Jai Relwani

Introduction: The aim of this comparative study was to evaluate patient reported outcome measures (PROMS) using the EQ5D-5L and EQ5D-5L visual analogue scale (VAS) following elective shoulder and elbow orthopaedic list delays arising from the COVID-19 pandemic. Methods: Patients on the elective waiting list for more than 26 weeks were included in the study. Telephone interviews were conducted utilizing EQ5D-5L and the EQ5D-5L VAS data at the time of addition to the waiting list and current status. Results: 75 out of 324 screened patients were eligible for inclusion. 62 (82.7%) patients still wanted to proceed with their planned procedure (group A) while 13 (17.3%) patients no longer wanted to proceed with surgery (group B). There was no statistically significant difference in the mean age, gender, initial trial of conservative treatment and limb laterality between these groups (P<0.05). There was a statistically significant difference in the mean duration of being on the waiting list between groups A and B (40.4 +/-19 weeks versus 62.9 +/-17.5 weeks respectively). Furthermore, statistically significant differences (P<0.05) in the current EQ5D-5L VAS scores were observed between these groups (52.4 versus 65.8 respectively). Conclusion: This study has shown that majority of patients on elective shoulder and elbow orthopaedic lists with prolonged waiting list delays and improved EQ5D-5L scores are likely to decline the planned procedure and vice versa. Nevertheless, the unplanned “watchful waiting” caused by the COVID-19 pandemic and leading to patients deciding to decline surgery, is not a substitute for timely planned surgery to alleviate patients’ suffering.

Introduction: Total elbow replacement (TER) is a surgical treatment option for haemophilic elbow arthropathy.Aim: To review the outcomes of TER in haemophilic elbow arthropathy. The primary outcome measures were perioperative blood loss, postoperative complications, revision rates and length of hospital stay (LOS). Secondary outcomes were elbow range of motion (ROM), functional outcome scores and the visual analogue pain scale (VAS).Materials and methods: PubMed, Medline, Embase and the Cochrane register were searched conforming to the PRISMA guidelines. Only studies with a minimum postoperative follow‐up of 1 year were included. Quality appraisal was performed utilizing the MINORS criteria.Results: One hundred and thirty‐eight articles were identified. Following article screening, only seven studies met the inclusion criteria. A total of 51 TERs in 38 patients were performed, with the Coonrad–Morrey prosthesis utilized in 51% of cases. The pooled postoperative complication and revision rates were 49% and 29%, respectively. Surgery‐related postoperative mortality was 3.9%. The mean preoperative Mayo elbow performance score (MEPS) was 43 ± 20 whereas the mean postoperative MEPS was 89 ± 6. Mean preoperative VAS was 7.2 ± 1.9 while the mean postoperative VAS was 2.0 ± 1.4. Mean preoperative and postoperative elbow flexion arcs were 54 ± 15 and 91 ± 10 degrees, respectively. Mean preoperative and postoperative forearm rotation arcs were 86 ± 40 and 135 ± 19 degrees, respectively.Conclusion: TER for haemophilic elbow arthropathy provides good to excellent improvements in pain and elbow ROM postoperatively. However, the overall complication and revision rates are relatively high, when compared to TER performed for other indications.

Osteoarthritis of the knee is a common debilitating disease in the elderly population. There are many treatment options available including physiotherapy, analgesics, steroid injections, arthroscopic debridement, high tibial osteotomy (HTO) and arthroplasty. Arthroscopic debridement is beneficial when patients are chosen with certain characteristics. This is a prospective case series where we have correlated the patient and disease characteristics, with the pre- and post-operative Oxford Knee Scores (OKS). This study was done in a single centre with appropriate ethical committee approval and consent. Forty-nine patients were enrolled in the study. The scores were recorded pre-operatively and at 12 months after the interventions. Analysis was done for correlation of the outcome with patient characteristics, radiological and arthroscopic grading. Patients below the age of 56 years, with partial thickness chondral lesions, grade I-III Kellgren-Lawrence (KL) radiological grading and grade I-II Outerbridge arthroscopic grading showed significant improvement at 12 months. Arthroscopic debridement is effective in younger patients with mild to moderate arthroscopic and radiologically graded osteoarthritis of the knee joint.

IntroductionThe aim of this study was to evaluate patient reported outcome measures using the EQ5D-5L and EQ5D-5L visual analogue scale (VAS) following elective shoulder and elbow orthopaedic list delays. This was further correlated with patients' intention to proceed with the planned surgery. MethodsPatients on the waiting list for more than 26 weeks were included in the study. Telephone interviews were conducted utilising the EQ5D-5L and the EQ5D-5L VAS at the time of addition to the waiting list and presently. Results75 out of 324 screened patients were eligible. 62 (82.7%) patients still wanted to proceed with their planned procedure while 13 (17.3%) patients in the other group no longer wanted to proceed. There was no statistically significant difference in the mean age, gender, initial trial of conservative treatment and limb laterality between these groups (p < 0.05). There was a statistically significant difference in the mean duration of being on the waiting list between these groups (40.4 +/- 19 vs. 62.9 +/- 17.5 weeks respectively). Furthermore, statistically significant differences (p < 0.05) in the current EQ5D-5L VAS scores were observed between these groups (52.4 vs. 65.8 respectively). ConclusionThis study has shown that majority of patients on elective shoulder and elbow orthopaedic lists with prolonged waiting list delays and improved EQ5D-5L scores are likely to decline the planned procedure and vice versa. Nevertheless, the unplanned 'watchful waiting' caused by the COVID-19 pandemic and leading to patients deciding to decline surgery, is not a substitute for timely planned surgery to alleviate patients' suffering.

Osteoarthritis of the knee is a highly prevalent disease globally, causing strain on healthcare resources and leading to a reduced quality of life. There are many treatments proposed for this condition, from conservative measures like analgesics and physiotherapy to surgical options like arthroscopy and total knee arthroplasty (TKA). Arthroscopic debridement and lavage provide significant improvement in a cohort of patients with particular features and can be a temporizing measure before TKA. This study aimed to investigate the results of this procedure, in a case series in the short-term and mid-term, in a low-resource setting. This was a case series of 20 patients, who presented with clinical and radiographic features of mild to moderate (Kellgren-Lawrence grades I-III) primary osteoarthritis of the knee. Arthroscopic debridement and lavage were performed and the Knee Society Score (KSS) was recorded pre-operatively and post-operatively in the short and mid-term at one month, three months, and twelve months. Statistical analyses was done for correlation, with different variables such as the presence of meniscal pathology, loose bodies, grade of osteoarthritis, malalignment, and body mass index (BMI). The KSS improved at one month, three months, and twelve months for all the patients. The improvement in the KSS scores was associated with varus malalignment of less than 10 degrees, a BMI of less than 25, and the presence of loose bodies. There were no adverse events or complications from this study. There was a significant improvement in a patient cohort with malalignment of less than 10 degrees, BMI of less than 25, meniscal pathology, and loose bodies. We can therefore recommend arthroscopic debridement and lavage as a temporizing measure before TKA in this particular cohort.

Virtual learning has become the preferred modality for health education during and after the coronavirus disease 2019 (COVID-19) pandemic. Peer learning is gaining a lot of significance lately and has been successfully tested in various settings. We combined virtual delivery of health education with peer-assisted learning and evaluated the effectiveness using peer-generated feedback and tested the effectiveness of the model for different cohorts. We performed this study as part of a formal educational course on Health Professions Education. The educators were volunteers from different informal multi-disciplinary groups, working in varied healthcare settings, globally. This involved eight teaching sessions which were delivered virtually and the feedback was recorded as responses to six items (questions), which the learners graded on the Likert scale. The average for each item and the larger domains was then calculated and analyzed. The feedback was provided by all the participants (53/53). In the feedback received item-wise, the best average rating was for legibility of the slides (4.8). The least rating was for adequate checking and assessment of prior knowledge (4.2). In terms of the broader domains, the best feedback was for the teaching material (4.6) and the lowest was for the planning of the sessions (4.4). Overall, the ratings for the domains and the items were above 3 on a scale of 1-5. Virtual delivery of healthcare education, facilitated by peer-assisted learning, is an effective model for health education when delivered for a small group, as evidenced by the overall peer feedback. This model can be tested for larger cohorts in the future.

Surgical site infections (SSIs) are a universally dreaded complication of any surgical procedure. The goal of this single-center study was to examine the issue of orthopaedic instrument wrapping defects with a focus on the importance of a high level of surveillance to enable identification of these defects in order to reduce the risk of instrument contamination. We also evaluated the impact on patient care, theatre staff, hospital finances and resource utilization during a defined study period in order to stimulate critical discussion and further research into potentially eliminating this problem via change in practice and advances in technology. To the best of our knowledge, this will be the first paper that looks at this problem from the above perspective within the United Kingdom National Health Service. We conducted a prospective service evaluation project over a 30-week period from December 2021 to July 2022 across our three hospital sites within the United Kingdom National Health Service. We collated data on defects found in orthopaedic instrument wrappings as detected by visual inspection under ambient or theater lighting and the resulting surgical case cancellations. Defect types included in the study were all puncture holes, abrasions or tears visible to the naked eye irrespective of their size. A total of 601 orthopaedic sets were rejected during the study period due to defects identified in the sterile instrument wrappings. Of these, 437 were due to holes/tears in the wrapping, 129 were due to wet inner wrappings and 35 were due to insecure wrappings. This directly resulted in same-day cancellation of 13 surgical cases or 0.27% of booked cases with extra sets required for the other affected cases. These 13 cases could not proceed as they involved loan kits where no remedial action could be taken. Remedial action was required for the other 588 operation list cases affected by the sterile wrapping defects. The majority of the identified defects and resulting theatre case cancellations (61.5%) were in hip and knee arthroplasty surgery. The calculated potential financial loss due to these problems was £145,000 over the seven-month study period. This financial cost is equivalent to the best practice top-up tariff in England for treating approximately 108 hip fracture patients based on £1,335 per patient. Our study identified defects in the sterile instrument wrappings affecting both the inner with or without involving the outer wrapping layer and resulting in cancellation of elective and trauma orthopaedic cases with resultant clinical and financial implications. There is a need to be more vigilant in identifying defects in drapes. Further research is warranted to improve ways of identifying defects in sterile wrappings and devise new protective mechanisms during sterilisation that can eliminate the use of sterile instrument wrappings.

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.