis (DVT), pulmonary embolism (PE), and major bleeding (MB). MEDLINE, EMBASE, and Cochrane Library (CENTRAL) databases were searched. Study quality was assessed using the Cochrane risk-of-bias checklist. Fixed- and random-effects models were fitted and compared. The median relative risk (RR) and odds ratio (OR) compared with no prophylaxis, with their 95% credible intervals (CrIs), rank, and probability of being the best, were calculated.ResultsForty-two (n = 24 374, 26 interventions), 30 (n = 28 842, 23 interventions), and 24 (n = 31 792, 15 interventions) randomized controlled trials were included in the DVT, PE, and MB networks, respectively. Rivaroxaban had the highest probability of being the most effective intervention for DVT (RR 0.06 [95% CrI 0.01-0.29]). Strategy of low-molecular-weight heparin followed by aspirin had the highest probability of reducing the risk of PE and MB (RR 0.0011 [95% CrI 0.00-0.096] and OR 0.37 [95% CrI 0.00-26.96], respectively). The ranking of efficacy estimates across the 3 networks, particularly PE and MB, had very wide CrIs, indicating high degree of uncertainty.ConclusionsA strategy of low-molecular-weight heparin given for 10 days followed by aspirin for 28 days had the best benefit-risk balance, with the highest probability of being the best on the basis of the results of the PE and MB network meta-analyses. Nevertheless, there is considerable uncertainty around the median ranks of the interventions.

Background: Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures. Aim: The aim of this work was to assess the cost-effectiveness of these strategies from the English National Health Service perspective to inform NICE guideline (NG89) recommendations. Materials and Methods: Cost-utility analysis, using decision modeling, was undertaken to compare 15 VTE prophylaxis strategies for eTHR and 12 for eTKR, in addition to "no prophylaxis" strategy. The analysis complied with the NICE Reference Case. Structure and assumptions were agreed with the guideline committee. Incremental net monetary benefit (INMB) was calculated, vs. the model comparator (LMWH+ antiembolism stockings), at a threshold of £20,000/quality-adjusted life-year (QALY) gained. The model was run probabilistically. Deterministic sensitivity analyses (SAs) were undertaken to assess the robustness of the results. Results: The most cost-effective strategies were LMWH for 10 days followed by aspirin for 28 days (INMB = £530 [95% CI: -£784 to £1,103], probability of being most cost-effective = 72%) for eTHR, and foot pump (INMB = £353 [95% CI: -£101 to £665]; probability of being most cost-effective = 18%) for eTKR. There was considerable uncertainty regarding the cost-effectiveness ranking in the eTKR analysis. The results were robust to change in all SAs. Conclusions: For eTHR, LMWH (standard dose) for 10 days followed by aspirin for 28 days is the most cost-effective VTE prophylaxis strategy. For eTKR, the results are highly uncertain but foot pump appeared to be the most cost-effective strategy, followed closely by aspirin (low dose). Future research should focus on assessing cost-effectiveness of VTE prophylaxis in the eTKR population.

In June 2012 the Orthopaedic Speciality Advisory of the Joint Committee on Surgical Training defined ‘minimum indicative numbers’ that trainees would have to meet before completion of specialist training. It has been speculated that regions have varied in their ability to provide operative opportunities to their trainees. This study aims to test the hypothesis that there are regional differences in operative training experience. The eLogbook database was interrogated for cases over a 12 month period from 7 August 2013 to 5 August 2015. Within each region, the mean of the cases registered by orthopaedic trainees in each year of training during the study period was calculated and summed to give a representative surgical experience for the years ST3-8. First surgeon only cases were analysed for 11 index procedures in 30 T&O rotations. Considerable variation in training existed across rotations. In three index procedures, including DHS, no rotation achieved the minimum indicative number required. All rotation...