Purpose of study: With the increasing demand for arthroplasty surgery, it is important to maintain a high quality of care. We describe a clinical governance framework for a simple, easy to implement method of assessing and monitoring radiological outcome following total knee arthroplasty.

Methods: We completed a two-year prospective study (January 2006 to December 2007 inclusive) of all total knee arthroplasty operations. This included 1,295 procedures, the majority of which were undertaken by two Consultant Surgeons and up to eight independent middle grade surgeons. The two Consultant Knee Surgeons assessed component position on standard post-operative weight-bearing antero-posterior and lateral knee radiographs on a weekly basis. They were blinded to both the patient and surgeon details, and used our own simple grading system, whose weighted Kappa variance showed ‘moderate’ interobserver (K = 0.41) and intraobserver reliability (K = 0.51). Our system comprised of only three ordinal scores, which were good (score of 1), acceptable (score of 2) and poor (score of 3).

Results: We provided individual surgeons with their results on a six-monthly basis. The average score for all the surgeons was good. The scores of the independent middle-grade surgeons were analysed by the Consultants, and feedback was provided in the form of formal advice and supervised surgery sessions. Repeat proportional analysis of their radiological scores showed significant improvements for all the individual surgeons (Pearson-Chi Square p value < 0.05).

Conclusions: Clinical governance is an important facet of excellence in medical practice. Our system allows continued prospective assessment of radiological outcome following total knee arthroplasty. By utilising such systems and ensuring an atmosphere of clinical excellence, we are able to employ more surgeons and undertake an increased workload, whilst maintaining high standards. This assessment tool can also be used to assess and appraise trainees during their progression.

Introduction: Many papers present results and outcomes of patients undergoing TKR or THR, these are often available to the general population and health care community and health care commissioners. These results are used as a standard to be expected by the interested parties. Patients undergoing lower limb arthroplasty fall into groups that can be broadly divided into standard and complex. Complexity can be further subdivided into local site of surgery problems, general co-morbidity problems or both.

We have come up with a 4-part stratification based on the patient’s primary condition and comorbidities and have evaluated this for a single-surgeon cohort of TKR patients and a multi-surgeon group of THR patients. We present the results and the implications of the findings and highlight the usability of the system.

Methods: Retrospective review of patient’s notes and radiographs recording lenght of stay, early post operative complications, demographic data, medical co-morbidities and local site of surgery issues. This information was used to stratify patients into 4 groups. Complex Primary 0 -standard joint replacement in a fit patient with simple pattern arthritis, Complex Primary I -a fit patient with locally complex arthritis, Complex Primary II -medically unfit patient with simple arthritis and Complex Primary III -medically unfit patient with complex pattern arthritis. We evaluated this for a single-surgeon cohort of TKR patients and a multi-surgeon group of THR patients, a total of 250 patients.

Results: The complication rates between the four groups were analyzed using logistic regression analysis and this revealed a highly significant trend among the four groups (p< 0.0001). Lenght of stay data was analyzed using non-parametric analysis of variance. This revealed a significantly increased lenght of stay in the CI and CII groups compared to the C0 group. Compared to CP0 patients, we found a 3-fold increase in cumulative complication risk in the CPII group, a 4-fold increase in the CPIII group. There were similar trends between CP0 and CPI and between CPI and CPII.

Discussion and Conclusion: This classification system correlates and quantifies increasing primary joint replacement complexity with increasing postoperative complication rates and length of stay. It is of use in stratifying patients for preoperative planning, risk counselling, and surgeon selection. These noted increases mean that this system can identify patient groups likely to incur greater cost during their treatment. It is potentially reproducible and usable for other types of surgery and can be applied to larger patient groups via institutional or national joint registries.

Purpose of study: With the increasing demand for arthroplasty surgery, it is important to maintain a high quality of care. We describe a clinical governance framework for a simple, easy to implement method of assessing and monitoring radiological outcome following total knee arthroplasty.

Methods: We completed a two-year prospective study (January 2006 to December 2007 inclusive) of all total knee arthroplasty operations. This included 1,295 procedures, the majority of which were undertaken by two Consultant Surgeons and up to eight independent middle grade surgeons. The two Consultant Knee Surgeons assessed component position on standard post-operative weight-bearing antero-posterior and lateral knee radiographs on a weekly basis. They were blinded to both the patient and surgeon details, and used our own simple grading system, whose weighted Kappa variance showed ‘moderate’ interobserver (K = 0.41) and intraobserver reliability (K = 0.51). Our system comprised of only three ordinal scores, which were good (score of 1), acceptable (score of 2) and poor (score of 3).

Results: We provided individual surgeons with their results on a six-monthly basis. The average score for all the surgeons was good. The scores of the independent middle-grade surgeons were analysed by the Consultants, and feedback was provided in the form of formal advice and supervised surgical sessions. Repeat proportional analysis of their radiological scores showed significant improvements for all the individual surgeons (Pearson-Chi Square p value < 0.05).

Conclusions: Clinical governance is an important facet of excellence in medical practice. Our system allows continued prospective assessment of radiological outcome following total knee arthroplasty. By utilising such systems and ensuring an atmosphere of clinical excellence, we are able to employ more surgeons and undertake an increased workload, whilst maintaining high standards. This assessment tool can also be used to assess and appraise trainees during their progression.

Objectives: To determine the effect of an Orthogeriatric team (OGT) upon patient management pre-operatively after its incorporation into a regional trauma centre of a district general hospital in the UK.

Design: Prospective audit covering all patients admitted with a fractured hip for surgery one year before and one year after the establishment of an OGT.

Method: A total of 288 fractured hips were operated on during February 2004 to February 2005. From February 2005 the OGT was created, consisting of a Staff Grade and 2 Senior House Officers (junior residents), assisted part-time by a consultant. Patients were medically managed and optimised for theatre; 301 patients underwent surgery in the 1st year from Feb 2005 to 2006.

The data was collected prospectively from admission, and entered onto a database.

Results: Before the set up of the OGT only one-quarter (25%) of patients were operated on within 24hours compared to almost one-half of patients (44%) under the care of the OGT. Of the patients waiting more than 24hours, delay while waiting for special tests was similar but there was a significant difference in the percentages of patients delayed due to lack of theatre time and poor medical condition. Only 5% of patients under the care of the OGT were delayed due to medical co-morbidity compared with 44% when solely under orthopaedic care.

Conclusion: Focused high-quality medical input provided by a specialist Orthogeriatric team resulted in significantly reduced delays to theatre for patients admitted with a fractured hip. This is in the context of our hip fracture population becoming increasingly frail with increasing medical problems and continuing pressures on operating time. In the environment of financial constraint, this study confirms that reduction in time to theatre, effective, appropriate investigation and lower complication rates are likely offset the cost of the team. This may provide a model for other units.

BACKGROUND: Complex tibial peri-articular fractures are known to be challenging with high complication rates. Techniques are evolving to assist the management of these injuries and this study looks at a Trauma unit’s experience to help evaluate indications, short and mid-term outcomes and complications.

METHOD: 4 year retrospective analysis of prospectively enrolled patients diagnosed with complex peri-articular fractures. Definitive treatment with Less Invasive Stabilisation System (LISS), low contact peri-articular plates and locking condylar plates, using minimally invasive percutaneous osteosynthesis (MIPO), irrespective of initial operative management were included. Follow up:until discharge from clinic with union and full weight bearing. Outcome: peri- and post-operative complications, loss of fixation, radiographic union, and range of motion.

RESULTS: 25 (15 proximal,10 distal tibial) operations by senior authors (RAB, SDD) over 4 years with a 16–88 year age (mean 44). Poly-trauma:7 (28%) of cases and 6 (24%) of the entire group were open fractures. Ten patients (40%): preceding damage-limitation procedure prior to definitive treatment (MIPO) and found to be over twice as likely to experience a complication compared to patients who did not. 3 (12%) of 10 had failed those alternative modalities. Overall infection rate was 24% (6 patients:2 deep wound infections; 4 open fracture wound infections). Infection was successfully managed with the use of debridement, flaps and antibiotics in 2 patients (8%); antibiotics alone on one (4%); in 3 patients with the delayed plate removal (12%), usually after union (1 revised with an intramedullary nail). Six plates (24%) were removed: 3 (12%) for infection; 2 (8%) for pain; 1 (4%) for plate fracture (revised). Other complications:2 (8%) significant wound breakdowns, one of whom required local flap cover. No mal-alignment issues; 1 patient developed common peroneal nerve neuropraxia. Patients who were operated after a week or more from injury were half (33%) as likely to suffer from a complication than those operated within a week (57%); P < 0.05 Chi-Square.

All progressed to union with 5 patients (20%) having metal work out at that end point and 8 (32%) healing without complication, further surgery or irritation. There were 18 re-operations in total in 9 (36%) of the patients.

CONCLUSION: Complex peri-articular fractures of the tibia continue to have a high re-operation rate with significant infection risk especially in open injury. Such techniques do provide a lower morbidity and short-term complication profile when compared with frames/hybrids and formal open fixation. The timing of minimal approach surgery is crucial and has yet to be fully defined. Within a department this type of fixation should be restricted to those with a specific interest, experience and training.

Background: The implications of clinical governance, changing epidemiology, financial restraints alongside the increasing demands of the informed consumer-patient mean we must continually adapt our practice to efficiently meet expectations.

As a busy regional Trauma and Orthopaedics Unit of a District General Hospital we are increasingly affected by economic agendas and have noted an increase in the presenting frailty of our fracture hip patients.

Our practice has already changed by the use of an Orthogeriatrics Team (OGT): optimising patient status pre-operatively and ensuring maximum post-operatively continuity. The OGT has significantly reduced time to theatre. With appropriate investigation and lower complication rates it will offset the cost of the team.

We wanted to see if the care of fractured hip patients could be further focused.

On this basis, a four-part clinical stratification system was devised for patients undergoing fractured hip repair:

Complex 0 (C0): Hip repair of a non-complex fracture pattern in an otherwise fit, healthy patient.

Patients and Methods: The first 50 patients operated on across the same three months in both 2004 and 2005 were retrospectively assessed from prospectively collected data.

Patients were grouped accordingly and age, length of stay, time to theatre and reason for delay, mental state examination score (MSE) on admission, and number of co-morbidities were also recorded.

Chi-square was performed on co-morbidity, MSE and theatre times with AVOVA used for age and length of stay data.

Results: No significant difference between groups for age.

Two fold increase in stay (2004 paired classes C0+I vs CII+III; P< 0.003).

Chance of more than 2 co-morbidities (C0+I vs CII+III): 52% vs 96% (2004) and 56% vs 92% (2005).

MSE with a positive dementia score: 26% vs 82% (2004; P0.001) and 39% vs 70% (2005; P< 0.05).

Time delays to theatre greater than 24hrs were seen 24% vs 92% (P< 0.001) in 2005. The correlating values in 2004 were 63% vs 87%.

Active treatment delaying theatre in the C0+I group 24% vs 57% (CII+III) in 2004 and 0% vs 78% 2005 (P< 0.001).

Conclusion: The benefit of the OGT can be seen clearly in most parameters and this classification system correlates and quantifies increasing hip fracture complexity with increasing post-operative burden even under their care.

Stratifying patients for pre- and postoperative planning, risk counselling, and surgeon selection can identify patient groups likely to incur greater cost during their treatment.

The classifications are easily reproducible and can be applied to larger patient groups via institutional or national joint registries.

We have previously noted that patients undergoing primary knee arthroplasty can be broadly divided into standard and complex. Complexity can be further subdivided into local site of surgery issues, general co-morbidity problems or both.

On this basis, we devised a simple to apply four-part classification system for patients undergoing primary total knee replacecments (PTKR) to facilitate cumulative risk estimation:

Complex 0 (C0): “Standard” knee replacement in a fit patient with a simple pattern of arthritis.

When a series of consecutive PTKR’s performed by the senior author was grouped according to our classification, all early postoperative complications and length of stay were evaluated and compared.

Compared to “standard C0 PTKR patients, we found a 3-fold increase in the cumulative complication risk in the CII group (p< 0.001), a 4-fold increase in the CIII group (p< 0.001) and an increased length of stay in the CIII group (p< 0.001). There were similar trends between C0 and other groups.

Further local studies to quantify the cost differentials of treating complex patients and their longer term outcomes and satisfaction are underway.

The senior author would like to discuss with the attending members of this BASK meeting the desirability of adopting such a system regionally or nationally, with the potential benefits for individual patients, surgeons, departments, Trusts and the healthcare system as a whole, and whether minor changes could and should be made to the National Joint Registry forms to accommodate this.

Aim: To assess the Oxford Knee Score (OKS) for the assessment of soft tissue knee pathology?

Method: In a prospective study, we compared the OKS against the International Knee Documentation Committee (IKDC 2000) and the Lysholm Scores (Lys). We also assessed the OKS with retrograde and antegrade (as currently used in Oxford) numbering. All patients completed 3 questionnaires stating which was the simplest from their perspective. We recruited 73 patients from the orthopaedic and physiotherapy clinics, meeting the following criteria:

Results: Linear regression analysis revealed no significant difference between all 3 scores (R²=0.7823, P< 0.0001). The OKS correlated best with the IKDC (r=0.7483, Fig1), but less so with the Lys (r=0.3278, Fig2). The reversed OKS did not correlate as well (R²= 0.2603) with either the IKDC (r= −0.2978) or the Lys (r= −0.2586). ANOVA showed the OKS to be significantly easier than Lys to complete (p< 0.0001), but not significantly easier than IKDC (p> 0.05).

Conclusion: The OKS is patient friendly and reliable in assessing soft tissue knee injury. This is particularly useful if the OKS is already in use within a department for measurement of severity of degenerative disease.

Background: We have devised a modified Pivot Shift test with which to assess ACL deficiency which does not require forced tibio-femoral subluxation. The test is scored on patient reaction to the initiation of the pivot shift without actually having to elicit that ‘shift’ which can be painful. We call the test the Pivot Apprehension test.

Methods: We retrospectively analysed a cohort of 81 patients who were potentially ACL deficient and sought orthopaedic intervention over a period of 3 years and correlate their initial ‘pivot apprehension’ score with the degree of ACL deficiency found at subsequent arthros-copy and/or MRI.

Results: Using contingency tables and Fishers Exact test we calculate that the test has a positive predictive value (for predicting ACL Rupture) of 94% (p=0.026) and a sensitivity of 89% (Specificity 60%). Linear Regression analysis shows a correlation coefficient (r) of 0.47 (p=0.0008).

Conclusion: The data we have collected in this study show that the ‘Pivot Apprehension Score’ is a clinical tool with a high positive predictive value for ACL injury which provides the same information as the Pivot shift test without having to cause painful tibio-femoral sub-luxation thus obviating the clinical need to elicit ‘pivot shift’ in the conscious patient.

The long-term results of patients with multiple knee ligament injuries, i.e. at least 3 ligament ruptures, including both cruciates, in patients entered prospectively onto the trauma database between 1985 and 1999, were reviewed. Forty patients with this injury had modified Lysholm scores at long term follow-up a mean of 8 years post-injury. The mode of operative treatment fell into 3 groups: direct suture or screw fixation of avulsions (Group 1), mid-substance ruptures treated with cruciate reconstruction with hamstring tendons (Group 2), or suture repairs of mid-substance ruptures (Group 3). All operative procedures were undertaken within 2 weeks of injury. Non-operative treatment involved a cast or spanning external fixator (2–4 weeks) followed by bracing. Statistical analysis was performed on the Lysholm scores.

The 40 patients in the study group were predominantly young males, 40% had polytrauma, 33% had isolated injuries. Thirteen patients (33%) had non-operative management, the remainder had early operative treatment of their ligament injuries, tailored to the type of ligament injuries identified.

Long-term patient outcome data shows statistically significant differences (p< 0.05) between the best results, in patients with direct fixation of bony avulsions (mean = 89), followed by those who had early hamstring reconstruction (mean = 79), followed by those who underwent simple ligament repairs (mean = 65). There was a statistically significant difference (p< 0.05) between the overall scores for the operative group (mean = 80) compared with the non-operative group (mean = 50).

Operative treatment of multiple ligament injuries, particularly fixation of avulsions and primary reconstruction of the posterior cruciate ligament appears to yield better results than non-operative or simple repair in the long term follow-up in this group with significant knee injuries.

This is a retrospective case review of 237 patients with displaced fractures of the acetabulum presenting over a ten-year period, with a minimum follow-up of two years, who were studied to test the hypothesis that the time to surgery was predictive of radiological and functional outcome and varied with the pattern of fracture. Patients were divided into two groups based on the fracture pattern: elementary or associated. The time to surgery was analysed as both a continuous and a categorical variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables.

For elementary fractures, an increase in the time to surgery of one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day.

When time was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated).

The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. The organisation of regional trauma services must be capable of satisfying these time-dependent requirements to achieve optimal patient outcomes.

Aim: To quantify changes in epidemiology, in-patient treatment and outcome of hip fracture patients over seven-year period.

Subjects and methodology: Retrospective randomised analysis of in-patient charts of patients with hip fractures admitted to a large 650-bed Acute District General Hospital in 1996 compared with 2003. The following data is gathered: Epidemiological data, baseline test data for anaemia and renal function, time to surgery from admission, post-operative complications, time to discharge from ward and functional outcome.

Results: In 1996, the total number of admissions over 6 months was 144 compared to 160 in 2003 for the same time period. The mean age has increased from 83 years compared to 85 years in 2003. Median mental test score declined from 9 in 1996 to 6 in 2003. The mean co-morbidities rose from 1.7 in 1996 to 2.8 in 2003. 11% of patients were medically unfit for surgery in 1996 compared to 30% in 2003 resulting in delay in time to theatre. 33% of patients were admitted from nursing homes in 2003 compared to 22% in 1996. The mortality rate was 12% in 1996 compared to 18% in 2003.

Conclusion: This study demonstrates that deteriorating pre-operative status in terms of age, ASA, mental test score and co-morbidities seems to have negated any of the system changes we introduced to improve our service. As patients with neck of femur fractures are often already suffering from other significant co-morbidities, the improvements in the overall health care system may not have an impact on the outcome of the patients concerned.

Introduction: The minimally invasive approach using the Oxford Unicompartmental Knee Replacement (UKR) in medial compartment osteoarthritis has gained significant popularity. A number of advantages have been attributed both to UKR and minimal invasive surgery in unilateral replacement.We have therefore evaluated the outcomes of simultaneous bilateral UKR at our institution and report a unique way of safely positioning these patients.

Method: Twenty patients were assessed undergoing bilateral UKR from 2001 to 2003. The study cohort included 11 females and 9 males with a mean age of 66 years. A matched cohort group undergoing simultaneous bilateral Total Knee Replacement (TKR) of 15 patients was evaluated as a control group. Peri -operative and later post- operative data was collected during hospitalisation or at standard outpatient follow -up. We will also demonstrate our unique patient positioning for bilateral UKR.

Results: No significant difference was shown regarding mean tourniquet times (97.8 min in bilateral UKR, 92.1 min in bilateral TKR) and mean Haemoglobin drop (2.15 gdl with bilateral UKR, 2.82 gdl with bilateral TKR). We note a significant benefit in mean blood product requirement between the bilateral unicompartmental (0 units) and total knee groups (3 units). Incidence of peri-operative complications was higher in the total knee group (4 in bilateral TKR, none in the bilateral UKR group). No complication required surgery. There was a reduced mean hospital stay of 6 days in bilateral UKR compared with 9.3 days in bilateral TKR. With regard to late complications, each group had one complication, of stiffness. Radiographic evaluation at a mean 9 months showed 4of 30 UKR to have minimal malposition, with no clinical correlation.Patient satisfaction was evaluated using the Oxford Knee Score, showing 12 patients (80%) obtained excellent or good results and 3 patients (20%) scoring a moderate or poor result. The patients in the moderate and poor groups all complained of unilateral stiffness.

Conclusion: It is possible to safely undertake bilateral simultaneous Oxford unicompartmental knee replacements using a minimally invasive technique using our described method of positioning, with good results for patients with symmetrical medial compartment knee arthritis.We note improved post-operative morbidity, physiological derangement and length of stay in our patients as compared to an age,sex,co morbidity-matched cohort of bilateral TKR patients

Of 1197 renal transplant recipients on the Oxford Transplant Programme, 25 (2%) needed arthroplasties for painful osteonecrosis of the hip. Nine of them had bilateral operations, giving a total of 34 primary total hip replacements (THR). The mean time from onset of symptoms to THR was 2.4 years and from transplantation to THR 5.1 years. The mean follow-up was 5.1 (1 to 14) years. THR relieved the pain in all the patients, but survival analysis indicated a lower survival rate than is usual for primary THR. There were eight major complications. One graft-related problem, early acute tubular necrosis, resolved rapidly after immediate treatment. One patient developed deep infection at 3.5 years after THR which settled with conservative treatment. Five hips developed aseptic loosening requiring revision arthroplasty at a mean of 8.8 years' follow-up. One patient had a non-fatal pulmonary embolism. THR is the treatment of choice for patients with painful osteonecrosis of the hip after renal transplant, but has higher rates of both early and late complications. Surgery should be performed in close association with a renal transplant unit.