Purpose of Study/Background. To identify whether patients were satisfied with the overall educational component of the specialist nurse (CNS)/occupational therapist (OT) led pre-operative assessment clinic in order to identify areas which required improvement. The pre-operative specialist nurse led clinic was set up in 2002. The aim was to provide high quality information to patients undergoing elective spinal surgery in order to manage expectations and optimise post-operative recovery. Initially the clinic was specialist nurse led however, in 2006 occupational therapy input was introduced in order to provide an increased depth of information in regard to function and activities of daily living post operatively. In addition this has allowed assistive equipment to be provided pre-operatively. The format of this clinic has enhanced the patient's journey by facilitating reduced length of stay and more timely discharge. Methodology. A questionnaire was forwarded to a random sample of two hundred patients who attended for pre-operative assessment in the twelve-month period between April 2014 & March 2015. Sixty questionnaires were returned (30% response rate). Results/Summary. Patients were asked 17 questions in total, 3 general, 6 regarding CNS and 8 regarding OT. The responses were rated ‘very good’; ‘good’ ‘average; ‘poor’. In the returned audits no ‘poor’ responses were recorded. Clarity of information given: Very Good-56%; Good-39%; Average-5%. Overall experience of pre-operative assessment: Very Good-66%; Good- 32%; Average-2%. Advice given by OT: Very Good-82%; Good-16%; Average-2%. Information given by CNS: Very Good-75%; Good-23%; Average-2%. Conclusions. The results indicate that the OT and CNS specialist education sessions are considered valuable by patients. We believe that we have achieved this through good team-working in a multidisciplinary setting. Patients who attend these clinics are often anxious regarding surgery, have un-realistic expectations in relation to what to expect post-operatively. A significant number of our patients are elderly and have multiple pathologies which we take into account. The education sessions link into our patient information leaflets which, expand on this allowing patients to clarify matters and ask questions. No Conflicts of Interest. No Funding Obtained

Consequent upon a retrospective audit of all acute tibial nail patients within GRI in 2010, it was agreed, due to variable follow-up, imaging and requirement for secondary intervention, a standardised protocol for management of acutely nailed tibial fractures within GRI was to be established. Subsequently, a Nurse Led Tibial Nail Clinic commenced in July 201. The majority of consultants (11 of 13) devolving follow up of these patients to a protocol based algorithm designed on evidence based principles and consensus expert opinion. Aims were to standardise/improve management of tibial nail patients in terms of patient education, weight bearing, imaging, follow-up intervals and also coordinate secondary intervention via a single consultant with an interest in limb reconstruction/non union. A secondary goal was to achieve measureable outcome data for this subgroup of patients. All patients underwent post operative radiographs prior to discharge, review in clinic at 10 days for wound assessment, 6 weeks for physiotherapy and 12 weeks where standard AP and lateral tibial radiographs were repeated. Patients are discharged at 12 weeks if the radiographs confirm bony healing on three cortices or more and fractures are clinically united. If not, repeat x rays are undertaken at 20 weeks. A parallel consultant led limb reconstruction clinic is available to review patients failing to demonstrate satisfactory progression to union with secondary intervention instigated thereafter as appropriate. Since commencement of the Nurse Led Tibial Nail Clinic, 60 patients have been treated with a tibial nail, 44 managed in the Tibial Nail Clinic. The mean number of radiographs has reduced from 6.4 to 3.1 per patient to discharge. Clinic visits are reduced from 6.4 to 3.9 per patient to discharge. Non compliance is low with 4.6% of patients failing to attend. Secondary interventions have been low (13%), confirming a relatively benign course of healing for most patients treated with an IM nail for acute tibial fractures. There has been one non union, no deep infections, two nail removals and one DVT. A protocol based specialist nurse led clinic is safe for patients, cost effective for the NHS and gives increased opportunity for measuring outcome and improving care in a previously heterogenously managed group of patients

In Northern Ireland the Health Visitor assessment at 6 months was demonstrated to be successful in detecting the majority of cases of DDH and was maintained, although moved to 4 months. There has been increased numbers of referrals resulting in prolonged waiting times for low risk infants. Methods. A retrospective review was performed of the records of all children treated for DDH in the three-year birth cohort from 2008 to 2010. Data was obtained by collating the records of the nurse led clinics, inpatient records and theatre logs from the three treating centres. Results. 584 children were treated, 87% female. Treatment rate was 7.7/1,000 live births (2003 = 5.2). Twenty-three cases were diagnosed later than 1 year of age, 0.3/1,000 (2003 = 0.6); 146 cases were diagnosed later than 6 months 1.9/1000 (2003=1.7) of these 62 required operative treatment, 0.8/1,000 (2003 =1.1). The median age at referral was 7 weeks and ranged from 0 to 119 weeks. The median delay to be seen was 29 days with a highly skewed distribution, which ranged from 0 to 39 weeks. We found if waiting times had been capped at 9 weeks, as has been the case for other orthopaedic conditions, 52 patients who were seen after 6 months would have been seen on average 140 days earlier. Conclusions. Maintaining the health visitor assessment has allowed us to continue to reduce the number of children diagnosed with DDH after the onset of walking. However, delays in the referral pathways have prevented us from improving earlier treatment rates for younger infants and have introduced an undue delay in the treatment of a cohort of low risk infants

This study reports the first 10-year clinical and radiological follow-up data for the Sigma PFC. The DuPuy Sigma total knee arthroplasty (TKA) is a modification of the well established Press Fit Condylar (PFC) TKA and is used extensively in the UK and worldwide. It is the most commonly used TKA in England and Wales, where it accounts for 34% of all primary TKA. A total of 235 consecutive Sigma TKAs were performed in 203 patients between October 1998 and October 1999, in our unit. Patients were seen at a specialist nurse led clinic 7 to 10 days before admission and at 6 months, 18 months, 3 years, 5 years and 7-10 years after surgery. Data was recorded prospectively at each clinic visit. Radiographs were obtained at the 5 year and 8-10 year follow-up appointment. Of 235 knees 171 (147 patients) were alive at 10 years. Twelve were lost to follow up. Nine knees (3.8%) were revised; five for infection and four underwent change of polyethylene insert. Ten-year survival with and end point of revision for any reason was 95.9%, and with and endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society score was 62 at 8-10 years compared with 31 out of 100 pre-operatively. Of 109 radiographs, 47 knees had radiolucent lines but none showed radiological evidence of loosening. Our results show that the PFC Sigma knee arthroplasty performs well over the first 10 years post implantation

Last minute cancellations of operations are a major waste of NHS resources. This study identifies the number of late cancellations at our elective orthopaedic centre, the reasons for them, the costs involved, and whether they are avoidable. Last minute cancellations of operations in a 7-month period from January to July 2009 were examined. 172 cases out of 3330 scheduled operations were cancelled at the last minute (5.2%). Significantly more cancellations occurred during the winter months due to seasonal illness. The commonest causes for cancellation in descending order of frequency were patient unfit/unwell (n=76, 44.2%), lack of theatre time (n=32, 18.6%), patient self cancelled/DNA (n=20, 11.6%), staff unavailable or sick (n=9, 5.2%), theatre or equipment problem (n=8, 4.7%), operation no longer required (n=8, 4.7%), administrative error (n=7, 4.1%) or no bed available (n=5, 2.9%). In 7 out of the 172 cancelled cases (4.1%) no cause was identified. 59.7% of the cases were potentially avoidable. 3.2% of Patients seen in the specialist pre-operative anaesthetic clinic (POAC) were cancelled at the last minute for being unfit or unwell, compared to 2.2% seen in the routine nurse led clinic. Last minute cancellations cost the hospital over £700,000 in 7 months

Introduction: We undertook an audit study to find out patient perception of being seen by a nurse practitioner in the clinic for a follow up appointment instead of a consultant and satisfaction with the joint clinic. Methods and materials: 100 patients were surveyed following their post-operation review with the nurse. Data was collected prospectively over a period of 6 months. Patients were asked to complete the questionnaire on the day of their appointment and to hand the survey prior to leaving. Hence we had 100% response rate. Results: Majority of the respondents were female (61%) with 50 % having had total hip replacements and the rest had knee replacements. 99% of respondents (94/95) felt that enough time was spent with them during the appointment. All respondents (100%) reported that they were able to ask questions and were answered satisfactorily. The consultant saw 26% of respondents; further 6% was seen by a registrar and the rest 68% were seen by the nurse specialist. Reasons for being seen by a doctor included check up or assessment, reviewing stitches and infection. 42% of respondents (33/79) were referred for further treatment either by the consultant (33%), nurse (64%) or registrar (3%). Reasons for further treatment included physiotherapy, plaster room, and further follow up (check up) appointment at 3–6 months to review the patient following surgery. 100% of respondents (97/97) were satisfied with the combined consultant/nurse clinic. 3 did not record their response. The vast majority of respondents (80%, 79/99) reported that they ‘don’t mind’ who they would have been seen by in the clinic. Discussion: The results indicate that patients are satisfied with the current clinic arrangements i.e. nurse-led clinic with the consultant being available. Hence there is a definite role for nurse led clinics for joint replacement surgery follow-ups

The burden of non vertebral fractures on the National Health Service is enormous. Osteoporotic fractures have an associated morbidity and mortality and as a consequent incur heavy financial burden with a current cost to the National Health Service of some £1.7 billion per year, hip fractures accounting for the greater part. We know from our own local experience in the North of Ireland that this previous service had failed to target these fracture patients for secondary prevention of osteoporosis (Northern Ireland Colles Fracture Study). Although hip fractures account for only 7% of all fractures they result in the utilisation of 25% of acute orthopaedic beds. The silent nature of osteoporosis makes a diagnosis prior to fracture difficult and attendance at a fracture clinic may be the first opportunity to diagnose this condition and to intervene with anti-resportive treatment. An osteoporosis service commenced in Greenpark Health Care Trust in 1996. In 2001, guidelines (Crest guidelines) for the prevention and treatment of osteoporosis were established and in April 2003 a pilot study for the fracture liaison service commenced with the appointment of a Fracture Liaison Nursing Sister. The responsibility of this Nurse included:. Liaison and attendance at Out-Patient Fracture Clinic to ensure that all patients presenting with a low trauma fragility fracture were assessed and referred appropriately for bone densitometry. An education and awareness role for patients regarding osteoporosis and fall prevention. To conduct additional nurse led osteoporosis clinic at Green Park Healthcare Trust for patients referred from the Out-Patient Fracture Service at the Royal Victoria Hospital. Current activity levels include 18 fracture clinics per week at the Royal Victoria Hospital site with approximately 35 patients per clinic. To date, the Fracture Liaison Nurse has been able to attend 54% of these clinics. The patients were identified by Fracture Clinic chart reviews to identify those greater than fifty years of age with a low trauma fracture and approximately 115 charts were reviewed weekly. At risk patients were interviewed with approximately 35 interviews carried out weekly. Patients were then recruited first for assessment and dexa scanning, measurements were made at both lumbar spine L1-L4 and at the femoral neck with approximately 22 patients weekly recruited. An assessment of osteoporosis risk was made, a plain bed dexa scanner (lunar prodigy scanner) and treatment options were decided depending on the patients T score and according to the CREST Guidelines. The patients were given bone health advice at their scanning visit. Clinic activity was recorded on a database (Gismo) and a computer generated letter to the GP was produced. Provisional outcomes included arrangements to rescan after 24 months, referral to falls assessment and referral to a Consultant Specialist Osteoporosis Clinic. Results: To date, 198 patients have been scanned. 28 were male and 170 were female. BMD results were as follows (T score at hip or spine):. - Normal (0 to −1 SD) 16.6%. - Osteopenic (−1 to −2.5 SD) 46.7%. - Osteoporotic (> −2.5 SD) 36.7%. The mean age for those scanned was 66 years and 3 months. Osteoporotic risk factors identified include a previous fracture (18%). Early menopause (19%), fall history (12%), Back pain and height loss (18%), smokers (11%), family history of osteoporosis (13%), alcohol excess (5%). Outcome – no treatment recommended 26%, 13% were already on treatment, 17% were prescribed treatment, 43% were prescribed Calcium and Vitamin D, 27% a Bisphosphonate, 20% a Bisphosphonate and Calcium and Vitamin D and 12% Evista (serm). Patient follow-up outcome included a follow-up of dexa scan at 24 months 20%, no hospital review planned 74%, 7% referred to a Specialist Osteoporosis Clinic and 6% were referred for a FALLS assessment. Conclusion: This service has highlighted the high prevalence of osteoporosis in patients attending a Fracture Clinic. An osteoporosis fracture increases significantly the risk of future fracture. Our current programme for evaluation and managing a patient with osteoporosis fractures is currently being audited to measure quality of service, treatment outcome and trends

We report the role of our advanced nurse practitioner (ANP) with particular relevance to cost effectiveness, patient satisfaction and data collection. Our nurse practitioner has been involved in arthroplasty care since 1996. Her duties include preoperative assessment, health advice, informed consent, clinical follow up and maintenance of a database for research/audit. Follow up radiographs are reviewed regularly by the entire medical team in a teaching environment. Relative costs of this service were calculated using outpatient charging data. 100 postal questionnaires were used to assess patient satisfaction. Patients answered 13 questions relating to the service they received. Knee arthroplasty follow up through the nurse led clinic was half the cost of follow up through the consultant led clinic. 80 patients returned the postal questionnaire. Responses were very supportive of the nurse practitioner service. 76 (95%) of patients were happy to be assessed by the ANP and felt that their problems were dealt with appropriately. 17 (21%) of patients felt they should be seen by a surgeon at some stage during their routine follow up. Overall, 75 (94%) of patients were very satisfied or satisfied with the service, 1 (1%) was dissatisfied and 4 (5%) did not answer this question. Increasing patient numbers and demand for high quality care combined with a decrease in doctors hours worked has lead to a shortage of time for discussion of ‘prehabilitation’ and postoperative care. Long term clinical and radiological follow up leading to adequate research and audit must not be compromised. A trained nurse practitioner working in conjunction with the surgical team is a cost effective way of improving total patient care, audit and research within a department. We have found a high degree of patient satisfaction with this approach