Background:

Lower limb reconstruction is performed in trauma centres where uplifted tariffs support the treatment of severely injured patients. Calculation of Healthcare Resource Groups (HRG4) codes is affected by the accuracy of clinical coding, determining the financial viability of this service in a district general hospital (DGH).

In this review, we present the data of one of the largest non-designer, mid- to long-term follow ups of the AGC.

We present a total of 1538 AGC knees during a 15 year period, of which 902 were followed up by postal or telephone questionnaire focused on Oxford Knee Scores, Visual analogues of function and pain and survival analyses performed. Mean length of follow up was 10.4 years.

85.7% of patients had an Oxford knee score of between 0 and 40, with 71.2% scoring between 0–30.

65.6% of patients responded with a Visual Analogue Score (VAS) of 0 or 1 at rest (minimum pain 0) and 53.9% reporting VA scores of 0 or 1 while walking.

87.5% of patients reported Excellent or good functional reports at final follow up and 90.3% reporting excellent or good pain control compared to per-operative levels.

Survival analysis confirms excellent survivorship.

This large cohort and multi-surgeon trial reproduces the excellent results as demonstrated by the designer centre (Ritter et al.). Mid to long term outcome sows excellent function and analgesia. Complication rates are low and the necessity for revision remains low.

Aim: To assess the impact of a proforma pathway on the care of patients following fractured neck of femur at Maidstone General Hospital compared to the gold standard set out in the British Orthopaedic Association and British Geriatric Society Blue Book – The Care of Patients with a Fragility Fracture.

Objectives: Initial audit of care prior to the introduction of the Proforma

Development of a multidisciplinary care pathway and proforma following BOA Standards for Trauma (BOAST) and National Hip Fracture Database (NHFD) guidelines

Background: The recent publication of the BOA and BGS Blue Book guidelines for care of patients with fragility fractures has defined a gold standard for the care of these patients. This has highlighted the areas of care that are commonly suboptimal and defined the requirements of a department providing ideal care. Both this, and the introduction of the NHFD and the resultant requirements for data collection and monitoring led us to develop a proforma for management and data collection.

Methods: An initial audit of care was performed. Notes were reviewed retrospectively for 62 patients and results were compared to the gold standard.

In June 2008 the proforma was implemented and data collected for reaudit (n=48). Direct comparison and statistical analysis was performed for the two groups of patients

Results: Comparison of the two audit groups shows dramatic and highly statistically significant differences in a number of areas of patient care, notably: mortality rates; appropriate A& E investigation and treatment; documentation of correct diagnosis and social history; mental test scoring; time to ward admission; time to surgery and osteoporosis treatment.

Discussion: The lack of a ring fenced, dedicated trauma ward leads to patients being admitted to outlying wards following fractured neck of femur. These wards are less likely to be as well equipped to deal with the unique requirements of these patients, which may explain the consistent problems with pressure area care and delay in discharge.

A strong recommendation for gold standard care is the provision of an orthogeriatric service with regular medical review both pre- and post-operatively. Currently no such dedicated service exists at Maidstone and this affects both the treatment of acute medical problems and the provision of falls investigation and treatment.

The introduction of the pathway has clearly benefitted the management of this difficult problem. With the support of the Rapid Improvement Program, further beneficial changes can be made to the care of patients following fractured NOF.