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The introduction of the modern total knee replacement has been revolutionary in treatment of degenerative joint disease. Over recent years there has been a significant increase in the number of primary replacements and revision procedures. Prosthetic joint infection is an important and devastating complication which has not been eliminated by modern day practice. Patient selection, operating environment, surgical technique and soft tissue management can reduce but not eliminate the incidence of infection. When infection occurs, it should be managed as part of a multidisciplinary team to ensure an optimal outcome. Revision for infection can be performed as a single-stage or two-stage procedure. When revision surgery fails, salvage options should be considered including: salvage arthroplasty, arthrodesis, resection arthroplasty and amputation. The challenges for the surgeon to overcome include: a poor soft tissue envelope, ligamentous or extensor mechanism disruption and bone loss. Complications are not uncommon with salvage options and therefore meticulous preoperative planning and a thorough consent process are mandatory. The management of patients with an infected implant should performed by consultants who have specialized expertise and who work in networks. This is necessary to achieve the best results. This article will also discuss the salvage options.

Objective: The objective of this study was to assess the ability of the American College of Surgeons (ACS) NSQIP surgical risk calculator to accurately identify patients at increased risk of perioperative complication following surgery for gynaecological malignancy. Methods: A retrospective review of 142 patients who underwent major surgery under the gynae-oncology team between 06/08/2018-16/04/2019 at the University Hospital of Wales. Pre-operative factors combined with a procedure-specific code generated the predicted risk of 13 post-operative complications for each patient. Brier scores assessed calibration and receiver operated curves (AUC) evaluated the discriminative power of NSQIP. Results: Complications were experienced by 50/142 (35.2%) patients. The calculator displayed adequate calibration when used to predict serious complications (Brier = 0.070), readmission (Brier = 0.058), return to OR (Brier = 0.000) and UTI (Brier = 0.001). It had the greatest discriminative power when predicting the risk of serious complications (AUC = 0.672; 95% CI, 0.481-0.863). The calculator successfully identified a majority of patients who had a complication as being of ‘above average risk’ for all complications, apart from return to OR, based on their pre-operative factors. Discussion: NSQIP has previously been demonstrated to be a useful pre-operative tool for evaluating the risk of post-operative complications in colorectal surgery. This study suggests that in the setting of gynaeoncology surgery the calculator does not have adequate discriminative power to be an absolute predictor of all complications, however, it may be useful in identifying patients who are likely to develop serious complications and those at above average risk of complications.

Introduction/Background The objective of this study was to examine the clinical utility of the American College of Surgeons (ACS) surgical risk calculator, developed as part of the National Surgical Quality Improvement Programme (NSQIP), in predicting perioperative morbidity in gynae-oncology patients, primarily, as a prediction model and secondly, as a tool to identify patients who are at increased risk of developing complications. Methodology A retrospective review of 142 patients who underwent major surgery under the gynae-oncology team between 06/08/2018–16/04/2019 at the University Hospital of Wales. Pre-operative factors combined with a procedure-specific code generated the predicted risk of 13 post-operative complications for each patient. Brier scores assessed calibration and receiver operated curves (AUC) evaluated the discriminative power of NSQIP. Results Complications were experienced by 35.2% (50/142) patients. The calculator displayed adequate calibration when used to predict serious complications (Brier = 0.070), readmission (Brier = 0.058), return to OR (Brier = 0.000) and UTI (Brier = 0.001). It had the greatest discriminative power when predicting the risk of serious complications (AUC = 0.672; 95% CI, 0.481–0.863). The calculator successfully identified a majority of patients who had a complication as being of ‘above average risk’ for all complications, apart from return to OR, based on their pre-operative factors. Conclusion NSQIP has previously been demonstrated to be a useful pre-operative tool for evaluating the risk of post-operative complications in colorectal surgery. This study suggests that in the setting of gynae-oncology surgery the calculator does not have adequate discriminative power to be an absolute predictor of all complications, however, it may be useful in identifying patients who are likely to develop serious complications and those at above average risk of complications. Disclosures Ines Murray – I can confirm that I have no conflict of interest with reference to this work. Kenneth Lim – I can confirm that I have no conflict of interest with reference to this work. Robert Howells – I can confirm that I have no conflict of interest with reference to this work. Rhidian Jones – I can confirm that I have no conflict of interest with reference to this work. Aarti Sharma – I can confirm that I have no conflict of interest with reference to this work. Sadie Jones - I can confirm that I have no conflict of interest with reference to this work.

Background: We aimed to identify the prevalence of acute hypoxaemic respiratory failure (AHRF) in the intensive care unit (ICU) and its associated mortality. The secondary aim was to describe ventilatory management as well as the use of rescue therapies. Methods: Multi-centre prospective study in nine hospitals in Wales, UK, over 2-month periods. All patients admitted to an ICU were screened for AHRF and followed-up until discharge from the ICU. Data were collected from patient charts on patient demographics, clinical characteristics, management and outcomes. Results: Out of 2215 critical care admissions, 886 patients received mechanical ventilation. A total of 197 patients met inclusion criteria and were recruited. Seventy (35.5%) were non-survivors. Non-survivors were significantly older, had higher SOFA scores and received more vasopressor support than survivors. Twenty-five (12.7%) patients who fulfilled the Berlin definition of acute respiratory distress syndrome (ARDS) during the ICU stay without impact on overall survival. Rescue therapies were rarely used. Analysis of ventilation showed that median Vt was 7.1 mL/kg PBW (IQR 5.9–9.1) and 21.3% of patients had optimal ventilation during their ICU stay. Conclusions: One in four mechanically ventilated patients have AHRF. Despite advances of care and better, but not optimal, utilisation of low tidal volume ventilation, mortality remains high.

There will always be the need to give GA to pregnant womrn, and it is paramount that the obstetric anaesthetist is well prepared to perform a GA quickly and safely. This chapter reviews the current evidence, drugs, and conduct of GA for CS, with emphasis on exemplary communication within the delivery suite team and meticulous airway assessment to identify features suggestive of additional anticipated difficulty. A helpful ‘pre-induction’ checklist illustrates the need for team-based communication in preparation and planning to mitigate against complications following induction. The latest guidelines from the Obstetric Anaesthetists' Association and Difficult Airway Society on the management of failed intubation and ventilation have been included. The chapter also includes up-to-date information on accidental awareness in obstetric surgery from NAP4, and the steps to avoid and manage aspiration if it occurs.

Pre-eclampsia is a common problem in pregnancy which can present at any time to any delivery suite. This article summarizes current best practice to enable the multidisciplinary team to deliver appropriate timely management to achieve best outcomes for both mother and baby.

INTRODUCTION There is no standardised treatment for fifth metacarpal neck fractures. Treatment of this common fracture can vary from immediate mobilisation to immobilisation in a plaster cast for 3 weeks. There is no literature identifying current practice amongst surgeons. SUBJECTS AND METHODS This survey's aim was to reveal current practice in Wales by means of a postal questionnaire sent to all Welsh orthopaedic consultants. RESULTS The questionnaire had a 60% response rate. Results demonstrated varied opinion regarding the degree of displacement warranting reduction. Overall, 10% of surgeons reduce the fracture at 30° of displacement, 29% at 40°, 18% at 50° and 20% at 60° of displacement. The treatment was also very varied. Most surgeons preferred to treat these fractures with neighbour strapping (43%,) while others preferred plaster immobilisation (39%) or immediate mobilisation (10%.) Only 22% of surgeons discharge these patients back to the community after their first visit to out-patients while 13% offer two follow-up appointments. CONCLUSIONS The treatment being offered for this common fracture in Wales is inconsistent. There is a need to develop evidence- based best practice guidelines which should standardise the treatment of this common injury. Perhaps, a large multicentre outcome study may enable this to be drawn up in the future.

Background Transient transaminitis has been identified following laparoscopic abdominal surgery. However, the importance of posture, duration of surgery, and mechanical retraction in its etiology remain unclear. Methods Liver function was assessed preoperatively then at 8, 24, 48 and 72 h following laparoscopic surgery including the following procedures: Nissen fundoplication (LN: n = 10); cholecystectomy (LC: n = 10); inguinal herniorrhaphy (LH: n = 10); and gastrectomy (LG: n = 5). Results Aspartate aminotransferase (AST) levels in LN patients exhibited a rapid rise within 8 h, peaking at 48 h before returning toward baseline. In the LN group, AST levels were significantly higher at 8 h and 24 hours compared to all other groups and compared to LG at 48 h and 72 h. At 6-week follow-up all AST levels were normal. No significant differences were seen in other hepatic parameters, and no correlation between AST and duration of operation, gender, or age was identified. Conclusions Antireflux surgery is associated with transaminitis related to hepatic retraction, which is independent of patient posture or duration of observation, and it resolves spontaneously with no clinical consequences.