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With the increasing life expectancy, a greater number of elderly patients are being referred to an orthopaedic department to have elective total knee arthroplasty (TKA). Total knee arthroplasty should be considered in the very elderly only after carefully balancing the benefits of surgery against the risks of surgery. The aim of this study was to analyse the mortality, morbidity and cost benefits of elective TKA in a cohort group of the nonagenarian population. Between 1990 and 2006, 42 patients ≥90 years of age had TKA surgery. Patient's notes were retrospectively analysed. A cost-benefit analysis was carried out by comparing the surgical costs against nursing home placement. The mean age at surgery was 90.4 years (range: 90-90.6). There was one major and 11 minor postoperative complications with no immediate or late postoperative deaths. The Knee Society Scores improved from 25 points (range: 8-44) to 81 points (range: 60-95), and the WOMAC Scores improved from 62 points (range: 54-73) to 41 points (range: 34-46) (p < 0.002). The calculated cost-benefit savings for 42 patients at 5 years after TKA was estimated to be £2,746,839. Total knee arthroplasty in the nonagenarian population is safe, beneficial and cost-effective.Résumé L'augmentation de la durée de vie fait qu'une population de plus en plus âgée présente les conditions pour bénéficier d'une prothèse totale du genou. La prothèse totale du genou doit être considérée dans cette population en comparant les bénéfices de la chirurgie et les risques de celle-ci. Le but de cette étude est d'analyser la mortalité, la morbidité, le rapport coût/bénéfice après prothèse totale du genou dans une cohorte de patients nonagénaires. Le rapport coût/bénéfice de ces 42 patients à 5 ans de l'utilisation de la prothèse a été estimé à 2.746.839£. La prothèse totale du genou dans une population de nonagénaire est une intervention sûre et qui permet un rapport coût/ bénéfice positif pour la société.

Aims The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway. Methods The probability of SARS-CoV-2 infection with a false negative test was calculated using a lower-end RT-PCR sensitivity of 71%, specificity of 95%, and the UK disease prevalence of 0.24% reported in May 2020. Subsequently, a case fatality rate of 20.5% was applied as a worst-case scenario. Results The probability of SARS-CoV-2 infection with a false negative preoperative test was 0.07% (around 1 in 1,400). The risk of a patient with an undetected infection being admitted for surgery and subsequently dying from the coronavirus disease 2019 (COVID-19) is estimated at approximately 1 in 7,000. However, if an estimate of the current global infection fatality rate (1.04%) is applied, the risk of death would be around 1 in 140,000, at most. This calculation does not take into account the risk of nosocomial infection. Conversely, it does not factor in that patients will also be clinically assessed and asked to self-isolate prior to surgery. Conclusion Our estimation suggests that the risk of patients being inadvertently admitted with an undetected SARS-CoV-2 infection for elective orthopaedic surgery is relatively low. Accordingly, the risk of death following elective orthopaedic surgery is low, even when applying the worst-case fatality rate.

Magnetic resonance imaging (MRI) is frequently used in the diagnosis of anterior cruciate ligament (ACL) and meniscal injuries. The aim of this retrospective study was to determine the reliability and value of MRI in our management of ACL and meniscal tears. 138 patients who had undergone a MRI to confirm or refute the clinical diagnosis of an ACL or meniscal tear were identified. Those who had subsequently undergone arthroscopy were selected. MRI findings and clinical diagnosis were compared with those at arthroscopy. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy of clinical diagnosis and MRI were then calculated. The overall accuracy for MRI was 91, 68 and 86% for detecting ACL, medial meniscal and lateral meniscal tears, respectively. Accuracy for clinical diagnosis was 90 and 64% for ACL and meniscal tears, respectively. In contrast to other series, our results indicate a lower accuracy of MRI in detecting pathology, especially of the ACL and medial meniscus. We noted a low sensitivity, specificity and positive predictive value but a high negative predictive value rendering MRI most useful as a negative diagnostic tool. We suggest that where symptoms and clinical findings support one of these diagnoses and arthroscopic therapeutic intervention is contemplated, that MRI scanning is not always beneficial. Our current practice of requesting scans to routinely confirm the diagnosis should be altered. Unnecessary MRI scanning increases the financial burden and delays patient treatment.

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The medical records of all children less than 1 year of age presenting to the Accident and Emergency Department over a 5-year period (1995-1999) with a fracture were retrospectively reviewed for possible abuse. Seventy-four children presented with fractures during the study period, with a mean age at presentation of 5 months (range 2 weeks to 1 year). Of these children, 46 had skull fractures and 28 had long bone fractures. Children were classified into one of seven categories: definite abuse, likely abuse, suspicious, likely accident, definite accident, neglect, or unknown cause. A three-tier system of grading for possible abuse was then used to analyze variance. The first tier consisted of the initial assessment by staff clinicians, the second retrospectively by an orthopaedic registrar, and the third retrospectively by a designated doctor in child protection (consultant pediatrician), all using the same information from the case notes. The use of the three-tier system of grading demonstrated a variance in the diagnosis of nonaccidental injury. The possibility of abuse was underestimated at the time of the original injury in over a quarter of cases (28.4%) when compared with the assessment by the consultant pediatrician. In 34 children (46%), there was no written documentation that nonaccidental injury was ever considered. While management depends on local guidelines and arrangements, the authors would advise that all children under 1 year of age with a fracture should be admitted to the hospital and referred to a pediatrician for child protection assessment.