Patient-reported outcome measures (PROMs) are increasingly being used to assess functional outcome and patient satisfaction. They provide a framework for comparisons between surgical units, and individual surgeons for benchmarking and financial remuneration. Better performance may bring the reward of more customers as patients and commissioners seek out high performers for their elective procedures. Using National Joint Registry (NJR) data linked to PROMs we identified 22,691 primary total knee replacements (TKRs) undertaken for osteoarthritis in England and Wales between August 2008 and February 2011, and identified the surgical factors that influenced the improvements in the Oxford knee score (OKS) and EuroQol-5D (EQ-5D) assessment using multiple regression analysis. After correction for patient factors the only surgical factors that influenced PROMs were implant brand and hospital type (both p < 0.001). However, the effects of surgical factors upon the PROMs were modest compared with patient factors. For both the OKS and the EQ-5D the most important factors influencing the improvement in PROMs were the corresponding pre-operative score and the patient's general health status. Despite having only a small effect on PROMs, this study has shown that both implant brand and hospital type do influence reported subjective functional scores following TKR. In the current climate of financial austerity, proposed performance-based remuneration and wider patient choice, it would seem unwise to ignore these effects and the influence of a range of additional patient factors.

Organizational learning of this simple procedure can be achieved through a multidisciplinary approach, and committed departmental education and feedback. The impact on length of stay and mortality were striking; however, there may be other confounding factors. Only two cases of true anaesthetic toxicity occurred in 1586 patients. The authors conclude that FICB is a safe procedure and a useful adjunct for preoperative pain control in patients with hip fractures.

The reason for the elevated pain scores and higher morphine requirement in the DHS group (DG) remains unclear. It could be related to highly sensitive periosteum reaction in the DG. It is important to recognize the difference in pain experienced between the groups, and analgesia should be tailored toward the individual based upon clinical assessment and knowledge of the surgery performed. A comprehensive understanding of this principle will allow for improved perioperative surgical care and patient experience.