12 GPs were invited to take part in a study in which the GPs would undertake training in out-patient techniques, to determine suitability of patients for arthroscopic surgery. The GPs would undertake to counsel the patients regarding the procedure itself and the post operative rehabilitation. They were then referred by means of a set referral form which included specific guidelines which allowed patients to be put directly onto the consultant’s waiting list. The patients would then be sent for surgery directly and be seen immediately pre-operatively by the operating consultant and consented. This group of direct access arthroscopy patients (36) were compared to a contemporaneous consecutive series of patients who had been referred in the normal manner and were undergoing operation at the time of the study period (October 1998 to April 2000.

In the group of patient submitted for direct access arthroscopy three patients had improved such that when they were offered admission dates they declined. A further three patients were deemed unsuitable for direct access arthroscopy and the referral was rejected by the consultant. Two patients declined three separate admission dates and were discharged, and a final patient did not attend his admission date. This left 27 patients who were admitted for direct access arthroscopy service. Of these, one patient was cancelled pre-operatively by the consultant as she had recently been admitted for investigation of cardiac abnormalities procedure and was therefore considered unfit for day case general anaesthetic procedure. Of the 26 patients who underwent arthroscopy all were discharged home the same day, and reviewed in the out-patient clinic at six weeks, and they were asked to complete a Patient Satisfaction Questionnaire, and were discharged from further review at that time.

When compared to a contemporaneous group of patients who had undergone arthroscopic surgery via the routine referral procedure, the group of patients admitted via the direct access route waited on average ten weeks (range 6 – 12) from GP consultation and referral to operation date. This compared to 41 week for the combined total out-patient and in-patient waiting times for the routine access group (range 18 – 132 weeks). Findings at arthroscopy were similar in the two groups with mostly meniscal lesions (18/26 direct access group compared to 15/26 routine access group). The therapeutic operation rate, i.e. procedures beyond simple diagnostic arthroscopy were undertaken, was high in both groups, 68% of the direct access group and 72% of the routine access group. Pre-operative diagnosis accuracy by the GPs was significantly higher in the direct access group of referrals. 65% of direct access referrals had the correct diagnosis made by the GP in the referral compared to 18% of correct diagnosis in the group undergoing routine referrals. Post operative recovery in terms of return to work , return to activities of daily living and discharge from clinic was the same in the two groups. Patient satisfaction was comparable in both groups.

In conclusion direct access arthroscopy reduces significantly the time the surgery and the number of visits by patients to primary or secondary care physicians. GP diagnostic rates were comparable to previously reported figures for registrar/middle grade pre-operative diagnostic rates for patients undergoing knee artrhoscopy. There was a high therapeutic operation rate suggesting few, if any inappropriate procedures were undertaken. The direct access arthroscopy service requires considerable time on the part of the consultant in both setting up the study and training the GPs to a reasonable standard and monitoring referrals and undertaking pre-operative screening of patients awaiting arthroscopy. There was a high inappropriate referral rate in that only 26 patients out of the 36 referred eventually underwent arthroscopic surgery. Although feasible we feel that direct access knee arthroscopy service needs refinement if it is to continue. We intend to introduce an orthopaedic practitioner who will accept referrals from GPs and then screen patients before placing patients on the consultant’s inpatient waiting list. Also the mechanism of extra lists needs to be put in place to ensure direct access patients do not “jump the queue” of patients who are already awaiting arthroscopic surgery.

The gamma interlocking nail, designed combining the advantages of the sliding hip screw with the intramedullary nail, was initially introduced for the management of unstable proximal femoral fractures. However the unacceptably high incidence of lateral femoral shaft fractures led to the development of the long gamma nail.

This is the result of a prospective study of the use of the long gamma nail in 35 patients over a 7 year period till March 2000. The mean age of the patients was 69.9 years. There were 13 men and 22 women. All but two of the fractures had a subtrochanteric component. Ten were pathological fractures.

An identical size of nail was used in all cases. Elderly patients were permitted to mobilise without restriction, whereas partial weight bearing was imposed on the younger patients till some signs of radiological healing. Patients were reviewed at a hip fracture clinic. Mean clinical follow up was 381 days and radiological follow up was 244 days. Mean hospital stay 22 days. The post operative mortality at 30 days was 20%, rising to 45% at one year.

General complications that occurred were pneumonia – 3, fat embolism – 1, myocardial infarction – 1, and GI bleed – 1. Four cases had superficial wound infection, which resolved with oral antibiotics. Fracture related complications occurred in 4 cases. These were intra-operative femoral shaft fracture – 1, fracture at tip of nail – 1, nail breakage – 2. All went on to heal after exchange nailing.

The long gamma nail does not appear to have reduce the post-operative incidence of femoral fractures, which is most likely related to the large size of the distal locking screws and stress concentration at the tip of the nail. The two cases of nail breakage appear to reflect metal fatigue failure in the setting of delayed union in younger patients.

12 General Practitioners (GP’s) were invited to take part in a study in which the GPs would undertake training in outpatient techniques, to determine suitability of patients for arthroscopic surgery. The GPs would undertake to counsel the patients regarding the procedure itself and the postoperative rehabilitation. They were then referred by means of a set referral form, which included specific guidelines, which allowed patients to be put directly onto the consultant’s waiting list. The patients would then be sent for surgery directly and be seen immediately pre-operatively by the operating consultant and consented. This group of direct access arthroscopy patients (36) were compared to a contemporaneous consecutive series of patients who had been referred in the normal manner and were undergoing operation at the time of the study period (October 1998 to April 2000.

In the group of patient submitted for direct access arthroscopy three patients had improved such that when they were offered admission dates they declined. A further three patients were deemed unsuitable for direct access arthroscopy and the referral was rejected by the consultant. Two patients declined three separate admission dates and were discharged, and a final patient did not attend his admission date. This left 27 patients who were admitted for direct access arthroscopy service. Of these, one patient was cancelled pre-operatively by the consultant as she had recently been admitted for investigation of cardiac abnormalities and was therefore considered unfit for day case general anaesthetic procedure. Of the 26 patients who underwent arthroscopy all were discharged home the same day, and reviewed in the out-patient clinic at six weeks, and they were asked to complete a Patient Satisfaction Questionnaire, and were discharged from further review at that time.

When compared to a contemporaneous group of patients who had undergone arthroscopic surgery via the routine referral procedure, the group of patients admitted via the direct access route waited on average ten weeks (range 6 – 12) from GP consultation and referral to operation date. This compared to 41 weeks for the combined total outpatient and in-patient waiting times for the routine access group (range 18 – 132 weeks). Findings at arthroscopy were similar in the two groups with mostly meniscal lesions (18/26 direct access group compared to 15/26 routine access group). The therapeutic operation rate, i.e. procedures beyond simple diagnostic arthroscopy were undertaken, was high in both groups, 68% of the direct access group and 72% of the routine access group. Pre-operative diagnosis accuracy by the GPs was significantly higher in the direct access group of referrals. 65% of direct access referrals had the correct diagnosis made by the GP in the referral compared to 18% of correct diagnosis in the group undergoing routine referral. Post operative recovery in terms of return to work, return to activities of daily living and discharge from clinic was the same in the two groups. Patient satisfaction was comparable in both groups.

In conclusion direct access arthroscopy reduces significantly the time to surgery and the number of visits by patients to primary or secondary care physicians. GP diagnostic rates were comparable to previously reported figures for registrar/middle grade pre-operative diagnostic rates for patients undergoing knee arthroscopy. There was a high therapeutic operation rate suggesting few, if any inappropriate procedures were undertaken. The direct access arthroscopy service requires considerable time on the part of the consultant in both setting up the study and training the GPs to a reasonable standard and monitoring referrals and undertaking pre-operative screening of patients awaiting arthroscopy. There was a high inappropriate referral rate in that only 26 patients out of the 36 referred eventually underwent arthroscopic surgery. Although feasible we feel that direct access knee arthroscopy service needs refinement if it is to continue. We intend to introduce an orthopaedic practitioner who will accept referrals from GPs and then screen patients before placing patients on the consultant’s inpatient waiting list. Also the mechanism of extra lists needs to be put in place to ensure direct access patients do not “jump the queue” of patients who are already awaiting arthroscopic surgery.