Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Purpose: Clinicians do not currently have a simple means of identifying patients at risk for developing incident and persisting knee symptoms in osteoarthritis (OA). We examined whether a clinically detected knee effusion predicts this. Methods: Data were extracted from the Osteoarthritis Initiative. All participants (n ¼ 4646) and the subgroup with baseline ROA (n ¼ 2249) were analysed. A bulge sign was assessed at baseline, 24 and 48 months, while a synovial fluid aspirate was performed at baseline to validate the clinical measure. Knee symptoms were assessed at baseline, 12, 24, 36, 48 and 60 months using the Western Ontario and McMaster Universities Osteoarthritis Index. Results: A clinically detected knee effusion was observed in 21.1% of people with, and 10.7% of people without, ROA. Participants with a clinically detected knee effusion had greater synovial fluid volume aspirated than those without (12.5 ml versus 6.7 ml, p < 0.001). In the total population, the presence of a clinically detected knee effusion was associated with more severe WOMAC scores (B range 0.34e2.98, 95% CI range 0.21e4.15) cross-sectionally and at each 12 month follow-up (OR range 1.22e1.34, 95% CI 1.07e1.53, all p 0.002). The presence of a clinically detected knee effusion at baseline was associated with incident pain (OR 1.61, 95% CI 1.26e2.05, p < 0.001) and poor function (OR 1.44, 95% CI 1.09e1.91, p ¼ 0.01), as well as persisting knee pain, stiffness and poor function (OR range 1.30e1.41, 95% CI 1.11e1.66, all p 0.002). Similar results were observed when those with and without ROA were examined separately. Conclusions: This is the first study to demonstrate that a clinically detected knee effusion is associated with incident and persisting knee pain. These data provide clinicians a simple method for identifying patients with knee OA most likely to develop, or have persistent pain, and who should be targeted in order to modify knee symptoms.

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SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

Understanding the patellofemoral joint in total knee arthroplasty P atellofemoral complications historically have contributed up to 50% of revision surgery. 1 With modern design refinements and improved techniques, the burden of revision from patellofemoral complications is less than it was previously; however, these complications remain some of the most challenging problems in knee arthroplasty. Complications involving the patellofemoral joint (PFJ) can occur with both resurfaced and nonresurfaced patellae. In resurfaced patellae, complications include patellar maltracking, fracture, avascular necrosis, clunk and anterior knee pain. In knees with nonresurfaced patellae, some of the same complications can take place, such as maltracking, clunk,