Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England.

Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant.

Introduction: The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur in patients with Diabetes mellitus.

Methods: of study: 62 patients aged 50 years or more (17 males & 45 females) who underwent AO screws for fracture neck of femur over 7 yrs (1999–2005) and followed-up for a minimum of 2 yrs formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic & GP letters was made. Age, residential placement, Garden’s classification of fracture, mode of injury, associated other co morbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. An in depth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. Reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions were critically analysed. Post-op physiotherapy, proportion of patients sustaining contra-lateral fracture NOF & its management and mortality statistics were reviewed.

Results: The mean age of patients was 67 yrs (range 52–96 yrs). 11 patients died in 2 years time. 41 patients were less than 75 years of age and 21 patients were more than 75 years of age. All the patients more than 75 years of age had undisplaced intracapsular fractures. 13 patients were type 1 and 49 patients were type 2 diabetic. Non-union & avascular necrosis occurred in 9 (17%) & 13 (26%) patients respectively. Revision surgery in the form of total hip replacement or hemiarthroplasty were performed in 21 (41%) cases. The incidence of avascular necrosis following osteosynthesis at 1 yr was 14%. Age, control of diabetes, post-operative complications, pre-fracture mobilization status and degree of impaction on AP & version on lateral radiographs were of statistical significance in predicting fracture healing and its associated complications. Complications like wound infection etc were more principally in patients who had poorly controlled diabetes.

Conclusion: Patients with diabetes mellitus have metabolic bone disease due to vasculitis. This increases the risk of complications associated with fracture fixation such as non-union, cut-through and avascular necrosis (AVN). The complications and revision surgery rate was high in patients with displaced fractures and with poorly controlled diabetes. Comorbidities like diabetes & patient’s age were also strong predictors of healing in addition to fracture configuration. Looking at very high complication and reoperation rate, our recommendation in patients with diabetes is primary hemiarthroplasty irrespective of femoral head displacement, if there is age more than 75 years.

Purpose: To review the existing coding for knee surgery and ascertain its appropriateness & accuracy for surgical procedures, associated co-morbidities and complications.

Methods: A retrospective review of 100 consecutive knee surgeries (50 arthroplasties and 50 arthroscopies) performed between July-August 2007 was undertaken. The coding data excel sheet and comprehensive hospital records were analysed.

Results: The accuracy of primary procedural codes was 100% & 88% respectively for arthroplasty & arthroscopy. However this respectively fell down to 56 & 60% when the accuracy for entire description of surgical procedure was taken into consideration. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility esp. for arthroscopies. In arthroplasties, patients had similar codes irrespective of whether they had patellar resurfacing or not. Co-morbidities were coded appropriately in 24% of arthroplasty & 36% of arthroscopy patients. The common co-morbidities missed were drug allergies, hypercholesterolemia, heart conditions (IHD, MI, AF, valvular pathologies) and h/o malignancy & deep vein thrombosis. Post-op adverse events were coded in only 2/5 arthroplasties (40%) and 0/3 arthroscopies (0%) respectively.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for reimbursement but also for data quality and audit. Coding database also serves as a powerful research tool. The financial implications with respect to generation of appropriate reimbursement i.e. healthcare resource group (HRG) codes (which are dictated by official population and census survey procedural [OPCS4.4] & international classification of diseases [ICD–10] co-morbidity codes) are discussed. The limitations of the existing coding system are highlighted and discussed. Literature emphasizes on the qualification of coders, legible & comprehensive documentation of surgeries & co-morbidities by treating physicians and regular interaction between coders and clinicians. Reimbursement for arthroscopy is less in the NHS unlike in BUPA where it is on par with open surgeries.

Introduction: Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centers for their management are initially admitted to DGHs. The referral is usually done by mailing patient’s x-rays/scans with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, mortality & morbidity, financial and medicolegal implications. We discuss these issues between index DGH (Poole Gen Hosp, Dorset) and its tertiary referral centers (Southampton/Reading/Bristol/Oxford/Stanmore).

Objectives: To review the existing management of spinal injury admissions at Poole DGH, analyse critical/ adverse incidents and efforts aimed at minimising them, to identify areas for improving patient care & safety and to draft a regional management protocol/care pathway for spinal admissions.

Methods: A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centers over 6 months (Jan–June 05) was undertaken. 28 of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of formulating clinical diagnosis, time of booking scans, time of performing scans, time of referral to tertiary centre, time of response from tertiary centre and time of transfer were retrieved from case notes and reasons for delay (if any) at each level were critically analysed.

Results: 7 of the 28 referrals had either neurodeficit or spinal instability. Common reasons for delay were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on scan results (av 1 day), delays due to missing/‘lost in transit’ scans (av 1.5 day), delay in obtaining opinion from tertiary centre (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were appx £73,000 & loss of 246 patient-days.

Discussion: Training of junior doctors at induction, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral to the tertiary centre were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre, Southampton to streamline referrals, circumvent lost in transit scans and enhance efficiency which has now grown into a national secure referral portal incorporating other referral centers.