Background Changes in professional boundaries have allowed many of the tasks traditionally undertaken by doctors to be delegated to Nurses and Allied Health professionals. The employment of an appropriately experienced specialist physiotherapist in orthopaedic clinics in the NHS to triage patients is well established. This paper examines the background, establishment and outcomes of the use of a Physiotherapist Extended Scope Practitioner (ESP) in the Orthopaedic Department at the Royal Hospital Haslar, Gosport.

Method The post at RH Haslar has evolved in the five years since its implementation. All military patients referred to RH Haslar Orthopaedic Department with spinal, predominantly low back, pain are assessed in the Military Spinal Triage Clinic. The Physiotherapist ESP case-manages patients with access to radiological and haematological investigations and onward referral to other specialities as appropriate.

Results In eighteen months 235 new patients have been assessed. Only 25 patients required review by the consultant spinal surgeon, while 5 were referred to non-spinal orthopaedic consultants with shoulder/hip pathology. A total of 18 patients were referred to Pain Clinic and 3 patients to rheumatology.

The results indicate that nearly 90% (n=210) of patients who would previously been reviewed by a consultant spinal surgeon could be managed by a Physiotherapist ESP. The waiting time to spinal surgery has reduced from approximately 8 months to between 6 and 16 weeks.

Conclusions It is concluded that an appropriately trained specialist physiotherapist is clinically and economically appropriate to manage patients in an Orthopaedic Department. This has important implications for optimising patient management and additionally supports the wider clinical employment of senior military physiotherapists.

Abstract. Introduction. There is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR. Methodology. REST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery. Results. 57 patients were randomised and 20 had surgery within the study timelines. All patients allocated the intervention attended an appointment and most engaged with treatment. The intervention group reported improvements in sleep (Sleep Conditions Indicator) and neuropathic pain (painDETECT) scores. Participants found the sleep treatments and study processes to be acceptable. The mean cost of the intervention was estimated at £134.45 per patient. Conclusion. The feasibility study has shown that patient recruitment is feasible, engagement with and adherence to the intervention is high, and the intervention is acceptable to patients and clinicians. Preliminary findings show that the intervention group had improved sleep quality and had reduced levels of pre-operative neuropathic pain. This study has demonstrated that a full RCT is feasible and identified areas for improvement to optimize the trial design

This study reports on the follow-up of Total Knee Arthroplasty patients in secondary care, by a physiotherapist working in an extended scope practitioner role, as a member of the orthopaedic team, and who had undertaken a negotiated work based learning module (NWBL) to develop practice skills in image interpretation at the School of Health Sciences, University of Liverpool. Following successful completion of the NWBL by the physiotherapist an audit was undertaken of the patients seen in a total knee arthroplasty review clinic during a twelve month period. The patients were reviewed at one, three, five or seven years post-operatively on the behalf of two orthopaedic consultants specialising in total knee joint replacement (TKR). A total of 508 TKR’s were reviewed in 438 patients. Of these 37 (7%) were booked for further review by the consultants; 24 (4.7%) regarding management of their TKR, 7 (1.5%) regarding management of their contra-lateral knee and 9 (2%) regarding management of another joint. Radiographs of a further 34(6.7%) patients were discussed with the consultants (usually within a week) but did not require a review appointment by them. The number of cases who had radiographs discussed with the consultants, but who did not require a further review appointment, suggests that the practitioner erred on the side of caution in image interpretation. The results suggest a physiotherapist working in an extended scope practitioner role can carry out yearly follow-up of TKR patients, provided the appropriate practice skills have been developed, thereby reducing the congestion in busy follow-up clinics and allowing the surgeons to concentrate on more complex cases. Practitioners working in such roles should be members of the orthopaedic team with regular communication with the orthopaedic surgeons

Around 20% of patients who have total knee replacement find that they experience long-term pain afterwards. There is a pressing need for better treatment and management for patients who have this kind of pain but there is little evidence about how to improve care. To address this gap we are developing a complex intervention comprising a clinic to assess potential causes of a patient's long-term pain after knee replacement and onwards referral to appropriate, existing services. The Medical Research Council recommends that development of complex interventions include several stages of development and refinement and involvement of stakeholders. This study comprises the penultimate stage in the comprehensive development of this intervention. Earlier stages included a survey of current practice, focus groups with healthcare professionals, a systematic review of the literature and expert deliberation. Healthcare professionals from diverse clinical backgrounds with experience of caring for patients with long-term pain after knee replacement were sent a study information pack. Professionals who wished to participate were asked to return their signed consent form and completed study questionnaire to the research team. Participants rated the appropriateness of different aspects of the assessment process and care pathway from 1–9 (not appropriate to very appropriate). Data were collated and a document prepared, consisting of anonymised mean appropriateness ratings and summaries of free-text comments. This document was then discussed in 4 facilitated meetings with healthcare professional held at the future trial centres. A summary report and revised care pathway was then prepared and sent to participants for further comments. 28 professionals completed the questionnaire and/or attended a meeting. Participants included surgeons, physiotherapists, nurses, pain specialists and rheumatologists. Mean appropriateness scores ranged from 6.9 to 8.4. Taking a score of 7–9 as agreement, consensus was achieved that the assessment should be performed at 3 months post-operative by an extended scope practitioner/nurse, treatment be guided by a standardised assessment of pain, and treatment individualised. There was also agreement that referrals in the care pathway to surgical review, GP and pain clinics were appropriate. Nurse-led/self-monitoring was rated lower (6.9) because of considerations about the need to ensure that patients receive appropriate support, follow-up and referral to other services. This work demonstrates the research methods that can be used to refine the design of a complex intervention. The process and findings enable refinement of an intervention for patients with long-term pain after knee replacement. The next stage of intervention development will assess the acceptability and reliability of the assessment process, and the usability of the intervention's standard operating procedures. The intervention will then be evaluated by a larger research team in a multi-centre randomised controlled trial, starting in late 2016

Introduction: Hip arthroplasty represents a large consumer of resources in orthopaedic surgery. Although the need for follow up is universally accepted, there is much debate on the duration and frequency of outpatient visits. To date there is no evidence regarding the cost effectiveness of follow up. There are no NICE guidelines for hip arthroplasty follow up. 90% of hip arthroplasty failures do so after 5 years. Joint replacement review is performed by a variety of personnel including orthopaedic surgeons, surgical care practitioners (SCPs) and extended scope practitioners (ESPs). Patients are reviewed in an outpatient clinic or by questionnaire. Methods: A questionnaire was sent out to orthopaedic surgeons working in the Sandwell and West Birmingham Hospitals Trust enquiring about their practice for following up patients who have had hip replacements. Information regarding the length of follow up, frequency of visits and the use of check radiographs was recorded. Results: The mean length of follow up was 28.8 months. (12–60 months). The mean number of visits in the first year was 3.9. (3–4). The mean number of total visits was 6. (4–9). The mean number of check radiographs performed in the first year was 2. Mean total number of check radiographs performed was 4. The mean cost for each patient is 590 pounds. (224–896 pounds). Discussion: There is considerable variation in hip arthroplasty follow up with ensuing cost implications. Guidance is required for the appropriate review, which will allow early detection of complications in an efficient and cost effective manner. In our trust a protocol has been suggested for the follow up of hip arthroplasty by ESPs and SCPs

Around 1% of the 185,000 primary hip and knee arthroplasties performed in the UK are followed by prosthetic joint infection (PJI). Although PJI affects a small percentage of patients, it is one of the most devastating complications associated with this procedure. Treatment usually involves further major surgery which can adversely affect patients' quality of life. Understanding current service provision provides valuable information needed to design and evaluate support interventions for patients. The aim of this survey was to identify usual care pathways and support in UK NHS orthopaedic centres for this population. The 20 highestvolume UK NHS orthopaedic centresfor hip and knee arthroplasty account for 33–50% of all cases treated for prosthetic joint infection. Infection leads at each centre were invited to participate in a survey about usual care provision and support for PJI. Questions exploredfollow up time-points; use of standard outcome measures; multidisciplinary care plans; supportive in-patient care and care after treatment; and onward referrals. Survey responses were recorded on a standardised proforma. Data were entered into Excel for analysis, then reviewed and coded into categories and frequency statistics to describe categorical data. A descriptive summary was developed based on these categories. Eleven of the highestvolume orthopaedic centres completed the survey. Follow-up of patients varied greatly across centres; some centres reviewed patients at weekly or 2 week intervals, while all centres saw patients at 6 weeks. Long-term follow-up varied across centres from 3–4 monthsto 12 monthly. Length of follow-up period varied from until the infection had cleared toindefinitely. Follow-up timepoints were only standardised in 4 out of 11 centres. Only 1 centre had a dedicated infection clinic. Advice on who patients should contact if they had concerns included the consultant, community nurse, extended scope practitioner or the ward, while 3 centres told patients to avoid calling their GP. Only half of the centres routinely used standardised outcome measures with patients with PJI. The majority of centres provided standard physiotherapy and occupational therapy (OT) to in-patients while approximately half also offered social support. Only one centre provided dedicated physiotherapy and OT on a separate infection ward. Three centres provided hospital at home or community services to patients in-between operative stages. Only 3 out of 11 centres stated they had specific multidisciplinary care plans in place for patients. Once discharged most patients were provided with physiotherapy, OT and social services if needed. Common barriersto referral included complexities of referring patients outside the hospital catchment area;lack of availability of community services, and shortage of staff including physiotherapists. Delays in rehab and social services could also be problematic. Findings show wide variation intreatment pathways and support for patients treated for PJI, both as inpatients and in the community. Only one of the 11 centreswho participated had a dedicated infection clinic. Only one centre suggested they individualised their physiotherapy support. A number of barriers exist to referring patients on to other support services after revision surgery

Aim: To evaluate patient satisfaction and the effectiveness of a telephone clinic designed to follow up patients who have received shoulder or elbow surgery. Method: Following wound checks in the community, patients are followed up in our department at six weeks, then three and six months respectively to assess level of progress and answer any questions patients may have. As outcome measures are already assessed by physiotherapists, a telephone clinic was devised to make better use of Consultant time. Patients were contacted by telephone at a pre-determined time by an extended scope practitioner physiotherapist who used a set of standard questions to obtain information about the patients’ progress. An opportunity was then given to the patients to discuss any issues they may have with regards to their treatment so far. Urgent hospital follow – up was arranged for patients requiring it depending on their level of progress and problems identified. Patients’ satisfaction and opinions with regards to the use of the telephone as a method of post-operative follow -up were ascertained by an independent researcher. Results: 50 patients were contacted over a 12-week period. Patients were satisfied by the level of information they were provided with and their subsequent management as a result of the telephone clinic. Patients particularly commented on the advantages of getting information at home with the avoidance of problems associated with attending for a hospital appointment. Three patients were given an urgent follow-up appointment as a result of the information gleaned during the telephone clinic. These included a patient with a stitch abscess and two with adhesive capsulitis. Conclusion: Telephone clinic follow up is an effective and safe method for monitoring patient progress post – operatively following shoulder or elbow surgery. It is well received by patients who save the time and effort associated with attending for a hospital consultation that often only lasts a few minutes. In the subject group identified the method of questioning was sufficiently sensitive to identify problems that required further management